205LEADING ARTICLES

Autoimmunity and Immunotransfusionin Burns

THE LANCETLONDON 28 JANUARY 1961

LAST year, discussing toxasmia in bums/ in the lightof new work we raised the old question whetherabsorption of non-bacterial toxins from the burned skinis a possible cause of illness and death. FEODEROV andhis colleagues 2-4 in Moscow had claimed that the bodywas flooded with antigens (which they believed to betoxic) derived from the burned skin, having detectedthese in the blood of recently burned patients andexperimentally burned animals for up to about fourteendays after burning; thereafter antibodies to the antigensappeared in the blood. The serological methods usedincluded prolonged complement fixation in the cold,which, unless special care is taken, may give non-specific reactions; and we suggested that confirmationby other, more sensitive, methods was necessary.Confirmation of aspects of this work has come from

two sources. First PAVKOVA et al.,5 6 of the burns unit inPrague, found by the sensitive technique of collodion-particle agglutination that, when an extract of unburnedskin from burned patients was used as an antigen,antibodies were detectable in the blood between thefourth and eighth days after burning. The titre reacheda peak about the fifteenth day, then gradually declinedas the patient’s condition improved and antibodyreappeared in convalescence. Secondly, ROSENTHAL etaI.7 8 in Chicago report that sera from recently burnedpatients contain toxic substances which they call"

cytotoxin " and " cytolysin

"

according to the effectstested. Cytotoxin was detected by the ability of thesera to inhibit the growth of Hela cell suspensions afterseventy-two to ninety-six hours in tissue-culture, andcytolysin by the lytic effect on the patient’s red blood-cells either of serum from the patient in the presenceof guineapig serum (complement) or of serum fromthose with healed burns. " Antitoxins " to thesewere demonstrated in the sera of those who hadrecovered from burns, mainly by ability of the sera toneutralise the cytotoxic effect of sera from patients withrecent burns. Interesting and important though thiswork is, some of the techniques are not above criticism-including the detection of lysin (antigen) and haemo-lysin (antibody) apparently by the same method, and theuse as a substrate of blood from patients with burns.The red blood-cells of patients with recent burns has1. Lancet, 1960, i, 153.2. Feoderov, N. A. Congr. int. Soc. Blood Transf. 1956, p. 54.3. Feoderov, N. A. Report to the European Congress on Hæmatology, 1959.4. Feoderov, N. A. Report to the International Congress of Research in

Burns, Washington, 1960.5. Pavkova, L., Dolezalova, J. Report to the Symposium on Plastic

Surgery and Burns, Mariánské Lázně, 1960.6. Dobrkovsky, M., Dolezolova, J., Pavkova, L. Report to the Inter-

national Congress of Research in Burns, Washington, 1960.7. Rosenthal, Sol. R., Hartney, J. B., Spurrier, W. A. J. Amer. med. Ass.

1960, 174, 957.8. Rosenthal, Sol. R., Hartney, J. B., Spurrier, W. A. Report to the Inter-

national Congress of Research in Burns, Washington, 1960.

increased fragility to saline and may undergo partialspontaneous lysin 9

Notwithstanding criticisms of technique, it seems

reasonable to conclude that serological changes do occurin patients with burns; but not all these changes arenecessarily immunologically specific: at least some arepossibly related to, or associated with, the rise of

y-globulins often found after burning, no doubt owingto bacterial infection. Possibly too, some of the responseis " non-specific " in the same sense that false-positiveWassermann reactions may be found in various non-

syphilitic conditions-though the same serologicalexplanation is not necessarily valid. The work needs tobe pursued with some of the newer sensitive serologicaltechniques, including perhaps the anti-globulin methodsof COOMBS.

