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Some observations in calcium fixation
SOME OBSERVATIONS
CALCIUM
FIXATION*
BERKHEISER,
E. J.
CHICAGO, ITH
IN
the past few years there has been considerabIe investigation and advance in the deveIopment of therapeutic agencies to correct caIcium deficiencies, but even so, the subject of calcium fixation and the mechanism thereof is stiI1 a probIem. CaIcium privation seems to be due rather to fauIty assimiIation than to dietary deficiencies. Hence, it wouId seem that if the patient is to be benefited materiaIIy, attention shouId be directed toward suppIying him with this minera in a form which is more easily assimiIabIe, than that in the food to which he is accustomed. With this in mind we prepared a mixture of organic caIcium and phosphorus, cIoseIy reIated to the minera composition found in normal bone and tooth structure.
W
The formuIa of this was Combined caIcium salts.. Phosphorus (lipoid). . Magnesium salts.. . SiIicic acid.. . . . . ..
.
. . . .
z grains 3/4grain x grain g grain
This was routineIy administered series of cases of fracture showing union and non-union. The period union varied from a few months and one-haIf years, as shown in the ing case reports.
to a deIayed of nonto four foIIow-
CASE I. W. B., white, maIe, aged thirteen, was admitted to the Lutheran MemoriaI HospitaI on Feb. 5, 1927 after having received multipIe injuries as a resuIt of being struck by an automobile. He was unconscious and bIeeding from ears, nose and mouth because of a skuI1fracture. His Ieft femur was aIso fractured, but because of his serious condition it couId not be reduced at the time. Four days Iater, under anesthesia, the fracture was reduced on the HowIey tabIe and pIaster spica was applied. X-rays demonstrated perfect position of the fragments. On March IO, 1927 there was considerabIe over-riding of the fragments (2 in.) so an open operation was performed. * Submitted
IN
ILL.
The caIIus was removed and an ivory peg was inserted into the meduIIary cana with the ends of fragments approximated. PIaster spica was applied. On March 30, 1927, x-rays showed threefourths of the bone ends in contact with considerabIe caIIus aIong the fragments but very IittIe at the ends. On ApriI 20, 1927 on remova of the cast the x-rays reveaIed about two-thirds of the ends of fragments in opposition with very IittIe caIIus at the site of fracture. The ivory peg was broken and there was a marked anguIation at the position of the fracture. A very definite faIse point of motion was present. No union had resulted. A Iong pIaster spica was appIied from the toes to the axiIIa correcting the angular deformity. This cast was worn tiI1 Sept. 13, 1927, when x-rays reveaIed the non-union (Fig. I). At this time another pIaster spica was appIied and because of his sIow non-union we thought it advisable to reinforce his diet with a mixture of inorganic and organic compounds of mineraIs to hasten his union. On Jan. 24,Ig28 or four and one-third months Iater the cast was removed and x-rays as well as physica examination reveaIed a marked scIerosis of the’ femur, with firm bony union (Fig. 2). The immobiIization was discontinued as his condition was cured.
CASE II. Joe: white, maIe, aged forty years, sustained a fracture of both bones of his Ieft Ieg by being run over by an automobiIe. He was taken to St. Mary’s Hospital earIy in Nov. 1923. On Nov. 17, 1923, a Lane pIate was appIied and Ieg was immobiIized in a pIaster cast. On Dec. I, 1923 the Lane pIate was removed and pIaster cast appIied. On Jan. 26, 1924 the Ieg was operated on again with the excision of sequestra and on Feb. 2, 1924 he was discharged. He was first seen by us on Nov. 4, 1923 at which time the Ieft Ieg was bowed outward at the junction of the Iower and middIe thirds. Measured from the top of tibia to the internal
for publication 294
M.D.
ApriI 28, 1930.
NEW SERIES
VOL. X, No. 2
Berkheiser-CaIcium
maIIeoIus, the leg shows more than 2 in. of shortening. There is a definite faIse point of motion in the tibia 5 in. above the interna
Fixation
FIG. 1.
FIG. 2.
maIIeoIus, whiIe the faIse point of motion in the fibuIa is N in. beIow that in the tibia. There is some enIargement of the veins aIong the front of tibia for a distance of 6 in. The scars from previous operation seem we11heaIed. X-rays at this time reveaIed a non-union with maI-position of the fragments. The upper end of the Iower fragment of the tibia is under the Iower end of the upper fragment of the fibuIa. We advised open operation. He was admitted to my Orthopedic Service at Cook County HospitaI, where I operated on the Ieg in Dec. 1925. Because of the malposition, a11structures had to be freed from the ends of a11fragments for quite a distance so that proper aIignment of the bones couId be accompIished. Then a sIiding bone graft of the tibia was made. Owing to the fact that his operative condition was not good the graft couId not be secureIy fastened and the wound was hastiIy closed. Plaster cast was applied.
