1236 DEC.

5, 1953 RHEUMATOID ARTHRITIS IN COAL-WORKERS MBDICAL JOURNAL

is partly explicable by the desire to find very early cases of
a disease in which the earliest symptoms and signs are not BLOOD SUPPLY OF THE FEMORAL
usually clearly defined.
(c) Inter-observer Error in Reading Characteristic X-ray
HEAD
Changes, of Rheumatoid Arthritis in the Hands and Feet.- BY
Two observers from the Manchester Rheumatism Research
Centre kindly read the films of the hands and feet of the 20 MICHAEL HARTY, M.Ch., F.R.C.S.
cases with typical " rheumatoid" chest x-ray films. Their University Lecturer in Anatomy, University of Cambridge
readings are plotted against each other in Table V. In read-
[WITH SPECIAL PLATE]
TABLE V.-Inter-observer Error in X-ray Diagnosis of Rheuma- Towards the close of the eighteenth century William
toid Arthritis
Hunter had raised London to the position of one of
Second Observer the best anatomy schools in Europe. He visited
Albinus, the celebrated Dutch anatomist, in 1748,
Norubtflr Slight Moderate Marked Total and admired his injected anatomical specimens. On
Hands returning to London, Hunter developed and elaborated
Normal or this technique, and many of his original examples are
doubtful 8 (1) 4 (3)
_ - 125
s Slight . .
Moderate
1() 1 (1)3 (3)
- preserved in the Hunterian Museum at the University
. - - 1 (1) I
O Marked. . -(1- )( of Glasgow. This collection contains a number of
.L Total 9 7 2 1 19 illustrations of the circulus articuli vasculosus, which
Hunter had described originally in 1743.
Feet
; Normal or Matenrals and Methods
doubtful 12 (4) .1 (1) -
= 3
g Slight. - -
The injected specimens used in this investigation were
.o Moderate - - 5 (5) 5
O Marked.. _ 1(1 ) removed from recent post-mortem bodies or from the
Total 12 1 5
anatomical dissecting-rooms. They were dehydrated and
1 19 cleared in oil of wintergreen (methyl salicylate). Red lead
The numbers in parentheses indicate proved cases of rheumatoid arthritis. and starch were employed for the intra-arterial injections in
Figs. 1 and 2 and indian ink was used for Figs. 6 and 7.
ing the films of the hands there was agreement in 13 of the Circulus Articuli Vasculosus.-Since Hunter's original
19 cases, but in 5 cases one observer noted changes (3 of description, this vascular articular anastomosis has been
which were osteoporotic changes only) which were not noted given various anatomical situations. In his account Hunter
by the other observer; in the remaining case the difference states, " All round the neck of the bone there is a great num-
was only one of degree. In reading the films of the feet, ber of Arteries and Veins, which ramify into smaller
however, there was agreement in 18 of the 19 cases. Table V Branches and communicate with one another by frequent
also indicates that the x-ray changes in the feet seemed less Anastomoses like those of the mesentery." These vessels
likely to be present than in the hands, but when present they he placed by the margins of the articular cartilages in the
were more severe. In this series, four cases of proved subsynovial tissue, (Figs. 1 and 2). Some more recent
rheumatoid arthritis had no changes in the x-ray films of the accounts put the circulus articuli vasculosus at the attach-
feet, whereas only one case had no changes in the x-ray films ment of the joint capsule to the bone. This attachment
of the hands; nevertheless, among these 11 cases of rheuma- may coincide approximately with the margin of the articular
toid arthritis six had moderate or marked changes in the cartilage in those diarthrodial joints which permit little move-
feet, whereas only two had moderate or marked changes in ments, such as thi joints between the intervertebral articular
the hands. Typical x-ray changes of rheumatoid arthritis facets. In the adult femoral neck, however, the regions are
were never read by either observer in this series for any case separated by from 2 to 5 cm. The head of the femur derives
which had no other clinical evidence of arthritis ; there was its main blood supply from the subcapital anastomosis, as
one case of proved arthritis which both observers agreed had the contribution via the ligamentum teres is, at any age,
no x-ray changes in the hands or feet. This study would limited to a small medial segment of the head of the femur.
have been improved if a normal control bone had been used Davies (1946), when discussing the dynamics of haem-
when each film was taken. Many films were read as " doubt- arthrosis, emphasized the richness and superficial position
ful" because osteoporosis cannot be accurately assessed of the capillary fringe in the synovial membrane.
without such a control. Retinacula.-The arterial circle at the base of the femoral
REFERENCES head is supplied by arteries situated on the neck of the femur
Ball, J. (1952). Ann. rheum. Dis., 11, 97. between the synovial membrane and periosteum. The vessels
Caplan, A. (1953). Thorax, 8, 29.
Cochrane, A. L., Cox, J. G., and Jarman, T. F. (1952). British Medical are concentrated postero-inferiorly, superiorly, and occa-
Journal, 2, 843. sionally anteriorly. The synovial membrane covering these
Collis, E. L., and Yule, G. U. (1933). J. industr. Hyg., 15, 395.
