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Diagnosis Deconstructed

Diagnosis Deconstructed: The Remarkable Purpose of Denis

Morchi, Ravi MD

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Emergency Medicine News: May 2013 - Volume 35 - Issue 5 - p 10
doi: 10.1097/01.EEM.0000430475.84387.3f

    It is 2003, and I am a fourth-year resident. The patient is 5 years old, and this is my sixth time trying to intubate him. All I see is pink. Is that an arytenoid? I am not sure. There is no attending and no other support at my side.

    Am I even on the right track? What will I do with him if I ever get the tube in? Can we maintain him in our ICU? An ICU made of spare parts. What is the endpoint to his underlying condition? Malignant distortion of his lower face and neck by an aggressive tumor, one that has shifted and obstructed his hypopharynx and glottic aperture. What will we do about that? Do general limitations to treatment in this environment apply to my patient? To his particular disease? I am not sure. I proceed for my seventh attempt. I hope Denis would agree and do the same.

    Denis is from Ireland. He started out as an engineer, with a performance deemed “lackluster” by his professors. They did not find him particularly clever or charismatic. He did not have any ability that made him attractive to the scientific world. Nobody sought after the space between his ears. So he switched to medicine.

    Denis' performance accelerated through medical school. He would choose surgery as a profession, and once he completed residency, he would find himself in the army and then stationed in Uganda where he later settled.

    Life was unfamiliar in Uganda. It was not like the UK. People were different. Days were hot and slow. Something was growing here. Growing fast. Man owned much land across Earth, but Denis lived in a place where microorganisms were fighting back. And winning. Organisms taking back lost territory from Homo sapiens.

    He noticed that the growth was particular to children, almost always between 5 and 8 years of age. Rapidly enlarging, encasing the lower face, and leading to death in months. He had never seen it before.

    Denis leaned on his scalpel, wanting to cut it out. But it grew fast. Encouraging blood vessels to feed it. Vessels that did not have normal architecture. Friable tissue would bleed heavily under the scalpel. And attempts to get adequate margins per the naked eye would not satisfy the cellular eye. This growth was aggressive, and if only a few cells remained, they would come back stronger and angrier.

    Fortunately for Denis, he had a Ford pickup truck. He rode this with two colleagues across sub-Saharan Africa. About 16,000 kilometers we believe. Chronicling the habits of this growth, he noticed it was equatorial in nature. It liked being there. Anywhere falciparum malaria could be found, it could be found. He called it the “sarcoma of the jaw,” but he was wrong on this account.

    Denis brought his experience back to the UK hoping others would want to help the most common growth in African children. Many were skeptical, their brains asking, “What could investing in research in Africa do for the modernized western world?” Nothing, it seemed. But Denis was motivated by the heart and not the head. He found a friend in London, and sent specimens of tissue to a pathologist named Tony.

    Tony, looking at the tissue, would make two historic discoveries: the growth was not a sarcoma, but rather was made of lymph cells, and, quite alarmingly, there was something not human about the tissue. It was foreign to Homo sapiens. There was another ingredient at work here. The maddening force behind deranged lymphocytes? Possibly. Tony and Denis had uncovered an alien residing within us.

    What to do about it in Africa? What is the endpoint for this growth? Denis had come to the sobering conclusion that a knife cannot cure all. So he departed from the classic Halsteadian surgical approach. Experimentation in Europe had shown radiation partially beneficial. But Denis could not haul such a machine out to rural Uganda. After all, where would he plug it in? The answer had to come in a different package.

    Man tried to kill man. This is nothing new. We have always been at each other's throats for one reason or another. The interesting thing is, 40 years prior to Denis, someone decided to raise the game. They found a more convenient way of killing and incapacitating than aiming a bullet. Gas. Gas employed to dismantle genetic material.

    What they did not see was that a derivative of the deadly molecule would one day act as savior for patients everywhere. And so it was with Denis in Uganda. He got his hands on the brainchild of man's desire to spread death, and he turned that around to give life. No protocol, no regulations, no governing body. No rules. This was Africa after all, and people were dying. Children were dying. Not fast and painless but rather slow, smoldering suffering. Grotesque distortion that isolated them from caregiver and community. Denis needed to put a stop to this.

    It proved to be amazingly effective. Deranged, disrespectful conglomerates of lymphocytes would shrink away in weeks at the command of a pill. To Denis' eyes, it would look like science merging with magic and to an African villager, nothing less than the work of the supernatural.

    Do I believe it the strangest of coincidences? A miraculous happenstance? The crossroads of chance and luck? That an engineer gone wrong would drift over an ocean to Uganda and pursue a mysterious disease across a continent in his Ford truck with no particular means of treating it? That a compound, once devised to take the life of fellow man, would later bring hope to the innocent and impoverished via the hands of a surgeon forced to abandon his scalpel?

    I do not believe in chance. I believe that when one scientist put the gas on display for war in 1917, its true purpose was unknown at the time. It actually existed for someone else, for another scientist to wield its life-saving derivative more than 40 years later. That was its real purpose. And so came into use this modification of nitrogen mustard we call cyclophosphamide.

    It has been 20 years since Denis died. His work shaped our view of oncology. He dedicated his life to the forgotten people of a neglected continent. One that the distinguished minds of his day deemed would offer little to the advance of modern medicine. Motivated by something deeper than the foreseeable and measureable, Denis followed his heart to a land occupied by alien forces. There he obtained tissue to show his friend, Tony Epstein. And their discovery would mark a shift in our understanding of neoplasia. That infectious agents, a virus in their case, could be the deranging force behind immortalized B-lymphocytes. The first sign that infection and cancer were not mutually exclusive but rather intimately related.

    It is 2013, and I am reviewing residency applications for our program. The one in my hand has a board score of 282. It even goes that high? Each of them is the best medical student that someone ever saw. All have stellar academic records, spent months volunteering in the developing world, started a nonprofit organization or two, and have completed anywhere from three to five marathons or triathlons in their spare time. No lackluster performances here.

    But who is the next Denis? Is he visible on paper? Or is she hiding invisible passion behind a modest curriculum vitae? I could not know.

    The Denis Burkitts of tomorrow may not be captured by a number, but I know they are out there. And for the amazing contributions they will make to our lives and the lives of our patients and loved ones, I thank you … in advance. For I know when you do it, it will not be by chance.

    Attitudes are more important than abilities. Motives are more important than methods. Character is more important than cleverness. And the heart takes precedence over the head>.

    — Denis Parsons Burkitt, 1911-1993.

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