Autopsy
The application of medicine in the administration of
Historical Overview
Anatomical Dissection
The knowledge of the early history of human
anatomy is scanty and the possibility to dissect human
bodies varied greatly at times. Very early Indian
medical literature indicates a knowledge of anatomy
that may have been acquired by dissecting bodies of
young children as the Hindu scriptures enjoined that
bodies of persons more than two years old had to be
burned [1].
The first known school of anatomy was in Alexan-
dria around 320 B.C., where human dissections were
carried out by famous anatomists, such as Herophilus
of Chalcedon (335–280 B.C.) and Erasistratus of
Iulis (c. 310–250 B.C.) to determine the normal
structure of organs and the changes made by dis-
ease [2].
According to several reports, occasional “autop-
sies” were performed already in the twelfth and thir-
teenth centuries. The English chronicle by William
of Malmesbury (c. 1080/1095-c.1143) mentions one
ordered by the Norwegian King Sigurd Jorsalfar
(1090–1130) in 1111, while stopping in Byzantium
(present Istanbul) on his return from Jerusalem, to
find out whether the cause of death of many of his fol-
lowers had been liver damage by too strong wine [3].
In 1391, King John I of Aragon gave the Uni-
versity of Lérida in Spain the permission to dissect,
once every 3 years, the body of a criminal. In Vienna
the first anatomical dissection took place in 1404, in
Prague somewhat later in 1460 and at the University
of Paris in 1478 [4].
The first known postmortem examination on the
American continent was performed in Hispaniola in
1533 and recorded by Fernandez de Oviedo in his
General and Natural History of the Indies [5].
The publication of the great textbook of anatomy
De Humani Corporis Fabrica in 1543 by Andreas
Vesalius (1514–1564), the “father of anatomy”,
marked the beginning of an overthrow of traditional
Galenic anatomy and theories, although it took more
than 300 years until the new concepts of pathogene-
sis of diseases and cellular pathology started to take
over from the old school of thought.
Medicolegal Autopsy
justice began long before medicine started to develop
into a modern science. The medicolegal investigation
of deaths was introduced very early from the require-
ments of the judicial system as it was of interest to
the society to know whether a person had died as a
result of violence or due to natural causes. The oldest
known instructions by the authorities about external
examination of corpses have been found in China
and dated to the Ching dynasty (∼2000 B.C.). Dur-
ing Song dynasty (960–1279 A.D.), a decree enacted
in 995 A.D., provided that a government official,
though not a physician, had to investigate a violent
or otherwise suspicious death within four hours. It is
not known whether autopsies were ever performed in
ancient China [6].
The earliest medicolegal autopsies took place in
Italy, probably in the middle of the thirteenth century,
at the University of Bologna. One was recorded by
Guglielmo de Placentinus Saliceto, or by William
of Saliceto (1210–1276 or 1277), a surgeon and a
teacher, on the medical faculty there and is mentioned
in his book Surgery [7]. Whether this really was an
autopsy or just an external examination of the corpse,
is questionable. Some authors have attributed the first
medicolegal autopsy to Bartolomeo da Varignana,
who, in addition to his professional and academic
activities, served the municipality of Bologna in
a medicolegal capacity. The public prosecutor had
ordered an autopsy in 1302 in a case suspected of
having died due to poisoning [8, 9].
According to O’Neill, medical historians have
long agreed that the fundamental motive for the
initiation of academic dissections in Western Europe
was forensic. The decretals of Pope Innocent III
contain several cases in which such examinations had
provided the evidential basis for a papal verdict [8].
In Europe the principles of medicolegal investiga-
tion of deaths were developed on the basis of the
criminal codes of the sixteenth century: the Bam-
berg Code in 1507, compiled by Johann Freiherr von
Schwarzenberg and which was soon adopted by a
number of other German states. These along with
the best known criminal statutes in Europe, Constitu-
tio Criminalis Carolina, the Caroline Code of 1532,
obliged the courts to use medical expertise in certain
medicolegal issues such as abortion, bodily harm,
homicide, or medical malpractice.
