New Concepts in Bone Healing

Elements in the food and water of Deaf Smith County, Texas, are discussed in relation to the low rate of dental decay and rapid healing of bone fractures. 

 

It has been said that the depletion of the minerals from the soils of England and Europe was directly responsible for the Black Death of 1448 and 1449. This gross ignorance in the care of the land was responsible for the death of one third to one half of the population of those countries. The Black Death depleted the labor supply to such a degree that practically all the farmland was turned back to grass, and it was not until the beginning of the 17th Century that the surviving people had enough of the proper foods to sustain a vigorous life. It is highly probable that the outstanding achievements of the Tudor period were a natural consequence of a restored agriculture. Since that time, the people of the world have been in constant search of rich agriculture lands on which to live or from which to secure their foods. Our present society is more concerned with how to maintain the fertility of their lands because there are no new and rich areas to which they can go.¹

There is a small area in the State of Texas that has received considerable publicity in the last few years because of its low rate of dental decay. This is located on the high plains of Texas in Deaf Smith County. The geology and topography of this area have been given considerable study. It has been my experience to have practiced surgery and orthopedics in this area for the past six years and this has given me the opportunity to see and observe not only the dental health of the people living in this area but also their bone structure and the healing of both spontaneous and traumatic fractures. The rate of bone healing and the reasons for the increased rate of healing is the purpose of this paper. My observations and findings will be listed in the following illustrations.

For several years prior to 1940, it had been noted by local dentists that people living in Deaf Smith County had a very low dental decay rate. It was at his suggestion that Dr. Edward Taylor of the Texas State Department of Health and his staff made an extensive survey of dental conditions in that county. The results of this survey were first reported in the Journal of the American Dental Association in August of 1942.² At that time, the school children of Deaf Smith County revealed 1.02 DMF teeth per child. This was by far the lowest rate of dental decay ever reported in a civilized country. Following this report, the U. S. Public Health Service Department did an extensive survey on water in the high plains area. From their findings it was deducted that this unusually low rate of tooth decay was due to fluorine in the drinking water. It was considered that the Deaf Smith County area had the optimum fluorine for good dental health. It is from this study that the American Medical Association, U. S. Department of Health, and other similar societies, have approved the fluorination of all drinking water in the United States. To some of us it was apparent that factors other than fluorine were at least partially responsible for these findings.

It has been observed for many years that cattle grown in this area were larger than cattle grown in surrounding areas. It is a known fact that a grown cow, six years of age, can be moved into this area and in two years will gain a minimum of 250 pounds. Most of the cattlemen consider this to be primarily due to increase in size of the skeleton and increase in weight of the bone structure. This has become an economic factor in buying cattle and moving them into that area. Extensive experimental work has been done on livestock produced in this area, including weight of skeletal structure, abortion rates in mother cows and incidence of spontaneous fractures in herd bulls. All of these findings support the contention that livestock produced in this area are of a superior physical development.

After practicing medicine in this area for several years, it became evident that we did not experience the difficulty with fractures that I had become acquainted with in Dallas, Texas. On closer observation of old people with broken hips, we noted that we were only seeing trochanteric fractures and no neck fractures. It also became evident that these fractures were healing within a relatively short period of time. It was observed during this time that it was easy to identify a local resident by the appearance of bone on the X-ray film. Even in the older age group, we do not see the demineralization and osteomalacia that is so common in other areas. Comparative measurements of the cortices of long bones revealed the cortex to be approximately one half greater in thickness than those of people living in other regions of comparison.

Due to the rapid callus formation noted in other types of fractures, we adopted a conservative method of treating trochanteric fractures. The idea for this method of treatment came from the hanging cast used on the humerus. At the present time, we have treated twenty-eight trochanteric fractures by this method; youngest of this group was sixty-four years and the oldest, one hundred one. There was no mortality and all of the patients had full weight bearing at ten weeks. The average healing for full weight bearing was eight weeks. By using this method of treatment, we were able to avoid the so-called hospital psychosis so common in elderly people by simply sending them home any time their mental status indicated a change to home environment. The average age of this group was 82.5 years.