The aspect of the reports from Moscow, Prague, andChicago which will most interest clinicians is thatconcerned with the therapeutic transfusion of plasmaor blood from patients with healed or healing burns.This therapy has developed out of the idea that passivetransfer of the skin-antibodies would neutralise the" toxic " antigens flooding into blood from the burnedskin. PUSHKAR 10 reports that donor blood was collectedfrom those with healed burns (the donors had burnscovering more than 7% of the body area) and was giveneither as plasma or whole blood as soon as possible afterthe accident, and always within forty-eight hours. 100-

400 ml. was given every day in the first week after

burning. Clinically impressive results are claimed,including the disappearance of

" toxxmic " symptoms.Some of this benefit may be due to the transfusion of

plasma or blood per se or to the combating of bacterialinfection through the passive transfer of antibacterialantibodies arising after infection of the burn in thedonors. ROSENTHAL ’ carried out a pilot trial with this"

immunotherapy " in 6 burned children. The donor

blood was collected from patients who had recoveredfrom extensive burns (25% or more of the body area)months or years previously, and was given from thefourteenth day onwards after burning. (The delay wasapparently not deliberate and seems to have been dueto the time needed to obtain the special blood.)Repeated transfusions of 250 ml. of plasma or 500 ml. ofblood were given. These workers, too, claim beneficialresults, including reduction of pyrexia and generalclinical improvement. Some of the effects were dramatic,but were shortlived unless further transfusion was given.In Prague, too, transfusion of blood or plasma fromthose with healed burns has been tried in a few cases,and the Czechoslovak workers are impressed with theclinical effects.

Encouraging though these reports are, further experi-ence is needed before the value of this treatment can be

regarded as established. The history of burns therapyis marked by many forms of treatment-such as tannicacid, adrenocortical extract, cortisone, and cortico-

trophin-which at first were acclaimed but in the end9. See Sevitt, S. Burns, Pathology and Therapeutic Applications. London,

1957.10. Pushkar, L. I. Report to the Symposium on Plastic Surgery and Burns,

Mariánské Lázně, 1960.

206

proved disappointing. A controlled clinical trial iscalled for. This should be carried out on carefullyselected cases-preferably in children in the first place,because of their smaller blood-volume and therapeuticneeds. They would be divided into concurrent " test "and " control " series in an unbiased way. The diffi-

culty is likely to be that of obtaining enough of the specialadult donors. A widespread campaign through thevarious regional blood-transfusion centres may be

needed in order to obtain enough, and then the plasmamight be centralised at one or another of our burnsunits for the trial. If this therapy is proved to bebeneficial, a special group of blood-donors may have tobe organised, comprising those with healed burns andpossibly some actively immunised with extracts of skin.

Diseases of Glycogen StorageTHE body humours lasted a thousand years: nowadays

those intellectual fancies which we dignify as " new

concepts of disease " come and go with the regularityof academic quinquennia. It is almost a shock to realisethat GARROD’S concept of inborn errors of metabolism 1

has already outlived the half-century. To the originalquartet of errors-albinism, alkaptonuria, cystinuria,and pentosuria-we could add today over fifty conditionswhich would satisfy GARROD’s criteria; and most suchdiseases can be assigned to one of three groups. The

haemoglobinopathies are so far the only ones in whichthe lesions have been tracked down to abnormal amino-acid sequences of single protein molecules, perhaps thedirect imprints of inherited mutant genes. At the otherextreme we can but dimly perceive the inborn chemicalerrors in such common metabolic diseases as diabetesor gout. In between is that exciting group of illnessesin which step by step we can now trace the clinical

syndrome to the defective action, but not yet to thedefective structure, of a single enzyme.A familial disease of excessive glycogen deposition

in the liver and occasionally in other tissues has beenknown for over thirty years,2-4 but only in the past tenhave we recognised some of the chemical lesionsresponsible for it. Glycogen metabolism is commonlyrepresented in the following simple manner:

Step 1, the phosphorylation of glucose to glucose-6-phosphate, takes place as glucose enters the cell and is catalysed

1. Garrod, A. E., Inborn Errors of Metabolism. London, 1909.2. von Gierke, E. Beitr. path. Anat. allg. Path. 1929, 82, 497.3. Parnas, J. K., Wagner, R. Biochem. Z. 1922, 127, 55.4. van Creveld, S. Medicine, Baltimore, 1939, 18, 1.

