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WING-COMMANDER ARMSTRONG: BONE-GRAFTING

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WING-COMMANDER ARMSTRONG: BONE-GRAFTING 1- 2 Established non-union. (24 months after fracture.) 3 Malunion, with tilting of the inferior articular surface of the tibia. (18 months after fracture.) 4- 5 Failureofreduction. (9weeksafterfracture.) 6- 7 Same case after grafting. 8- 9 Failure of reduction, including traction. (6 weeks after fracture.) 10-1 I Same case after grafting. 12-13 Gap due to comminution. 14-15 Gap due to too extensive debridement. 16-17 Delayed union. (14 weeks after fracture.) 18-19 Same case after grafting. 20-21 Delayed union. (After 25 weeks in plaster.) 22-23 Same case after grafting. 24-25 Same case a year after operation.
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Page 1: WING-COMMANDER ARMSTRONG: BONE-GRAFTING

WING-COMMANDER ARMSTRONG: BONE-GRAFTING

1- 2 Established non-union. (24 months after

fracture.)3 Malunion, with tilting of the inferior

articular surface of the tibia. (18 monthsafter fracture.)

4- 5 Failureofreduction. (9weeksafterfracture.)6- 7 Same case after grafting.8- 9 Failure of reduction, including traction.

(6 weeks after fracture.)10-1I Same case after grafting.12-13 Gap due to comminution.14-15 Gap due to too extensive debridement.16-17 Delayed union. (14 weeks after fracture.)18-19 Same case after grafting.20-21 Delayed union. (After 25 weeks in plaster.)22-23 Same case after grafting.24-25 Same case a year after operation.

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spleen of the same patient (fig. 6, c and d). Blood-formingcells can be seen in rabbit spleens by obtaining a little of thepulp from the spleen and diluting it with formal-saline, after-wards making a wet film for observation under high magni-fication.

Since there are blood-tumours which are not connectedwith the general circulation, classified as’ angiomas, I

thought that possibly a study of them would help me toconfirm the discovery made in this gastric sarcoma. Istudied the,blood of a large angioma of the calf of the leg,after extirpation, by making a puncture of a vasculardilatation of a bluish colour, and by staining some ofthe smears obtained with May-Grunwald-Giemsa. Theblood differs strikingly in colour and thickness fromcapillary blood obtained from the surface of the tumourafter resection. The differential count obtained from theblood tumour was as follows : polymorph eosinophils12%; polymorph basophils 3% ; lymphocytes 54% ;mononuclears 31%. There was a total absence ofnucleated red corpuscles from any group, either normo;.Pilast or megaloblast. The pictures of the angioma,(figs. 4 and 7) give a good idea of the extensive damageproduced in the cells by the spreading of the smear.The same damage occurs in smears obtained fromroutine sternal puncture.The differential count of the tumour blood, which does

not contain any neutrophil polymorphs, is in strikingcontrast to the differential count of the patient’s peri-pheral blood : neutrophil polymorphs 53% ; lympho-cytes 34% ; mononuclears 13%. The eosinophil poly-morphs in the blood of the tumour showed clearly howthe eosinophil granules swell; but some of the cells hadlost a large number of eosinophil granules owing to thedestruction produced by the smear, and only a fewremained in the protoplasm. Other cells were withoutgranules at all, but it was possible to see the shape of thegranules in the protoplasm where they had been beforethey were destroyed by smearing (fig. 4, a, band c).Some of the mononuclear cells still contained- the full-

size red corpuscles and others contained some swolleneosinophil granules, but a large number of the cells hadempty vacuoles in -the protoplasm where the red cor-puscles had been present before they had been damagedby the smear. The nuclei of these mononuclear cellswere of different shapes and sizes, varying from thenucleus of a transitional cell (fig. 7, a) to that of a typicalmononuclear (6g. 7 d). It was also possible to see clearlyanother cell which could be classified as a Turck cell witha few eosinophil granules inside (fig. 7 c). The differingcharacteristics of the cells and their nuclei can be attri-buted to the fact that puncture of the tumour disturbedcell development, and the -cells are seen in intermediatestages of their evolution. This is borne out by thepresence of eosinophil granules which have not developedinto full-size red corpuscles. The final stage in thishæmopoiesis is the evolution of the nucleus as a lympho-cyte ; and lymphocytes formed 54% of the total whitecells of the tumour. This process can be seen by studyinghaemopoiesis in different tissues. Portions of the proto-plasm of the mononuclear cells have the same colour andstructure as the platelets, fig. 7 d, and there were somebodies present of the same size as the red corpuscleswhich could easily be taken for giant platelets (fig. 7 b).A complete study of the blood from this angioma and

of the sarcoma of the stomach gave me concrete evidencethat from the granules of the eosinophil ’come the fullydeveloped red corpuscles ; and the different kinds ofremaining nuclei from the cells help to maintain themonophyletic theory of blood-cell formation, whichuntil now did not include the formation of the redcorpuscles.