JWMI
or surgery
295
His postoperative convaIescence was quite normaI, but in a few weeks’ time, because of an offensive odor the cast was opened and the
FIG.
FIG. I. CASE I. Fracture of femur with deIayed:union seven and one-half months’ duration or six months after open reduction. FIG. 2. CASE I. SoIid union four and one-third months Iater.
American
3.
FIG. 4.
FIG. 3. CASE II. Fracture of tibia and fibuIa with nonunion of three years’ and seven months’ duration. FIG. 4. CASE II. Solid bone union six months Iater.
ffap of skin sIoughed off exposing the free bone graft, which was removed. He was discharged from the Cook County HospitaI and came to my Orthopedic Service at the Home for Destitute CrippIed ChiIdren on Feb. 19, 1926 for dressings. From this date to June 6, 1927 the Ieg was immobiIized in either a cast or a brace, in which weight bearing was permitted. During this time many had advised amputation. On June 6, 1927 there was stiI1 a definite non-union (Fig. 3). At this time his diet was reinforced with a mixture of organic and inorganic compounds of mineraIs with the view of obtaining union, and immobihzation was continued. In Jan. 1928 x-rays together with physical examination revealed a firm union of bone (Fig. 4). Since that time he has received no treatment and has been doing heavy manua1 Iabor. CASE III. E. S., thirty years of age W. sustained an injury in a faI1 from a motor cycle on JuIy IO, 1929. Two attempts were made to reduce it, the second attempt under gas anesthesia. On Aug. 3, he was first seen by us. He had a
296
American Journal of Surgery
Berkheiser-CaIcium
cast on the arm. X-rays reveaIed considerable maIposition in that the upper end of the Iower fragment was displaced to the uInar and exten-
Fixation
NOVEMBER, 19x0
driIIed hoIes in the ends of the bones. A long pIaster cast was appIied from the shoulder to the fingers.
FIG. 6. CASE III. Union in six weeks.
A
B
FIG. 3~ & B. CASE III. Fracture of radius with delayed union of two and one-half months’ duration.
sor side. There was no evidence of caI1u.s. Because of the maIposition and the Iack of union, open reduction was advised. On Aug. 3 at St. Francis HospitaI the fractured ends were exposed. There was no evidence of callus. The fragments were approximated and because of the patient’s opposition to the insertion of foreign materiaIs the fragments were secured by strong catgut, through
On Sept. 27, 1929 as shown in the x-ray (Fig. s), there was very IittIe evidence of caIIus, and there was a definite false point of motion. At this time on investigation of a reason for his Iack of union it was Iearned that just before his accident he had been a donor for severa bIood transfusions. He was then given some of the minera saIts and when he was seen again, on Nov. 13, he had gained severa pounds in weight and his marked anemia had disappeared. At this time union seemed to be quite firm, and x-rays showed (Fig. 6) a definite caIIus. He was advised to continue to wear a coaptation spIint from the wrist to the eIbow for fear of another possibIe injury. CASE IV. A Iady of about fifty-five years of age feI1 on an ice-covered driveway, injuring her right hip on Jan. 14, 1929.
NEW SERIES VOL.
X, No. z
Berkheiser-CaIcium
Fixation
AmericanJournalof Swev
297
PhysicaI examination was negative, except for the characteristic findings of a fracture of the neck of the femur with 1% in. of shortening.
out on normaI rabbits. These animals were from the same Iitter and they had shared the same food and environment. Their
FIG. 7. CASE IV. Fracture of neck of femur treated by Whitman method for two and one-half months showing definite space between fragments.
FIG. 8. CASE IV. Solid weight bearing
On Jan. 16 under ether the fracture was reduced, and immobihzed after the Whitman Method. On April I, the Iegs were approximately the same length, but x-rays (Fig. 7) at that time did not reveaI a firm union, but did show a definite space between the fragments. At this time she was given some additional minera saIts and another short pIaster spica was appIied. X-rays taken on May 25 (Fig. 8) revea1 a definite solid bony union. The space between the fragments was fiIIed with bony caIIus. The cast was removed and she has waIked on the Iimb since, without any waIking cahper or other support, and there has been no change in the angle formed by the head, neck and shaft of the femur. As a further step in testing of the substance, experiments
the efficiency were carried
7 weeks later.