2 Autopsy

The “father of the Swiss legal medicine” Felix

Platter I (1536–1614) from Basle has been said to
have performed more than 300 autopsies. In France
the first medicolegal autopsy was performed by
Ambroise Paré (1510–1590) in 1562. The autopsy
of King Stephen Báthory of Poland in 1586 was
probably the first one performed in the Eastern
Europe [10].
Our knowledge about the old autopsy procedures
is poor and, apart from a few exceptions, detailed
written autopsy reports are relatively recent.
In addition to codification of the principles of
medicolegal investigations, some countries went fur-
ther providing detailed instructions as to the per-
formance of medicolegal autopsy. By far the best
example of this is the Austrian decree of 1855.
The objective of medicolegal investigation of the
deceased and the duty of medicolegal expert has
probably never been defined with such brevity and
clarity than in Section 1 of the Austrian decree. It is Figure 1 Front-page of the Austrian decree on medicole-
noteworthy that it is still valid legislation in Austria. gal investigation of corpses January 28, 1855
“The medicolegal examination of the deceased is
of great importance and therefore it is an imperative However, hospital or clinical autopsy became
duty of the expert, that the examination must be meaningful first after the introduction of modern
carried out with utmost accuracy, as very often, concepts of pathogenesis of diseases by Carl von
the honor, freedom, property, and life of the person Rokitansky (1804–1878) and cellular pathology by
accused of a criminal act, as well as the rule of law, Rudolf Virchow (1821–1902).
depend upon it”. (Authors’ translation of Section 1 Gradually in the beginning of the nineteenth
of the Austrian decree on medicolegal examination century increased attention was paid to the actual
of corpses from January 28, 1855, Figure 1.) autopsy technique. In 1846 Rudolf Virchow, then
The decree gives detailed instructions in 134 para- prosecutor in Berlin, insisted on regularity, method,
graphs for the performance of medicolegal autopsy. and definitive technique. The classical techniques,
The Prussian edict of 1875 is similar but not as which are still in use today are, more or less
detailed as the Austrian one and both of them can, modifications of those introduced by Rokitansky
so far, be considered as the culminating point of leg- (organs are dissected in situ), Virchow (organs are
islation dealing with the performance of medicolegal removed one by one), Ghon (thoracic and cervical
autopsy. organs, abdominal organs, and urogenital system
are removed as organ blocks) and Letulle (cervical,
thoracic, abdominal, and pelvic organs are removed
Clinical Autopsy as one organ block), among others [11].
In 1872 Francis Delafield’s A Handbook of Post-
Early attempts to solve medical problems through mortem Examination and Morbid Anatomy was pub-
autopsies can be found already in the Middle Ages lished in New York and German and English editions
e.g., in the chronicle of Fra Salimbene. He referred of Rudolf Virchow’s book on autopsy technique were
in his description to one dissection performed by an published in 1876.
unnamed Cremonese physician, of a victim of the
malady that swept through the cities of Northern Italy The Present Autopsy
in 1286. Similarly, victims of bubonic plague had
been dissected in Perugia during the outbreak of an There is considerable variation in the types and stan-
epidemic in 1348 [8]. dards of medicolegal systems throughout the world

from nonexistent to well-functioning organizations
with sophisticated autopsy practices. Generally the
lack of forensic and medicolegal services is a char-
acteristic of developing countries, usually including a
poor judiciary and educational system, but the aware-
ness of the importance of high standard medicolegal
autopsy for the protection of individual rights varies
a lot even in industrialized countries due to historical
and/or political reasons.
Most countries have not provided laws to regulate
the actual performance of medicolegal autopsies.
There exist both international recommendations and
national guidelines by the competent authorities or
professional bodies such as the Royal College of
Pathologists in the United Kingdom or minimum
standards by individual forensic institutes.
