Objective-To study the impact of skin surgery in general practice on the workload of a pathology laboratory and to identify what further training might be helpful.Design-Analysis of skin biopsy specimens from general practitioners before and after their new contract to determine numbers of specimens, changes in diagnoses, adequacy of treatment of malignant tumours, and areas of low diagnostic accuracy.

A 40-year-old woman developed a persistent pruritus with erythema of the head and upper trunk, which started within 2 weeks of a hydroxyethylstarch (HES) infusion and was still present 2 years later. Histological examination demonstrated a striking dermal infiltrate of KP1-positive foamy macrophages which had electron-lucent vacuoles. The timing of the onset, the body site distribution, the exclusion of other possibilities and an appropriate history of high dosage HES infusion, suggested that this was the cause of the eruption. Staining with periodic acid-Schiff (PAS) surprisingly was negative but we could not stain HES in vitro with this histochemical stain, and we postulate that the unique extent of the infiltrate and the negative PAS stain in our patient may indicate an impaired ability to degrade this chemical. This may be an important factor in the poorly understood pathogenesis of persistent pruritus induced by HES.

Summary A case of toxoplasma hepatitis presenting with cholestatic jaundice is described. The diagnosis was based on serological testing and evidence of hepatitis on biopsy.

SUMMARY We present a case of Jaccoud's arthropathy in a 59-year-old woman. She developed painless correctable ulnar deviation at the metacarpophalangeal joints of both hands following 4 attacks of rheumatic fever. Radiology did not show the hook lesions previously described, but we do not consider this sign essential for the diagnosis. There was no clinical evidence of rheumatoid arthritis. We were able to examine 3 complete joints from the left little finger at necropsy. Pathological examination of this kind has been possible only once before. The histological findings were fibrous thickening of the joint capsule, secondary degenerative changes, presumably due to longstanding joint deformity, and no evidence of significant synovial pathology.The relationship between chronic valvular heart disease and chronic deforming arthritis is of great interest. Among the least common is the chronic post-rheumatic fever arthritis of Jaccoud (1869).It is important to make the correct diagnosis to reassure the patient of the benign nature of the arthritis, and to avoid subjecting him to unnecessary treatment with anti-rheumatic drugs. These interfere with control of the concomitant anti-coagulant therapy in patients with atrial fibrillation from severe rheumatic heart disease, as well as having toxic effects in their own right. Only 1 patient with classical clinical features of this condition has hitherto come to necropsy. We, therefore, present the second case of Jaccoud's arthropathy, who came to necropsy. Case reportThe proposita, a housewife, born November 10, 1910 presented at the age of 60 with severe exertional dyspnoea, orthopnoea, and ankle swelling. She gave a history of recurrent attacks of rheumatic fever at the ages of 11, 14, 17, and 37. At the age of 44 she became breathless on exertion. Her mother had crippling arthritis.On examination she had a malar flush and was cyanosed. There was ankle oedema. In the cardiovascular system the pulse showed atrial fibrillation and the jugular venous pressure was elevated. The heart was enlarged and there was evidence of mitral stenosis and incompetence, namely a loud pansystolic murmur, a moderately loud opening snap, and a long, loud mitral diastolic murmur.Chest x-ray showed considerable cardiac enlargement, an enlarged left atrium, pulmonary congestion, and marked right ventricular prominence. In the electrocardiogram there was evidence of atrial fibrillation and the effects of digitalis therapy. Right and left heart catheterisation confirmed (1) mitral stenosis and incompetence and suggested (2) recent pulmonary emboli and (3) minimal aortic valve disease.Two years later she was referred to the Rheumatology Department at St. George's Hospital because of stiffness and ulnar deviation of her fingers.The following additional history was elicited. She had noticed ulnar deviation of the fingers following the third attack of rheumatic fever at the age of 17. At the age of 50 she had developed intermittent pain of the wrists, hands and feet with swelling of the metacarpophalan...

Sudden cardiac death can usually be resolved by the pathologist into ischaemic heart disease, non-vascular cardiac disease such as aortic stenosis or hypertrophic obstructive cardiomyopathy and infrequently a morphologically normal heart on naked eye examination. When ischaemic heart disease is present one third of cases have a recent occlusive coronary artery thrombosis. Two thirds of patients have coronary stenosis only; the minimum degree of disease reasonably associated with sudden death is one area of 85% stenosis. The majority of patients, however, have multiple areas of stenosis. The predominant causes of non-ischaemic sudden death are severe LV hypertrophy, hypertrophic obstructive cardiomyopathy and the prolapsing mitral valve syndrome. Where the heart and coronary arteries are morphologically normal, review of any previous ECG's, a family history and histological examination of the myocardium and conduction system may reveal a cause or at least allow a reasonable assumption of cardiac arrhythmia to be made. Sudden unexpected death where the circumstances strongly suggest a cardiac cause may pose problems for the pathologist. Ischaemic heart disease (coronary atherosclerosis) is undoubtedly the most frequent cause but even when this is so the detailed pathology is controversial. It is when coronary artery disease is conspicuously absent, often in young individuals previously in good health, that a problem exists. Sudden death in infancy (cot death) is a different entity with its own problems and is not here discussed further.