Dr.

Swaminathan Manickam
At the end of this module, you should be able
to
 explain the common terms in pathology.
 explain the aetiology and pathogenesis of
diseases.
 identify and describe the pathological
features both macroscopically and
microscopically.
 correlate the pathological processes with
clinical features.
 explain the effects and complications of
diseases.
Pathology is the
scientific study of
disease.
 The word ‘Pathology’ is derived
from two Greek words:
 pathos meaning suffering, and
 logos meaning study
 Disease is opposite of health
 i.e. what is not healthy is disease

 Health is a condition when the individual is

in complete accord with the surroundings,
while

 Disease is loss of ease to the body

(dis-ease).
The functional disturbances so produced may
be mirrored by structural changes just as, in
turn, structural damage may be followed by
loss or alteration of normal function.

The sum of these effects finds expression in

the symptoms which the patient experiences
and the signs which the clinician (physician,
surgeon, doctor observes
 Aetiology
 Incidence
 Epidemiology
 Pathogenesis
 Clinical features
 Morphologic features
 Prognosis
 Treatment
 Aetiology is the cause of a disease;
i.e. the initiator of the subsequent
events resulting in the patient’s
illness.

• The causal factors responsible for the

lesions are included in etiology of
disease (‘why’ of disease)
1. Inborn
2. Acquired
1. Genetic and result from:
a. Inherited defects
b. Mutations

2. Congenital disease is present at

birth
e.g. the effects of maternal rubella
virus infection or of drugs
administered to the mother such as
thalidomide
Acquired diseases are due to
environmental causes

Acquired diseases may be due to:

1. Known causes, e.g. infective,
chemico-physical, drugs and/or
poisons
2. Unknown causes (idiopathic)
 Some Diseases are
Iatrogenic

 Iatrogenic
disease is any ill
health induced
by a medical
practitioner’s
(doctors) actions
is the incidence and population
distribution of a disease
 By pathogenesis we mean the
sequence of events from the initial
application of an injurious agent to
the final expression of the disease in
morphologic and functional terms
 Pathogenesis is the mechanism
causing the disease,

 i.e. the mechanism through which the

aetiology (cause) operates to produce
the pathological and clinical
manifestations
 E.g. Atherosclerosis of coronary arteries
 Focal arterial thickening consisting of an
admixture of proliferated connective tissue,
lipids and tissue debris; plaque may soften &
rupture; thrombosis
 Cause significant degree of stenosis of the
arterial lumen; if severe will reduce arterial
perfusion of part of the heart muscle
 Central chest pain; ventricular arrythmias;
shock; cardiac failure or sudden death. In
structural terms death (necrosis) of
underperfused muscle (myocardial infarction)
will occur
 Clinical features; signs and symptoms;
functional derangements and their
clinical significance

 The functional implications of the

lesion felt by the patient are
symptoms and those discovered by
the clinician are the physical signs
 Morphologic features; macroscopic,
microscopic

 Pathologic changes or morphology

consists of examination of diseased
tissues by gross appearance and
microscopic examination.
 Macroscopic or gross appearance is the
naked eye appearance
 Size in cm – e.g. 4x4x4 cm
 Shape - e.g. rounded, ovoid, nodular, flat
 Colour – e.g. dark, tan, yellow
 Solid, homogenous; cystic, fluid filled sac
 Photographs can be taken for record
 Specimens can be displayed in perspex
containers (pots) in pathology museum
 Microscopic appearance is the histologic
appearance ; haematoxylin & eosin stain
 Architecture; pattern, sheets, glands, clusters
 Cell size & shape – e.g. small, large or spindle
cell
 Nucleus, cytoplasm, cell membrane
 Necrosis
 Inflammatory infiltrate
Gross Microscopic
 Liver - enlarged
 Yellow
 Greasy