The twenty-eight cases reported above indicate my personal experience with trochanteric fractures. Since I did not observe a single neck fracture over a period of six years, I made an extensive check of doctors practicing in this area for as long as thirty years and found that they had had the same experience. In other words, we do not see common neck fractures in people living in this area.

In order to show comparative healing times and types of fractures common to given localities, I am reporting below the results of broken hips in Deaf Smith and Dallas Counties, Texas between 1940 and 1950:

Dallas County

1. Trochanteric
   a. 28% of all hip fractures
   b. Average age: 63 years
   c. 11% mortality
   d. Average healing time: 6.3 months
   e. 83% operated-Neufeld nail
2. Neck Fractures
   a. 72% of all hip fractures
   b. Average age: 81 years
   c. 21% mortality
   d. Average healing time: 9.4 months
   e. 24% non-union

Deaf Smith County

1. Trochanteric
   a. 100% of all hip fractures
   b. Average age: 82.5 years
   c. 0% mortality
   d. Average healing time: 8 weeks
   e. No operative cases

The above table is self-explanatory and I will not elaborate further except to say that the experience in Dallas County is about the average for the Southwest.

In order to attempt an explanation of the increased healing properties of bone and the low dental decay rate of the people in Deaf Smith County, Texas, it is necessary to review the physical and chemical properties of the bone and teeth. The teeth are usually thicker than those observed in other areas, and in practically all cases have multiple areas of hyper-calcification. These are small white areas that can only be seen by close observation. There is a very small amount of brown enamel seen in individuals living in this area. On microscopic section, these areas are hard and more porous than those observed in normal teeth. The enamel has a very high gloss, and I am told by the dentists that it is unusually hard. According to spectrographic analysis, the bone structure carries the same chemistry as the teeth.

The chemical answer for this was thought to be fluorine in the drinking water; however, it has been known for some time that water and foods have a very high magnesium and iodine content and recently we have proven that all of the trace elements known to be essential are present in the water and foods grown in that area. This fact has been borne out in the complete spectrographic analysis of grains, potatoes and other vegetables produced in this area.

In order for us to better understand the inorganic chemistry of bone healing, I would like to review the changes observed in non-union or poor union of bones. The case presented below is an eight month non-union of the middle third of the femur in an 18 year old male. It will be noted that the percentage of change in the chemical constituents is greater in phosphorous with a compensatory shift of magnesium. The chart below will give the actual chemicals in the proximal and distal fragments:

 

Non-Union Bone Chemistry

It will also be noted that the decrease in bone ash agrees with the radiographic evidence of demineralization usually observed in the distal fragments.

The chemistry of normal bone has been well established.

In text book and laboratory analysis, the calcium and phosphorous ratios are given as 2:1. I would like to present an actual spectrographic analysis of normal bone in the Dallas County and Deaf Smith County residents:

 

Normal Bone

The inorganic constituent of bone has been agreed on by physiologists as being 45%. In analytical procedures this is termed “bone ash.” As you will note from the above diagram, the bone ash of the Dallas resident is 52% and in a Deaf Smith County resident it is 68% The difference in bone ash is thought to be the reason why it is easy to identify a Deaf Smith County resident from his radiographic examination. You will note from the above analysis that the magnesium content is approximately five times as high in a Deaf Smith County resident as in the Dallas County resident. We attach considerable significance to this comparative study.

Keeping in mind the above chemistry, I would like to show a radiograph of a comminuted trochanteric fracture in an eighty-five year old male. This fracture was sustained in a car accident and was treated in the manner previously described. This radiograph was taken four weeks post trauma and, as you will note, shows considerable callus at this time. We are able to present more favorable four week healing evidence but since this is the usual manner of treating these fractures, I have presented it for your consideration. This is the only hip out of my series of 28 that I felt justified in nailing. This was strictly because of the severe comminution. This 85 year old male had full weight bearing at six weeks and was using only a cane for balance. This film was made four weeks post-trauma and 27 days post-nailing. (Fig. 1.)

Figure 1

 

In review of clinical and research data that has been accumulated from this area there is evidence to support the fact that there are multiple factors responsible for the low dental decay rate, and the increased bone healing. I would like, at this time, to enumerate briefly the factors involved and discuss a few of them in detail.