ORIGIN OF THE EOSINOPHILS

The question then arose, " whence do the eosinophilsoriginate ? " The accepted theories of eosinophil forma-tion are unconvincing in the light of these observations.During routine examinations of bone-marrows I foundthat between the myeloblast and the eosinophil myelocytea stage is missing where the number of protoplasmaticeosinophil granules in the cell should be graduallyincreasing. Instead, the myelocytes are always full ofeosinophil granules, some of them being coarser than thegranules of the eosinophil polymorphs -present in thesame bone-marrow. It has also been observed that in

eosinophilic leukaemias most of the eosinophils in theperipheral blood as well as in the bone-marrow arepolymorphonuclear and that myelocytes are extremelyfew.

I discounted the current theory of eosinophil poly-morph formation from the myeloblast through the eosino-phil myelocyte in the bone-marrow, and began to studyinstead the possibility of its being formed by the evolu-tion to eosinophil granules of the neutrophil granulesfound in the ordinary polymorphs. When stained withLeishmann or May-Grunwald-Giemsa, some blood filmsshow neutrophilic granules difficult to classify as such,because it is hard to distinguish them from eosinophilicgranules. To differentiate the granules of the eosino-phils more clearly I stained the peripheral blood andbone-marrow films with a simpler stain (hæmatoxylinand eosin). This has the advantage of not staining anygranules other than. the eosinophil granules.

I was careful not to overstain the sections and blood-slideswith eosin since this makes the supporting tissue very redand blurs the slide. The method differs from the classic

staining method in that diluted eosin is applied for 20-30min., instead of a saturated alcoholic solution applied for 1-2min. Using a 5% aqueous solution as stock I make 0-5% bymixing 10 c.cm. of this stock with 65% distilled water and25% absolute alcohol; this 0-5% alcoholic solution of eosinis used as a counter-stain. The method leaves the support-ing tissue less red, so that the blood-forming cells are notcamouflaged.I was readily satisfied that the neutrophil polymorph

’in the peripheral blood and bone-marrow is not con-nected in any way with the eosinophil group. It thenbecame necessary to analyse other organs to find theorigin of the eosinophil cells. The spleen was immedi-ately ruled out by the fact that splenectomy is followedby an important temporary rise of these cells in theblood. Other organs, such as the pituitary, which showcells with eosinophilic affinity, were also ruled out becausethe eosinophil cells had no possible connexion with theeosinophil leucocytes. _

There is a group of organs in the body, however, whereeosinophil cells are normally present in large numbers,and also in some pathological conditions. The presenceof these cells is not mentioned in the histological andphysiological textbooks, but the organs which containthem are the stomach and intestines ; moreover theseorgans, as is well known, show large patches of lympho-cytes, some of which have been specially described asPeyer’s patches.

In the gastric mucosa, the number of eosinophil cellspresent in a section of 5 microns is approximately 5 cellsper gland tubule 2; and as there are about 35 millionglands in the gastric mucosa it can be estimated thatthere are at least 175 million eosinophil cells in thisorgan alone. The same, more or less, applies to theintestinal mucosa. In the deepest parts of these mucosasit is simple to follow the evolution from mononuclearcells of the lymphatic tissue which are free of eosinophilgranules to mononuclar cells which have a large num-ber of granules inside. It is also possible to see inthese mucosas a nuclear karyokinesis which transformsthe rod-shaped nucleus of the mononuclear cell into thatof a polymorph.In the intestinal mucosa the lymphocyte becomes

fixed and makes up eosinophil granules, the cell at thisstage having the appearance of what is known as thePaneth cell; this eventually shrinks until it becomesthe size of a fully developed eosinophil polymorph whichis then ready to wander in the tissues and pass throughthe wall of a lymphatic or capillary vessel ; naturegives the polymorphs their nuclear shape because thediameter of the lobules is much smaller than the nucleardiameter of any mononuclear cell.When the eosinophil polymorphs, with lobulated

nuclei, have developed from the lymphocytes they enterthe circulation and drift towards the haemopoietic organsor to any tissues suffering from pathological processes.In these sites they secrete the red corpuscles, and theremaining protoplasmic nuclei become lymphocytes

2. All microscopical studies are done in two dimensions only—length and breadth. This estimation of approximately 5 cells pergland means that these are the cells seen in a section of 5 microns ;accepting the gland as a cone the number of cells should be larger.

G 2

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again, as the studies of the blood of the angioma andsarcoma showed.