 Normal liver
 Liver cells show
cytoplasmic
vacuoles
 Vacuoles are of
variable sizes
Small to large
 From the diagnostic angle, it is clearly
important to know whether a given disease has
a characteristic lesion which can act as its
marker
 A ‘lesion’ refers to a morphological change in
cells or tissues, and the recognition of the
existence of lesions will obviously depend on
the degree of sophistication of the methods
used to examine the affected tissues
 Lesion is the structural or functional
abnormality responsible for ill health
 e.g. granulomatous lesion, necrotising lesion
 Prognosis forecasts the known or
likely course (outcome) of the
disease
 drugs or chemotherapy,
 surgical,
 Radiotherapy
 Physiotherapy
 Traditional and Complementary
Medicine
Some of the greatest advances in the scientific
study of disease emerged from internal
examination of the body after death.

Autopsies (necropsies or post-mortem

examinations) have been performed scientifically
from about 300 BC and have thus helped to clarify
the nature of many diseases.

As these examinations were confined initially to

the gross (rather than microscopic) examination of
the organs, this period is regarded as the era of
morbid anatomy
 When many symptoms, signs and post-
mortem findings were first believed to have
natural explanations, the underlying disease
was postulated to be due to an imbalance of
the four humours - phlegm, black bile, yellow
bile and blood - as proposed by Empedocles
(490-430 BC) and Hippocrates (c. 460-370
BC). These concepts are now obsolete.
 Galen (129-c. 200) built on Hippocrates'
naturalistic ideas about disease by giving
them an anatomical and physiological basis.

 However, it was probably Ibn Sina (980-1037)

-commonly known as Avicenna - who, by his
Canon of Medicine, pioneered advances in
medicine through scientific discovery by
observation, experimentation and clinical
trials.
 Earliest concepts of disease were
the religious beliefs that affliction
or disease was the outcome of
‘curse’ or ‘evil eye of spirits|
 Hippocrates (460-377 BC), the
great Greek clinical genius of all
times and regarded as ‘the father
of medicine’. (picture)
 Cornelius Celsus(53 BC-7 AD) first
described four cardinal signs of
inflammation - rubor (redness),
tumour (swelling), calor (heat), and
dolor (pain)
 Complications and sequelae
are the secondary, systemic
or remote consequences of a
disease
A constellation (cluster) of signs
and symptoms,
e.g.
 Down’s syndrome
 Cushing’s syndrome
 Symptoms are patient’s
complaints attributable to the
presence of a disease (e.g.
pain, malaise, nausea)
 Fatigue, weakness, tiredness
 Difficulty in breathing,
swallowing
 Signs are the observable
manifestations of a disease
(e.g. swelling, fever, abnormal heart
sounds)
 That which the doctor observes or
elicits
e.g. pallor, cyanosis, redness, heat,
tenderness, pitting oedema of the
ankle or leg
◦Inspection
◦Palpation
◦Percussion
◦Auscultation
 Diagnosis is the act of naming a
disease in an individual patient

 Provisional or Clinical diagnosis

 Differential diagnosis
 Specimen: blood, urine, stools, sputum,
tissue fluid
 Cytology smear, microbiology culture
 ECG, EMG, EEG
 Tissue biopsy (histopathologic specimen)
diagnosis
 Radiologic diagnosis (imaging) -Xray,
Ultrasound, Computerised Tomography
(CT), Magnetic resonance imaging (MRI)
 Pathology is best learnt in
two stages
 General Pathology (Disease
mechanisms)

 Systemic pathology
 The causation, mechanisms and
characteristics of the major categories of
disease are the foundations of pathology.

 Many specific diseases are mentioned by way

of illustration. Ideally, the principles of
disease causation and mechanisms should be
understood before attempting to study
systematic pathology.
 General pathology is about the mechanisms and
characteristics of the principal types of disease process (e.g.
congenital versus acquired diseases, inflammation,,
degenerations)

 The study of the reaction patterns (pathologic changes

occurring) in cells and tissues to a wide range of unfavourable
circumstances. The tissue is composed of parenchymal cells
and interstitial connective tissue and is the prototype of every
tissue in the body