Various international bodies have been interested
in achieving harmonized and internationally recog-
nized rules concerning the performance of medicole-
gal autopsies. In Europe the “Sevilla Working Party
on the Harmonization and Standardization of Foren-
sic Medicine (SWP)” was established in 1985 by
Professor Luis Frontela Carrerras of Seville, Spain,
carrying out groundwork and collaborating with the
Council of Europe to create minimum standards for
autopsy protocols. The Minnesota Lawyers Interna-
tional Human Rights Committee had taken the initia-
tive to draft international standards for the investiga-
tion of suspicious deaths, including autopsy. In May
1989, UN Economic and Social Council adopted in
its resolution 1989/1965 “the Principles on the Effec-
tive Prevention and Investigation of Extralegal, Arbi-
trary, and Summary Executions”, which had been
created by cooperation with intergovernmental and
nongovernmental organizations. In 1991, the General
Assembly of the United Nations endorsed the Model
Autopsy Protocol of the United Nations. SWP’s work
was continued by the European Council of Legal
Medicine (ECLM), whose document “Harmonisation
of the Performance of the Medicolegal Autopsy” was
adopted by the General Assembly in London in 1995
and which largely served as basis for the Pan Euro-
pean, Council of Europe – Recommendation No.
R (99) 3 On the Harmonisation of Medico-Legal
Autopsy Rules and Its Explanatory Memorandum,
which was adopted by the Committee of Ministers
in February 1999 [12].
In spite of the invention of new medical imaging
techniques such as computed tomography (CT), mul-
tislice computed tomography (MSCT), or magnetic
Autopsy 3
resonance imaging (MRI) clinical autopsy has been
shown to have maintained its clinical, educational,
and epidemiological value and remained an essential
factor in the quality assurance of medical care [13]. In
spite of this, there has been a progressive decline in
autopsy rates in recent decades in most industrialized
countries on all continents [14–16].
In 1971, the Joint Commission on Accreditation
of Hospitals (JCAH) in the United States ended its
requirement for minimum rates of autopsy for certifi-
cation. Until then, a mandatory 20% autopsy rate had
been required for accreditation of postgraduate train-
ing. The idea had been that each institution should
set its own rate but the dropped requirement seems
to have had a negative impact on autopsy rates and,
according to an estimate, the national autopsy rate
of nonforensic deaths may have fallen roughly to
5% [17].
There are several reasons for this decline and
the emphasis of contributing factors varies according
to the country. Clinicians may be too reliant on
the new diagnostic techniques and poorly motivated
to obtain consent from the relatives to perform
an autopsy. Pathologists are less enthusiastic, and
owing to low autopsy rates, less experienced to
perform autopsies and this task is often delegated to
inexperienced trainees. Further factors that probably
have contributed to the decline of autopsies are
fear of malpractice litigation, if errors in clinical
judgment are detected, and cost-cutting pressures,
when autopsies do not produce income [18, 19].
Objectives of Autopsy
Autopsy is a detailed systematic external and internal
examination of a corpse carried out by a pathologist
or one or more medicolegal experts to ascertain
the underlying and possible contributing causes of
death and, depending on the jurisdiction, also the
manner of death. Before the pathologist can begin
the examination, he must be sure that he has been
authorized to perform the autopsy on that particular
body. As infection risks are common in mortuary
and autopsy may involve also other risks, such as
electrical, chemical, and radiological hazards, these
must be assessed and necessary health and safety
precautions taken. The autopsy and all ancillary
investigations must be carried out in compliance
with the relevant legislation and possible national
4 Autopsy
guidelines in a manner consistent with medical ethics
and respecting the dignity of the deceased.
An autopsy is performed to achieve one or more
of the following objectives:
• to identify or record characteristics that may assist
in identifying the deceased;
• to determine the cause of death or, in the new-
born, whether live birth occurred;
• to determine the mode of dying and time of death,
where necessary and possible;
• to demonstrate all external and internal abnormal-
ities, malformations, and diseases;
• to detect, describe, and record any external and
internal injuries;
• to obtain samples for any ancillary investigations;
• to obtain photographs or retain samples for evi-
dential or teaching use;
• to provide a full written report and expert inter-
pretation of the findings; and
• to restore the body to the best possible cosmetic
condition before the release.
In addition to the anatomical dissection, there are
basically two main types of autopsy and, although
in principle, a single standard should be applicable
to all autopsy examinations, this is not the case in
practice, owing to different traditions and structures
in education of medical specialists and wide variation
in autopsy practices, from partial autopsy to full
examination of all body cavities including ancillary
investigations such as histology of all major organs,
depending on the country and jurisdiction.
The clinical or hospital autopsy must, in most
jurisdictions, be consented by the deceased person,
before death, or the next of kin after death. It is
usually performed to investigate details of a known
disease process, e.g., the exact type or spread of a
malignant disease or the effectiveness of therapy. It
can also be performed for medical audit or research
purposes.