This ha-mopoiesis is always seen in the presence ofplasma cells and eosinophils. For this reason, notknowing that the red corpuscles were evolved from theeosinophils, I took the plasma cell to be the parent of thered corpuscles. Now that I am in possession of differentfacts I conclude that those plasma cells which haveeosinophilic granules in the protoplasm are the equivalentof the eosinophil myelocyte in the spleen and bone-marrow. As yet, however, I cannot say whetherthe plasma cells without eosinophil granules are thenucleated protoplasmic remnants passing through anintermediate stage after forming red corpuscles, or

whether they have ’another function.Until now blood has been studied as a static tissue, and

the differential count interpreted as a permanent pictureof a fixed proportion of cells contained in the circulatingblood. Because of this, some may ask how is it possibleto explain the full development of the red corpusclesfrom the eosinophil cells when the eosinophils are

normally present in the peripheral blood as only 2%of the white corpuscles ? I can only point out that thesame applies to the chemical components of the blood,and if these were also accepted as being in a static stateit would be impossible to understand where the 2000calories come from which the body needs daily whenthere is such a small quantity of proteins, fat and glucosein pheripheral blood. These chemical products mustbe in a dynamic metabolism ; if we accept the blood-cellsas also being dynamic, then knowing that the blood,circulates all over the body in less than a minute, it iseasy to understand how the circulation, with 7000 whitecells per c.mm. and 2% eosinophils can carry, theoretic-ally, during one day, about 200,000 eosinophils per c.mm.Fig. 9 shows how the cells are constantly changing in thesame patient over a period of 17 hours. Every eosinophilcontains more than 60 granules, and if all these developedevery day, the result would be the daily production ofabout 12 million red corpuscles per c.mm. ; the eosino-phil cell could be responsible for the formation of all redcorpuscles.

SUMMARY

The lymphocytes in the gastric and intestinal mucosas,by karyokinesis of the nucleus become fully developed

eosinophilcells afteran inter-mediatestage asPanethcells. Thefully de-velopedeo sino-phils wa4-der to theblood-streamand to thehaemo-p o i e t i corgans,carryingF!g. 9-Eosinophil counts in a single subject over 17 hours.

the preformed red corpuscles. In the haemopoietieorgans they develop their complete function of secretingthe red corpuscles, expelling the protoplasmic remnantswhich are the platelets ; the remaining nucleus becomesa lymphocyte again. The lymphocytes probably thenreturn from the haemopoietic organs to the gastric andintestinal mucosas, so completing the extra-uterine cycle.of red corpuscle formation. -

CONCLUSIONS

There are two processes of blood formation, heredescribed as intra-uterine and extra-uterine.The eosinophil polymorph is the carrier of preformed

red corpuscles from the gastric and intestinal mucosasto the haemopoietic organs in normal conditions, or toother tissues and organs in pathological conditions.B The lymphocyte, through the intermediate stage of

Paneth cell, becomes an eosinophil cell in the gastricand intestinal mucosas.

Fig. 8-Gastric sarcoma, showing hmmopoiesis.

The granules of the eosinophil cell are preformed redcorpuscles.

After bursting and extruding the red corpuscles themononuclear remainder of the eosinophil cell becomesa lymphocyte.The eosinophil myelocyte of the bone-marrow is not

a predecessor of the eosinophil polymorph, but is a

successor.

The gastric and intestinal mucosas are the organs wherethe blood is formed.

I would like to thank Prof. F. Wood Jones for his kindcriticism and discussions ; Mr. J. B. Dean, Bsc, who hasdone all the photomicrographs in connexion with this work;my technician, Mr. Butcher, for his help with histologicalwork ; and my secretary.

BONE-GRAFTINGIN THE TREATMENT OF FRACTURED

TIBIA AND FIBULA

J. R. ARMSTRONG, M D, M CH BELF, F R C SWING-COMMANDER RAF; REGISTRAR TO THE FRACTURE CLINICAND ORTHOPÆDIC DEPARTMENT, CHARING CROSS HOSPITAL, LONDON ;

REGISTRAR TO THE METROPOLITAN HOSPITAL

(Illustrations on Plate)

FRACTURES of the shafts of the tibia and fibula arecomparatively common injuries, with certain character-istic features. These features include a tendency tore-displacement after an initial accurate reduction,frequent slow union leading to non-union if unrecognised,and disability, often serious, if the fractures are allowedto unite in imperfect alignment or with rotational dis-placement (Watson-Jones 1940). For these reasons it isnot surprising that the results of treatment are oftenimperfect, especially as there appears to be a tendencyto regard these fractures as relatively simple injuries.Treatment by open operation is, however, only rarelynecessary, particularly if adequate conservative methodsare employed from the outset. It must be emphasisedthat, heavy though the penalty of failure of conservativetreatment may be, the result of failure of operativetreatment may well be tragedy. -

INDICATIONS FOR OPEN OPERATION

There are four absolute indications and two relativeindications for operation. The absolute indications are :

1. Established non-union.—When the fractured sur-

faces have become sealed off by a,layer of dense sclerosedbone no form of conservative treatment will result inbony union. Figs. 1 and 2 (on plate) show a 24-months-old fracture which had been treated in plaster for 12 °

months, followed by drilling the bone ends and plasterfor a further 6 months. Removal of the plaster wasfollowed by increasing pain and disability, and the radio-grams show an ununited fracture with sclerosis of thebone ends. The drill fragment is a legacy from theprevious operation elsewhere.

2. Malunion sufficient to cause serious disability.-Insuch cases disability can only be relieved by division of


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