reguIar diet after they were weaned consisted of an abundance of oats, hay, carrots and cabbage. Under ether anesthesia the tibia and fibuIa of these animaIs were fractured and splinted in maIposition. These animaIs were a11 fed on this diet, but to one-haIf of them was administered a daiIy dosage of this calcium phosphorus mixture, amounting to I/~O,OOOof the animaI’s body weight. X-ray photographs were taken at weekIy intervaIs. In the first group of animaIs receiving a norma diet minus the minera mixture, a moderate caIIus resuIted after two weeks, but it required sIightIy more than three weeks’ time to get a weight bearing union. In the second group of animaIs receiving the norma diet reinforced with the minera mixture, x-rays showed a marked soIidifi-
298
AmericanJournaI ofSurgery
Berkheiser-CaIcium
cation and a weight bearing union in less than two weeks’ time. To obviate the variation in animaIs it
A
I3
Fixation
NOVEMBER. ,930
was a definite production of caIIus and a weight bearing union in Iess than two weeks, whiIe in three weeks there was a
C
FIG. 9. A, B, c. Views of degree of normal repair in experimenta fracture of tibia and fibuIa of a rabbit on norma diet. A, seventh day, n, fourteenth day, C, twenty-first day.
was next decided to carry out the same experiment on a singIe anima1. AccordingIy, the tibia and fibuIa of the Ieft Jeg were fractured and successive x-rays were taken at seven-day intervaIs as shown in Figures A, B, c. Some caIIus was noted on the fourteenth day and more on the twenty-first day, aIthough the union was not very firm. At this time (twenty-first day) the right tibia and fibuIa were aIso fractured and the diet was reinforced with 20 mg. (1/50,000 of body weight) daiIy of the calcium-phosphorus mixture. Here the x-rays showed (Figs. D, E, F) that there +4x%
II
E
F
FIG. g, D, E, F. Views of degree of repair of fracture of tibia and fibula in same animal during next three weeks with same norma diet reinforced by mineral mixture. D, seventh day, E, fourteenth day, F, twenty-first day.
very marked production of caIIus as shown by Figure F. As the author is a cIinician rather than a chemist, these experiments have been conducted from the standpoint of their possibIe vaIue in actua1 practice. No unique theories, therefore, have been advanced to account for the modus operandi of treatment, save that it is based on a rationa therapeutic principIe. It is feIt that the resuIts obtained in these investigations are suffIcientIy encouraging to warrant further research aIong these Iines.
CALCIUM
FIXATION*
BERKHEISER,
E. J.
CHICAGO, ITH
IN
the past few years there has been considerabIe investigation and advance in the deveIopment of therapeutic agencies to correct caIcium deficiencies, but even so, the subject of calcium fixation and the mechanism thereof is stiI1 a probIem. CaIcium privation seems to be due rather to fauIty assimiIation than to dietary deficiencies. Hence, it wouId seem that if the patient is to be benefited materiaIIy, attention shouId be directed toward suppIying him with this minera in a form which is more easily assimiIabIe, than that in the food to which he is accustomed. With this in mind we prepared a mixture of organic caIcium and phosphorus, cIoseIy reIated to the minera composition found in normal bone and tooth structure.
W
The formuIa of this was Combined caIcium salts.. Phosphorus (lipoid). . Magnesium salts.. . SiIicic acid.. . . . . ..
.
. . . .
z grains 3/4grain x grain g grain
This was routineIy administered series of cases of fracture showing union and non-union. The period union varied from a few months and one-haIf years, as shown in the ing case reports.
to a deIayed of nonto four foIIow-
CASE I. W. B., white, maIe, aged thirteen, was admitted to the Lutheran MemoriaI HospitaI on Feb. 5, 1927 after having received multipIe injuries as a resuIt of being struck by an automobile. He was unconscious and bIeeding from ears, nose and mouth because of a skuI1fracture. His Ieft femur was aIso fractured, but because of his serious condition it couId not be reduced at the time. Four days Iater, under anesthesia, the fracture was reduced on the HowIey tabIe and pIaster spica was applied. X-rays demonstrated perfect position of the fragments. On March IO, 1927 there was considerabIe over-riding of the fragments (2 in.) so an open operation was performed. * Submitted
IN
ILL.