The medicolegal or forensic autopsy necessitates,
owing to legal issues involved, the highest possible
standards of practice. It is ordered by the compe-
tent legal authority (a coroner, a medical examiner, a
procurator fiscal, a magistrate, a judge, or the police)
to investigate sudden unexpected, suspicious, unnat-
ural, or criminal deaths. Also unidentified bodies or
deaths occurring in special circumstances such as
deaths in police custody or during imprisonment are
often subjected to a medicolegal autopsy. In most
jurisdictions, permission of the next of kin is not
required [20–22].
Autopsy Techniques
The basic technique of autopsy has remained the
same since 1850s but various imaging techniques
such as CT, MSCT, MRI, percutaneous needle biop-
sies, or endoscopic techniques have been applied,
either for preautopsy screening purposes, or as so
called “minimally invasive autopsy” if full autopsy
is not possible.
Both clinical and medicolegal autopsy may
involve different strategies and techniques depending
on the questions they are expected to answer and
pediatric autopsy technique is generally somewhat
different from the one in adults. The Royal College
of Pathologists (the United Kingdom) has published
a set of Guidelines on Autopsy Practice and
scenarios for specific types of death, to facilitate the
improvement of the standards of autopsy performance
and reporting [23].
The scope of medicolegal autopsy is often broader
than that of clinical autopsy, with special emphasis
on all information concerning the circumstances of
death, often necessitating a visit to and investigation
of the scene of death. Both types of autopsies should
consist of full external and internal examination of
the body including the dissection and investigation
of all three body cavities.
The External Examination
In medicolegal autopsy, the examination of the cloth-
ing is often an essential part of the external examina-
tion, whereas in clinical autopsy it is generally not.
The description of the body includes age, sex,
build, height, ethnic group and weight, nutritional
state, color of the skin as well as other characteristics
of the deceased including color of irises and sclerae,
presence or absence of petechiae; color, length,
density and distribution of hair, or any abnormalities
such as scars or tattoos. All injuries must be described
in detail, measured, and photographed. Postmortem
changes relating to rigor mortis, hypostasis, and
decomposition should be described in detail. The
examination should be carried out carefully and
systematically and include head, neck, trunk, upper
and lower extremities, and the back and description
of all body orifices.

The Internal Examination
The state of body cavities includes the description of
the presence of gas (pneumothorax), fluids (effusions
or exudates), or foreign bodies and the measurement
of their volume, appearance of the internal surfaces,
and anatomical boundaries as well as location and
external appearance of organs.
The classical autopsy techniques vary mainly in
the order in which the organs are removed. All organs
have to be dissected, the outer appearance as well as
the cut surfaces described and weights recorded. The
hollow organs have to be opened and their content
described and measured. All relevant vessels, arteries
and veins as well as ducts have to be dissected.
All abnormalities must be described by location and
size.
Ancillary Investigations
Many pathological processes are not visible to the
naked eye, therefore, postmortem histology is nec-
essary and of great value, not only in confirming
but also for excluding any pathological changes in
a cause of death investigation. As a rule, com-
plete histological examination of all major organs
is considered an essential part of every postmortem
and this principle has been adopted by many
guidelines.
The need for other ancillary investigations
depends on whether the cause of death has been
established with the necessary degree of certainty,
and if not, additional samples may have to be
taken for toxicological or other investigations such
as bacteriology and virology. For toxicology this
may include peripheral blood, vitreous humor,
cerebrospinal fluid, bile, hair samples, or other
relevant tissues. Depending on jurisdiction, whenever
the results of ancillary investigations are subject to a
criminal investigation and may be used as evidence
in a court of law, it may be necessary to prove
that there has been an unbroken chain of evidence
from sampling through tests to trial. Also possible
restrictions owing to national legislation must be
considered, when retaining tissues at autopsy.