 General pathology explores and explains the development of

basic pathologic mechanisms without detailing the additional
specific changes occurring in different organs
 Systemic pathology is about the descriptions of
specific diseases as they affect individual organs or
organ systems (e.g. appendicitis, lung cancer,
atheroma)

 The pathologic mechanisms discussed in the

general pathology section are related to the various
organ systems

 In each system, normal structure, function, and the

symptoms and signs that arise from pathologic
changes are discussed first

 The diseases in each organ system are then

considered, with emphasis given to those that are
more common, so that students can become
familiar with most of the important diseases
 encountered in clinical practice
 Systematic pathology is our current
knowledge of specific diseases as they affect
individual organs or systems.

 Each specific disease can usually be

attributed to the operation of one or more
causes and mechanisms featuring in general
pathology.
 Thus, acute appendicitis is acute
inflammation affecting the appendix;

 carcinoma of the lung is the result of

carcinogenic agents acting upon cells in the
lung, and the behaviour of the cancerous
cells thus formed follows the pattern
established for malignant tumours;
and so on.
 the term pathology is used in a
narrower sense to denote that
speciality of medicine concerned with
the performance and interpretation of
laboratory procedures

 There are many divisions of pathology

 The end product of a pathologic procedure is a
pathology report that contains the result of the
procedure
 This may be a number (in chemical tests) the
name of a microorganism (in microbiology), or a
diagnosis based on the microscopic features of a
tissue section (in surgical pathology)
 Interaction with the laboratory in terms of
ordering the most appropriate laboratory
procedures and being able to interpret the
pathology report correctly is a vital part of the
 training of all physicians and dental surgeons
 Subdivisions of clinical pathology
 Pathology in practice has major subdivisions:
 • histopathology: the investigation and diagnosis
of disease from the examination of tissues
 • cytopathology: the investigation and diagnosis
of disease from the examination of isolated cells
 • haematology: the study of disorders of the
cellular and coagulable components of blood
 • microbiology: the study of infectious diseases
and the organisms responsible for them
 • immunology: the study of the specific defence
mechanisms of the body
 • chemical pathology: the study and
diagnosis of disease from the chemical
changes in tissues and fluids
 • genetics: the study of abnormal
chromosomes and genes
 • toxicology: the study of the effects of
known or suspected poisons
 • forensic pathology: the use of pathology for
legal purposes (e.g. investigation of death in
suspicious circumstances).
 Our growing knowledge of the nature and
causation of disease has emerged from applied
advances in technology.

 Gross Pathology
 Light Microscopy
 Histochemistry
 Immunohistochemistry and Immunofluorescence
 Electron Microscopy
 Biochemical Techniques
(continued)
 Haematological techniques
 Cell cultures
 Medical microbiology
 Molecular pathology
 is the identification of the causes of
disease.
 This fundamental objective leads to
successful therapy and to disease
prevention.
 Without pathology, the practice of
medicine would still rely on myths and
folklore.
 There are two difficulties commonly facing
new students of pathology: language and
process. Pathology, like most branches of
science and medicine, has its own vocabulary
of special terms. These need to be learnt and
understood not just because they are the
language of pathology: they are also a major
part of the language of clinical practice.
By: Anushia d/o Swaminathan
◦ The processes of histological techniques:
tissue fixation
tissue processing
tissue embedding
tissue sectioning
tissue staining with H&E

TISSUE SLIDE
1) Tissue removal 2) Fixation

4) Staining

3) Paraffin blocking
 TISSUES => autopsies, biopsies, whole organs

 LOGGING => book/computer & identification number

 GROSSING => cut into smaller size

 FIXATION => soak tissues in fixative

 DEHYDRATION => soak in alcohol to remove water

 CLEARING => xylene to clear alcohol

 INFILTRATION/ => xylene flows out & paraffin wax flows in

IMPREGNATION
 EMBEDDING => put tissue in molten paraffin wax

 ORIENTATION=> positioning the tissue

 TRIMMING => remove excess paraffin on tissue

block

 SECTIONING => use microtome to cut tissues into

thin slices

 FISHING => stick sections on slide

 DRYING => dry sections in the oven

 STAINING => dyeing the sections

 MOUNTING => stick coverslip on sections

 LABELLING => stick/write label on the slides

• Laboratory receives specimens in the form of:
• autopsies, biopsies, whole organ.