by the enzyme, hexokinase. Steps 2 and 5 are catalysed by thesame enzyme, phosphoglucomutase; but steps 3 and 4 requirethe collaboration of two enzymes each. In step 3 a phos-phorylase removes the phosphate groups from the glucose-1-phosphate molecules and attaches the bared first carbon atomsto the tail end of a glycogen nidus. When a chain has reachedthe critical length of eight glucose residues, a second enzymeestablishes a branch-point by converting an a-1-4 to an

<x-l-6 linkage. This "brancher" enzyme determines thecharacteristic tree-like structure of the glycogen molecule.In step 4 a phosphorylase splits off the phosphate groups fromthe outermost tier of glucose units, and a

" debrancher "

enzyme catalyses the cleavage of the <x-l-6 linkages at the

branch-points. Step 6 represents the final release of glucosefrom the cell, and many metabolic paths converge on it:it is catalysed by the enzyme, glucose-6-phosphatase.Among the enzymes involved in glycogen metabolism,

the phosphorylases differ from one tissue to another,and even in a single organ they probably exist inboth active and inactive forms; and their activation

depends on distant hormonal influences as well as onlocal changes.5-7 Of glycogen itself it has been said thatno two molecules are identical in any one individual:their disparity in weight, size, and branching pattern isclearly reflected in the varied amounts whicb can beextracted from the same tissue by different techniques;and stable and unstable fractions may have distinct

physiological roles. 8-10 It is hardly surprising, there-

fore, that our metabolic scheme should have severalweaknesses and at least one major flaw. One of itsweaknesses is that it accounts for changes in the quantityof body glycogen only by molecular growth and shrink-age : the way in which new seeds of glycogen arise,either from existing molecules or from oligosaccharides,remains unknown. Its major flaw is that it representsglycogen synthesis as the mirror image of glycogenbreakdown; and for some years now this test-tube

assumption has been contradicted both by animal

experiments and by clinical findings. Adrenaline and

glucagon-hormones which enhance phosphorylaseactivity 11-both favour glycogen breakdown; and thereis no reason why the activation of an enzyme whichcatalyses a reversible reaction should always have a

unidirectional effect.1’ Similarly, high concentrationsof K in rat-liver slices favour glycogenesis, while highconcentrations of Na - - activate phosphorylase and

promote glycogenolysis.13 Such observations have led tothe discovery of a pathway for glycogen synthesis whichdepends for the provision of x-l-4-glucosidic units, noton glucose-1-phosphate (and phosphorylase), but on acomplex hexose nucleotide, uridine diphosphate glucose(U.D.P.G.).14-18 This substance can be broken down5. Cori, C. F., Cori, G. T., Green, A. A. J. biol. Chem. 1943, 151, 39.6. Cori, G. T., Swanson, M. A., Cori, C. F. Fed. Proc. 1945, 4, 234.7. Stetten, D., Jr., Stetten, M. R. Physiol. Rev. 1960, 40, 505.8. Meyer, K. H. Advanc. Enzymol. 1943, 3, 109.9. Manners, D. J. Advanc. Carbohyd. Chem. 1957, 12, 261.

10. Stetten, M. R., Katzen, H. M., Stetten, D., Jr. J. biol Chem. 1958,232, 475.

11. Sutherland, E. W., Cori, C. F. ibid. 1951, 188, 531.12. Sutherland, E. W. Enzymes: Units of Biological Structure and

Function. New York, 1956.13. Hastings, A. B., Ashmore, J., Cahill, G. F., Jr. Arch. Biochem. Bioph

1956, 65, 83.14. Lamer, J., Villar-Palasi, C., Richman, D. J. Ann. N.Y. Acad Su

1959, 82, 345.15. Beloff-Chain, A., Chain, E. B., Catanzaro, R., Longinotti, L Biochim.

biophys. Acta, 1954, 14, 259.16. Leloir, L. F., Cardini, C. E. J. Amer. chem. Soc. 1957, 79, 6340.17. Munch-Petersen, A., Kalckar, H. M., Cutolo, E., Smith, E. E. B.

Nature, Lond. 1953, 172, 1036.18. Hauk, R., Brown, D. H. Biochim. biophys. Acta, 1959, 33, 556