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Case of Indirect Fracture of the Right Patella and Direct Fracture of the Left Patella

Dr. F. PARKES WEBER: In both Dr. Batty Shaw's cases, the one shown to-night and the one described by Mr. Higham Cooper and himself in the Transactions of the Clinical Society of London (1907, xl, p. 259), the bone changes (as far as they can be revealed by Rontgen rays) are so unlike those which occur in typical cases of " Pulmonary Hypertrophic Osteo-arthropatby" that, in spite of Dr. Batty Shaw's very clear explanation of his views, I would not admit either of the cases under that heading. I venture to suggest that both the cases are examples of a previously undescribed bony change (an " osteopathy"), in some way causally connected with congenital malformation of the heart and the secondary circulatory conditions and polycythaemia associated with it. I have, however, seen several adult patients with congenital malformation of the heart and chronic cyanosis (as in Dr. Batty Shaw's two patients) in whom no obvious changes in their bones were noted. It would be, perhaps, also advisable to take the Wassermann reaction in the patient shown to-night, because the appearance of his legs somewhat suggests the symmetrical change in the tibite which sometimes (though rarely) occurs as a late phenomenon in cases of congenital syphilis and which has been termed the "osteitis deformans "of inherited syphilis on account of its resemblance to Paget's osteitis deformans.1