Ellman, P., and Ball, R. E. (1948). British Medical Journal, 2, 816. vascular bundles is thrown into longitudinal ridges, to
Fletcher, C. M. (1948). Ibid., 1, 1015, 1065.
-Mann, K. J., Davies, I., Cochrane, A. L., Gilson, J. C., and Hugh-
which the term " retinacula" was first applied by Weit-
Jones, P. (1949). J. Fac. Radiol., Lond., 1, 40. brecht, of St. Petersburg, in 1742. The postero-inferior
Gough, J. (1947). Proc. Coni. on Silicosis, Pneumokoniosts and Dust retinaculum is a very definite structure in the human femur,
Suppression In Mines, p. 7. London. and shows as a duplication of synovial membrane measuring
Harrison, C. V., King, E. J., Dale, J. C., and Sichel, R. (1952). Bit. J.
industr. Med., 9, 165. 1 cm. or more in 76% of specimens examined (Figs. 2, 3, and
Kellgren, J. H. (1952). British Medical Journal, 1, 1093, 1152. 4). This pleat of synovial membrane always contains
Lawrence, J. S., and Aitken-Swan, J. (1952). Brit. J. industr. Med., 9, 1.
Long, D. A., and Miles, A. A. (1950). Lancet, 1, 492.
- - and Perry, W. L. M. (1951). Ibid., 2, 902.
medium-sized arteries, situated at the attachment to the peri-
Magarey, F. R., and Gough, J. (1952). Brit. J. exp. Path., 33, 76. osteum of the neck or anywhere along the pedunculated area
Pearse, A. G. E. (1950). Lancet, 1, 954.
Pickering, G. W. (1952). British Medical Journal, 1, 1207.
(Figs. 2, 4, and 5).
Rees, W. L., and Eysenck, H. J. (1945). J. ment. Sci., 91, 8. The Pericapsular Anastomosis.-The afferent arteries to
Rose, H. M.,-Ragan, C., Pearce, E., and Lipman, M. 0. (1948). Proc. Soc. the retinacular vessels are derived from another anastomosis
exp. Biol., N. Y., 68, 1.
Schiller, E. (1953). Brit. J. Industr. Med., 10, 1. on the capsular attachment towards the base of the neck.
Shapiro, R., Taylor, B., and Taubenhaus, M. (1951). Proc. Soc. exp. Biol.,
N. Y., 76, 854.
This pericapsular corona, which is part of the trochanteric
Stocks, P. (1949). General Register Office, Studies on Medical and Popula- anastomosis, gets its blood supply from the ascending
tion Subjects No. 2, Sickness in the Population of England and Wales
in 1944-47. H.M.S.O., London.
branches of the medial femoral circumflex, the superior
Vienning, E. H.. Johnson, L. G., and Rose, B. (1951). Proc. Second Clin. gluteal, the obturator, and profunda femoris arteries, as welt
A.C. T.H. Conf., 2, 49. as from small communications from the acetabular marginal
 DEC. 5, 1953 BLOOD SUPPLY OF FEMORAL HEAD BRIMSH 1237
vessels. Arteries leaving this pericapsular anastomosis enter BIBLIOGRAPHY
numerous bony foramina at the base of the femoral neck Babcock, quoted by Mercer, W. (1950). Orthopaedic Surgery. London.
Davies, D. V. (1946). Lancet, 2, 815.
and pierce small openings in the attachment of the joint Harris, H. A. (1933). Bone Growth in Health and Disease. London.
capsule. All these arteries are accompanied by a rich plexus Hunter, W. (1743). Philos. Trans., 42, 514.
Mercer, W. (1952). Practitioner, 169, 331.
of veins, which play an important part in the intravascular Ssawwin, Die Blutversorgung des Huftglenks, Chirurgya, Bd. II, S, 461.
thrombosis associated with avascular necrosis of the femoral Teacher, J. H. (1900). Catalogue of Anat. and Path. Preps. Glasgow.
Walmsley, T. (1915). J. Anat. Physiol., 49, 434.
head. Watson Jones, R. (1943). Fractures and Joint Injuries. Edinburgh.
Ontogeny Weitbrecht, J. (1742). Syndesmologia sive Historia Ligamentorum Corporis
Humani. St. Petersburg.