Drinking Water

The most constant food of all people, animals and plants is water. The large volume of popular publicity that has been built up around the Deaf Smith County water can best be summarized by a comparative study of that water which is from the deep well source and the Dallas County water which is surface in origin. The following spectrographic and wet analyses will show the. difference in the chemical properties of the two waters:

Water Supply

Factors consistently increased in water and foods are:

1. Fluorine–The effect of fluorine in bone metabolism is still a debatable factor; however, as has been observed in the mines in Portugal, an excess of fluorine, or so-called fluorosis, results in marked overgrowth of the cortices and complete obliteration of the medullary canal, giving a fatal aplastic anemia. We present the question if an optimal intake of fluorine might be a factor in the accelerated growth and increased density of bone in people and livestock in this area. It has been suggested by Neuman³ that fluorine may be involved in hetero-ionic exchanges for the hydroxyl group which may alter the atomic pattern of hydroxyapatite. He was also able to show that when 5 to 10 per cent of the unit cells showed fluorine substitution in. the lattice that it changed the X-ray diffraction of bone.
2. Iodine–The role of iodine in general nutrition and bone metabolism is still under intense study. The radioactivity of this halogen indicates that it might perhaps serve an important role in future bone metabolic studies. Chemical analysis of bone from humans in the area reported show approximately five times the iodine content as do bones studied from the Dallas area. We attribute at least some of the increased radiopacity of these bones to the increased iodine content.
3. Magnesium–Very little of the physiology of magnesium is known at the present time; however, it is known to play a significant role in bone apatite. Its radioactive properties are known and these suggest that it can play the major role in healing processes. It is capable of emitting both gamma and beta rays and yet it is very unstable, having a radioactive life of only 9½ minutes. We were able to show, as listed in previous charts, that there is a compensatory rise in magnesium content in bone healing; also it is known to rise with a fall in calcium as seen in the aged person. We were able to show that it is approximately five times as high in the young healthy male adult living in Deaf Smith County, Texas as it is in other healthy male adults living in other parts of the State. We are now in the process of trying to evaluate more closely the role of magnesium both in normal bone apatite and in the healing process.
4. Manganese–It is known that a deficiency of manganese will retard normal bone growth, resulting also in soft and easily fractured bones. The actual role of manganese in bone metabolism is unknown at the present time. As shown in the chart of water analyses and as borne out on a repeated spectrographic procedure, the people living in this area have a relatively high intake of manganese.
5. Trace Elements–During the past few years, interest has grown in the so-called trace elements and the role they play in the nutritional processes of plants and animals. At present, it is known that boron, cobalt, copper, iodine, iron, magnesium, manganese, molybdenum and zinc are required by plants and/or animals. (These supplement the elements present in relatively large amounts; phosphorous, chlorine, potassium, sodium, hydrogen, nitrogen, oxygen, carbon, sulphur.) As refinements in analytical procedures develop, it is almost certain that a number of other elements (below the present limits of sensitivity) will be established as essential.⁴ All grains and beef products produced in Deaf Smith County area contain all trace elements known to be essential to plant and animal nutrition.
6. High Protein Diet–It is a known fact that people living in a cattle-producing area eat a higher protein diet than those living in a metropolitan area. Physiologists have demonstrated many times that the protein bound portion of calcium, magnesium and phosphorous is most essential in maintaining bone apatite. During our recent studies we demonstrated conclusively that it is very difficult to maintain a normal nitrogen balance during bone healing even with a 300 gram daily intake. It has been estimated that immobilization of a minimum of 25% of body muscle is sufficient to keep any patient out of nitrogen equilibrium.
7. Vitamin C–On repeated vitamin assays on food products grown at different altitudes, it has definitely been shown that the vitamin content is directly related to the altitude and the number of days of sunshine available to the growing plant. Follis,⁶ at Johns Hopkins, has demonstrated conclusively that adequate Vitamin C intake is essential to the normal functioning of the osteoblast. His work was carried out in scurvy with emphasis on the effects of Vitamin C on bone and cartilage. In assays on vegetables grown in Deaf Smith County, Texas, it has been shown that they are high in Vitamin C.