The caIIus was removed and an ivory peg was inserted into the meduIIary cana with the ends of fragments approximated. PIaster spica was applied. On March 30, 1927, x-rays showed threefourths of the bone ends in contact with considerabIe caIIus aIong the fragments but very IittIe at the ends. On ApriI 20, 1927 on remova of the cast the x-rays reveaIed about two-thirds of the ends of fragments in opposition with very IittIe caIIus at the site of fracture. The ivory peg was broken and there was a marked anguIation at the position of the fracture. A very definite faIse point of motion was present. No union had resulted. A Iong pIaster spica was appIied from the toes to the axiIIa correcting the angular deformity. This cast was worn tiI1 Sept. 13, 1927, when x-rays reveaIed the non-union (Fig. I). At this time another pIaster spica was appIied and because of his sIow non-union we thought it advisable to reinforce his diet with a mixture of inorganic and organic compounds of mineraIs to hasten his union. On Jan. 24,Ig28 or four and one-third months Iater the cast was removed and x-rays as well as physica examination reveaIed a marked scIerosis of the’ femur, with firm bony union (Fig. 2). The immobiIization was discontinued as his condition was cured.
CASE II. Joe: white, maIe, aged forty years, sustained a fracture of both bones of his Ieft Ieg by being run over by an automobiIe. He was taken to St. Mary’s Hospital earIy in Nov. 1923. On Nov. 17, 1923, a Lane pIate was appIied and Ieg was immobiIized in a pIaster cast. On Dec. I, 1923 the Lane pIate was removed and pIaster cast appIied. On Jan. 26, 1924 the Ieg was operated on again with the excision of sequestra and on Feb. 2, 1924 he was discharged. He was first seen by us on Nov. 4, 1923 at which time the Ieft Ieg was bowed outward at the junction of the Iower and middIe thirds. Measured from the top of tibia to the internal
for publication 294
M.D.
ApriI 28, 1930.
NEW SERIES
VOL. X, No. 2
Berkheiser-CaIcium
maIIeoIus, the leg shows more than 2 in. of shortening. There is a definite faIse point of motion in the tibia 5 in. above the interna
Fixation
FIG. 1.
FIG. 2.
maIIeoIus, whiIe the faIse point of motion in the fibuIa is N in. beIow that in the tibia. There is some enIargement of the veins aIong the front of tibia for a distance of 6 in. The scars from previous operation seem we11heaIed. X-rays at this time reveaIed a non-union with maI-position of the fragments. The upper end of the Iower fragment of the tibia is under the Iower end of the upper fragment of the fibuIa. We advised open operation. He was admitted to my Orthopedic Service at Cook County HospitaI, where I operated on the Ieg in Dec. 1925. Because of the malposition, a11structures had to be freed from the ends of a11fragments for quite a distance so that proper aIignment of the bones couId be accompIished. Then a sIiding bone graft of the tibia was made. Owing to the fact that his operative condition was not good the graft couId not be secureIy fastened and the wound was hastiIy closed. Plaster cast was applied.
JWMI
or surgery
295
His postoperative convaIescence was quite normaI, but in a few weeks’ time, because of an offensive odor the cast was opened and the
FIG.
FIG. I. CASE I. Fracture of femur with deIayed:union seven and one-half months’ duration or six months after open reduction. FIG. 2. CASE I. SoIid union four and one-third months Iater.
American
3.
FIG. 4.
FIG. 3. CASE II. Fracture of tibia and fibuIa with nonunion of three years’ and seven months’ duration. FIG. 4. CASE II. Solid bone union six months Iater.
ffap of skin sIoughed off exposing the free bone graft, which was removed. He was discharged from the Cook County HospitaI and came to my Orthopedic Service at the Home for Destitute CrippIed ChiIdren on Feb. 19, 1926 for dressings. From this date to June 6, 1927 the Ieg was immobiIized in either a cast or a brace, in which weight bearing was permitted. During this time many had advised amputation. On June 6, 1927 there was stiI1 a definite non-union (Fig. 3). At this time his diet was reinforced with a mixture of organic and inorganic compounds of mineraIs with the view of obtaining union, and immobihzation was continued. In Jan. 1928 x-rays together with physical examination revealed a firm union of bone (Fig. 4). Since that time he has received no treatment and has been doing heavy manua1 Iabor. CASE III. E. S., thirty years of age W. sustained an injury in a faI1 from a motor cycle on JuIy IO, 1929. Two attempts were made to reduce it, the second attempt under gas anesthesia. On Aug. 3, he was first seen by us. He had a
296
American Journal of Surgery
Berkheiser-CaIcium
cast on the arm. X-rays reveaIed considerable maIposition in that the upper end of the Iower fragment was displaced to the uInar and exten-
Fixation
NOVEMBER, 19x0
driIIed hoIes in the ends of the bones. A long pIaster cast was appIied from the shoulder to the fingers.
FIG. 6. CASE III. Union in six weeks.