Sometimes special procedures and modifications
of normal dissection techniques are necessary. Imag-
ing techniques or conventional X-ray should be per-
formed before autopsy, if there is suspicion of e.g.,
air embolism, nonaccidental injury in children, or a
Autopsy 5
death involving firearms or explosives. Where neck
trauma is suspected, the brain and the organs of the
chest cavity have to be removed prior to the dissec-
tion of the neck, to drain the blood from the area
to avoid artifactual bleeding. Postoperative autop-
sies may present various problems with medicolegal
implications, such as complications of anesthesia,
surgical intervention, or postoperative care. However,
detailed description of these special dissection pro-
cedures and techniques is beyond the scope of this
presentation.
Autopsy Report
The report is an essential part of the autopsy, but its
structure may vary according to the type of autopsy
and sometimes may be limited to a list of postmortem
diagnoses and conclusions as to the causes of death
in the case of a hospital autopsy.
Medicolegal autopsy reports are usually more
detailed and structured consisting of a preamble with
personal particulars of the deceased, with the date,
time, and place of the autopsy as well as the personal
data and qualifications of the pathologist and other
relevant information to the circumstances concerning
the autopsy, summary of the background information
about the deceased, findings of the external, internal
and supplementary investigations as well as commen-
tary and conclusions with the causes of death and
also manner of death depending on the jurisdiction
(usually within noncoronial/medical examiner type of
medicolegal systems). The report should be unam-
biguous, comprehensive, and intelligible also to the
nonmedical reader. In addition to the factual, posi-
tive and negative gross, microscopical and analytical
findings, the pathologist should conclude with a dis-
cussion of the significance of the findings. Where the
findings are of uncertain nature and there are several
competing causes, the pathologist should try to give
an opinion as to their probability.
References
[1] Ó Neill, Y. V., Sushruta Samhita (The Compendium of
Sushruta). The Lancet (1912). 180(4650), 1025–1026.
[2] King, L.S. & Meehan, M.C. (1973). A history of
the autopsy. A review, American Journal of Pathology
73(2), 514–544.
[3] Grøn, F. (1934). Lot Sigurd Jorsalfar en av sine menn
obdusere i Bysans? Norsk Magasin for Lægevidenskaben
95, 1405–1418.
6 Autopsy
[4] Rabl, R. (1952). Die Wertung der Sektionen im Wandel
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[5] Jimenez, F.A. (1978). The first autopsy in the New
World, Bulletin of the New York Academy of Medicine
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[6] Tz’u, S. (1981). The Washing Away of Wrongs, The
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[7] Cunha, F. (1941). William of Saliceto – The School of
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[8] O’Neill, Y.V. (1976). Innocent III and the evolution of
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[9] Siraisi, N.G. (1977). Taddeo Alderotti and Bartolomeo
da varignana on the nature of medical learning, Isis
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[10] Maksymowicz, K. (2008). Forensic medicine in Poland,
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eds, Schmidt-Römhild, Lübeck.
[11] Ludvig, J. (2002). Principles of autopsy techniques,
immediate and restricted autopsies and other special
procedures, in Handbook of Autopsy Practice, J. Ludvig,
ed, Humana Press, Totowa, p. 592.
[12] Nancy, G. Siraisi (2000). Council of Europe, Recom-
mendation no. R (99) 3 of the Committee of Ministers
to member states on the harmonization of medico-legal
autopsy rules. Forensic Sci Int, 111(1–3), 5–58.
[13] Burton, J.L. & Underwood, J. (2007). Clinical, edu-
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[14] Svendsen, E. & Hill, R.B. (1987). Autopsy legislation
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[18] Yesner, R. (1986). Quality assessment of the autopsy,
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[19] Hasson, J. & Schneiderman, H. (1995). Autopsy training
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[20] Saukko, P. & Pollak, S. (2000). Postmortem exami-
nation: procedures and standards, in Encyclopedia of
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[21] Saukko, P. & Knight, B. (2004). Knight’s Forensic
Pathology, Edward Arnold, London.
[22] Saukko, P. & Pollak, S. (2005). AUTOPSY, procedures
and standards, Encyclopedia of Forensic and Legal
Medicine, Elsevier, Oxford, p. 166.
[23] The Royal College of Pathologists (2002). Guidelines
on Autopsy Practice, The Royal College of Pathologists,
London, p. 34.
Further Reading
Lu, G.D. & Needham, J. (1988). A history of forensic medicine
in China, Medical History 32(4), 357–400.
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PEKKA J. SAUKKO AND STEFAN POLLAK