The factors listed above are all common to the residents in Deaf Smith County, Texas. It is assumed that any or all of these factors could play a part in the low dental decay and increased bone healing noted in people living in this area.

Although we have reported only the fractures most common to the aged, I have observed similar rates of healing in other areas such as the lower third of the tibia and bones of the forearm.

Summary

1. There has been observed in people living in a small geographic district in the high plains of Texas an increased rate of bone healing and low dental decay.
2. There is an absence of the common femural neck fracture seen in other parts of the country.
3. In comparative studies of people in Deaf Smith County, Texas and Dallas County, Texas there is an age incidence of at least twenty years more and a healing rate approximately one third greater in the same type of fractures.
4. Consistent chemical findings indicate an intake of optimal fluorine, high iodine; high magnesium, and all the known essential trace elements that may be necessary for proper bone healing.
5. High protein and high Vitamin C intake are desirable in the healing bone.

Supplement

On the basis of the above findings, I have undertaken a clinical study to determine if patients showing evidence of delayed union or non-union could receive benefit from the factors outlined in the above report. This investigation is still in progress, but if it is permissible, I would like to present three cases to show the possible clinical and radiographic improvement in the healing processes.

Case No. 1

L. G., age 44, suffered fracture of both bones of the forearm on 7/6/51. At that time, Rush nails were inserted with resulting good position. On 6/1/52 a non-union was declared and another operative procedure was done, removing the pin from the radius and inserting a cancellous graft (Fig. 2) On 8/29/52 X-ray study revealed very little callus formation and the fracture line is still distinctly seen. These findings, plus the duration of the fracture, suggests non-union, or certainly extremely slow healing. At this time the patient was placed on capsules containing the elements outlined as desirable in our report, and in five weeks good solid union, both clinically and radiographically, were present. (Fig. 3)

 

Figure 2, Figure 3

 

Case No. 2

P. M. C., age 68, was admitted to Parkland Hospital, the diagnosis intertrochanteric fracture of right hip. A Neufeld nail was inserted and satisfactory position obtained. Eight months later there was declared a non-union and cutting out of the pin, at which time the pin was removed. On 6/2/52 this patient was started on the capsules as outlined, and the state of the bone on that date is shown in Fig. 4. Nine weeks later on 8/12/52, good bone union had been accomplished as shown in Fig. 5.

Figure 4, Figure 5

 

Case No. 3

P. M., a white male, age 57, was admitted to Parkland Hospital 3/1/51 with a badly comminuted trimoleolar fracture of his right ankle. Nine months later he was declared non-union and a cancellous graft was done at that time. Six months following the graft, very poor healing, if any, was reported. Fig. 6 represents eight weeks of therapy on the routine we have described as being common factors for people living in the area studied.

Figure 6

 

I present the above cases to show the possible advantage of the healing properties inherent in the chemical composition of water and foods in Deaf Smith County, Texas.

My special thanks to P. M. Girard, M. D., Professor of Orthopedic Surgery, Southwestern School of Medicine, Dallas, Texas; to Carl A. Moyer, M. D., Washington University School of Medicine, St. Louis, Missouri; and James E. Loveless, M. D., Dallas, Texas for their encouragement and help in preparing this paper.

 

References Cited:

1. Howard, Sir Albert, C.I.E., M.A. The Soil and Health.
2. Taylor, Edward, D.D.S., Texas State Health Department. “Studies of Caries Immunity in Deaf Smith County, Texas.” American Dental Association, August, 1942.
3. Newman, W. F. “Bone As a Problem in Surface Chemistry.” On classified report, Atomic Energy Project, UR110, Rochester, University of Rochester, AEP, March 22, 1950.
4. Mitteldorf, A. J. and Landon, D. O. “Spectrographic Analysis of Beef for Mineral-element Content,” Army Research Foundation of Illinois Institute of Technology.
5. Follis, Richard H. “Histochemical Studies on Cartilage and Bone with Ascorbic Acid Deficiency,” Bulletin Johns Hopkins, vol. 89, #1, July, 1951.