A
B
FIG. 3~ & B. CASE III. Fracture of radius with delayed union of two and one-half months’ duration.
sor side. There was no evidence of caI1u.s. Because of the maIposition and the Iack of union, open reduction was advised. On Aug. 3 at St. Francis HospitaI the fractured ends were exposed. There was no evidence of callus. The fragments were approximated and because of the patient’s opposition to the insertion of foreign materiaIs the fragments were secured by strong catgut, through
On Sept. 27, 1929 as shown in the x-ray (Fig. s), there was very IittIe evidence of caIIus, and there was a definite false point of motion. At this time on investigation of a reason for his Iack of union it was Iearned that just before his accident he had been a donor for severa bIood transfusions. He was then given some of the minera saIts and when he was seen again, on Nov. 13, he had gained severa pounds in weight and his marked anemia had disappeared. At this time union seemed to be quite firm, and x-rays showed (Fig. 6) a definite caIIus. He was advised to continue to wear a coaptation spIint from the wrist to the eIbow for fear of another possibIe injury. CASE IV. A Iady of about fifty-five years of age feI1 on an ice-covered driveway, injuring her right hip on Jan. 14, 1929.
NEW SERIES VOL.
X, No. z
Berkheiser-CaIcium
Fixation
AmericanJournalof Swev
297
PhysicaI examination was negative, except for the characteristic findings of a fracture of the neck of the femur with 1% in. of shortening.
out on normaI rabbits. These animals were from the same Iitter and they had shared the same food and environment. Their
FIG. 7. CASE IV. Fracture of neck of femur treated by Whitman method for two and one-half months showing definite space between fragments.
FIG. 8. CASE IV. Solid weight bearing
On Jan. 16 under ether the fracture was reduced, and immobihzed after the Whitman Method. On April I, the Iegs were approximately the same length, but x-rays (Fig. 7) at that time did not reveaI a firm union, but did show a definite space between the fragments. At this time she was given some additional minera saIts and another short pIaster spica was appIied. X-rays taken on May 25 (Fig. 8) revea1 a definite solid bony union. The space between the fragments was fiIIed with bony caIIus. The cast was removed and she has waIked on the Iimb since, without any waIking cahper or other support, and there has been no change in the angle formed by the head, neck and shaft of the femur. As a further step in testing of the substance, experiments
the efficiency were carried
7 weeks later.
reguIar diet after they were weaned consisted of an abundance of oats, hay, carrots and cabbage. Under ether anesthesia the tibia and fibuIa of these animaIs were fractured and splinted in maIposition. These animaIs were a11 fed on this diet, but to one-haIf of them was administered a daiIy dosage of this calcium phosphorus mixture, amounting to I/~O,OOOof the animaI’s body weight. X-ray photographs were taken at weekIy intervaIs. In the first group of animaIs receiving a norma diet minus the minera mixture, a moderate caIIus resuIted after two weeks, but it required sIightIy more than three weeks’ time to get a weight bearing union. In the second group of animaIs receiving the norma diet reinforced with the minera mixture, x-rays showed a marked soIidifi-
298
AmericanJournaI ofSurgery
Berkheiser-CaIcium
cation and a weight bearing union in less than two weeks’ time. To obviate the variation in animaIs it
A
I3
Fixation
NOVEMBER. ,930
was a definite production of caIIus and a weight bearing union in Iess than two weeks, whiIe in three weeks there was a
C
FIG. 9. A, B, c. Views of degree of normal repair in experimenta fracture of tibia and fibuIa of a rabbit on norma diet. A, seventh day, n, fourteenth day, C, twenty-first day.
was next decided to carry out the same experiment on a singIe anima1. AccordingIy, the tibia and fibuIa of the Ieft Jeg were fractured and successive x-rays were taken at seven-day intervaIs as shown in Figures A, B, c. Some caIIus was noted on the fourteenth day and more on the twenty-first day, aIthough the union was not very firm. At this time (twenty-first day) the right tibia and fibuIa were aIso fractured and the diet was reinforced with 20 mg. (1/50,000 of body weight) daiIy of the calcium-phosphorus mixture. Here the x-rays showed (Figs. D, E, F) that there +4x%
II
E
F
FIG. g, D, E, F. Views of degree of repair of fracture of tibia and fibula in same animal during next three weeks with same norma diet reinforced by mineral mixture. D, seventh day, E, fourteenth day, F, twenty-first day.
very marked production of caIIus as shown by Figure F. As the author is a cIinician rather than a chemist, these experiments have been conducted from the standpoint of their possibIe vaIue in actua1 practice. No unique theories, therefore, have been advanced to account for the modus operandi of treatment, save that it is based on a rationa therapeutic principIe. It is feIt that the resuIts obtained in these investigations are suffIcientIy encouraging to warrant further research aIong these Iines.