• Small biopsies specimens are placed in fixative

solution - protect from drying.

• Large surgical specimens may arrive unfixed in plastic bags/

saline moistened towels - kept in refrigerator (will slow
down autolysis) - until examined by the pathologist.

• Mailing specimens - fixed before mailing.

 • The MLT receive the specimen

• Record the identification no.

• Use tag & attach to specimen

• Record identification no. in laboratory register

• Sketch of specimen - outline only - helpful in tracking

• Transfer the specimens with identification tags into small

container with fresh fixative

Bone & calcified tissues - cut into small blocks with a saw -
they need decalcification (hydrochloric acid)
 Purpose of fixation

 Types of fixatives

 Application to various staining methods

 To prevent the process of autolysis (self destruction) &

putrefaction (bacterial attack).

 To be as close as possible to their living state

to retain shape/volume & preserve tissue substances &

proteins.

 To harden & protect the tissue from subsequent treatment.

 To aid staining reactions.

 Fixation is done twice :
a) initial fixation - large amount of tissues/organ
involved.
b) re- fixing done in histology lab - should be cut
thin (3-5 mm thick) - to facilitate penetration in
a short time 3-5 hrs.

 Volume of fixative:
– 15-20 times the volume of tissue block.

 Minute specimens should be wrapped:

- use cigarette paper/lens paper.
- to avoid losing specimen during tissue processing.
 Preservation of cellular detail.

 Rate of penetration.

 Amount of shrinkage/swelling.

 Staining methods to be used.

1)Aldehydes (crosslinking -Formalin
fixatives) -bind chemically to -Glutaraldehyde
protein molecules at≥1 points; -Paraformaldehyde
forming chemical bridges between
protein chains
2)Alcohols (precipitating -95% ethanol
fixatives) -change the -100% methanol
shape/structure of protein -Carnoy’s fixative
molecules without binding to them
3)Picrates -Bouin’s fixative
4)Mercurials -Zenker’s fixative
-Helly’s fixative
5)Oxidising agents -Osmium tetroxide
-Dichromate
-Permanganate
Fixative solutions Vapour fixation Fixative for 1µ
sections & EM
10% formaline Formaldehyde Glutaraldehyde
Zenker’s fixative Osmium tetroxide
Helly’s fixative Paraformaldehyde
Carnoy’s fixative
Bouin’s fixative
 Most common fixative used.
 Pure formaldehyde is a vapour.
 When completely dissolved in water forms a solution
containing 37-40% formaldehyde (“formalin”).

 The usual ‘10% formalin’ used in fixation of tissues is a

10% solution of formalin:
Formalin (37% Formaldehyde) 100 mL
Sodium chloride 9g
Distilled water 900 mL

 10% neutral buffered form (NBF).

 Irritant to respiratory epithelium & eyes.
To prepare 1 litre:

 Distilled water (900 mL)

 Formalin (37% formaldehyde solution) (100 mL)
 Sodium phosphate, monobasic, monohydrate (4 g)
 Sodium phosphate, dibasic anhydrous (6.5 g)

 pH 7.2-7.4
 MOA:-fixes proteins by complex cross-linking.

 Formalin penetrates tissue well, but is relatively slow.

 A buffer (10% NBF) prevents acidity that would:

promote autolysis &
cause precipitation of formol-heme pigment in the
tissues.

 Unbuffered formalin fixativesbrown pigments:

◦ in contact with blood-containing tissues.
 Osmolarity

pH Size of
specimen

Time interval Factors involved

Volume of
from removal in fixative fixative
to fixation
preparation

Penetration
Temperature
rate

Duration
 Poor microtomy.

 Loss of nuclear detail.

 Irregular holes.

 Poor staining.

 Symptoms worst in the middle of the tissue.