During the growth period the circulus articuli vasculosus is
situated on the periphery of the epiphysial plate of cartilage
and sends branches deeply to the bony epiphysis as well as
recurrent vessels to the actively growing metaphysial region HYPOOTHERMIA WITH AUTONOMIC
(Fig. 6). The marked vascularity of this juxta-epiphysial
area, compared with the adjacent diaphysial bone, is obvious BLOCK IN MAN
in injected specimens (Fig. 7). Harris (1933) pointed out that BY
these metaphysial vessels terminate in large tortuous loops JOHN W. DUNDEE, M.D., F.F.A. R.C.S.
as end-arteries-in contrast to the epiphysial vessels, which
anastomose freely. The retinacula in the growing child are' T. CECIL GRAY, M.D., F.F.A. R.C.S.
well developed, but they are shorter and more firmly attached
to the periosteum of the neck than in the adult hip-joint. (From the Department of Anaesthesia, University of
Freshly injected specimens demonstrate that the greatest Liverpool)
concentration of intra-osseous blood vessels is in the region P. R. MESHAM, M.B., Ch.B., D.A.
of Babcock's triangle. This triangle appears in antero-
posterior skiagrams as an area sparse in trabecular bone AND
situated inferiorly to the femoral head. An equally obvious W. E. B. SCOTT, M.B., B.Ch., D.A.
triangle, often obscured by the acetabular rim, is seen superi-
orly at the junction of head and neck (Fig. 8). In fact, the (From the Royal Southern Hospital, United Liverpool
whole base of the head is surrounded by this triangular Hospitals)
tunnel, which is utilized by blood vessels to supply and drain
the head of the femur. The afferent arteries to this vascular The reduction of oxygen consumption that accompanies
circle can be seen entering the subcapital bony foramina a fall in body temperature and the possibilities that
(Fig. 2). induced hypothermia opens up in the field of cardiac
Conclusions surgery and for the poor-risk patient have been the
The head and neck of the femur derive their signifi- topics of numerous recent publications (Bigelow,
cant blood supply from the pericapsular anastomosis Callaghan, and Hopps, 1950; Bigelow, Lindsay,
at the base of the neck. The vessels which pierce the Harrison, Gordon, and Greenwood, 1950; Churchill-
capsular attachment are subject to severe trauma and Davidson et al., 1953; Annotation, Brit. J. Anaesth.,
compression in dislocations of the hip-joint and in basal 1953 ; Lancet, 1953). So obvious are the advantages of a
fractures of the femoral neck. These factors, together state of affairs wherein the cellular oxygen requirements
with pressure from local haemorrhage, jeopardize the are markedly reduced that they need not be -further
vascular channels of the head of the bone. discussed.
Basal fractures of the neck of the femur in childhood In the past local hypothermia had been produced for
are frequently complicated by avascula,r necrosis of the a variety of purposes-for example, the relief of pain
head. The more firm attachment of the synovial rmem- (Bell, 1812) and the treatment of carcinoma (Arnott,
brane to the periosteum of the neck is suggested as an 1851)-but it was not until 1936 that Smith and Fay first
aetiological component for this complication. While induced generalized hypothermia as a treatment for neo-
the epiphysial plate of cartilage is present the head of plasm (Smith and Fay, 1939). These workers appre-
the femur depends on the retinacular vessels for its ciated the necessity of abolishing the body's normal
nutrition, as the consensus of reliable opinion is that reactions to cold-namely, shivering and vasoconstric-
the vessels in the ligamentum teres are immaterial for tion-to facilitate the cooling, and for this purpose they
the vitality of the head. used deep narcosis. The increase in oxygen consump-
Babcock's triangle is a common site for the early tion produced by shivering had already been noted by
manifestations of bony tuberculosis of the hip-joint in Voit in 1878, and it was not until 1916, when Krogh
children. This very vascular growing region, which is eliminated this reaction by curarization, that a fall in
subject to repeated minor traumata and has a slow rate oxygen consumption could be demonstrated at lowered
of blood flow, offers a well-protected culture bed for body temperatures (Martin, 1930).
any circulating tubercle bacilli. In 1948 McQuiston pointed out the possibility of
In transvesical adduction fractures of the femoral applying the principle to cardiac surgery in hypoxaemic
neck the superior and anterior retinacular vessels are children, and published details of 25 cases (McQuiston,
always torn, whereas the vessels in the pedunculated 1949).
postero-inferior retinaculum often escape actual rupture The term " artificial hibernation" was originally used
in their continuity but are badly distorted. This altera- by Simpson (Simpson and Herring, 1905) and later by
tion of alignment and lumen, which slows or obstructs Smith and Fay (1939) to describe the state of induced
the local circulation and may lead to eventual throm- generalized hypothermia. The recent reintroduction of
bosis and avascular necrosis, is a strong argument in the term is due in the main to the French workers
favour of early and gentle reduction of this fracture as Laborit and Huguenard (1951). They first studied
advocated by recent writers. the potentiation of anaesthesia by promethazine
(" phenergan ") and diethazine (" diparcol ") (Laborit,
I am grateful to Professor J. D. Boyd for departmental facilities,
1950), and postulated that these drugs produced
to Dr. A. M. Barrett for the post-mortem material, to Mr. J. A.
Fairfax Fozzard for the photography, and to Mr. R. Smith for a partial block of the autonomic nervous system,
technical assistance. thus diminishing the body's unfavourable reactions