The How of The Forensic Autopsy

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What Is Postmortem Pathology: Why and How We Do It

M Flomenbaum, MD, PhD, Deputy Chief Medical Examiner, Maine, USA
2014 Elsevier Inc. All rights reserved.
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Introduction
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This section addresses issues concerned with the diagnoses of

pathological conditions after death. If the person was a patient
in a hospital who died of natural causes (more on cause and
manner of death later), the usual route for a pathological
investigation would be an autopsy, performed in the hospital
by a hospital pathologist. If the person died unexpectedly,
outside of the hospital, or from underlying causes other than
natural disease, ideally an autopsy would be done under the
auspices of a medical examiner or coroners pathologist. These
cases often involve more than just medical investigation and
are often done in conjunction with investigations of the circumstances surrounding the death. Because of the greater
impact on society at large (compared to the more patientspecific hospital autopsy) these cases are referred to as
forensic (dealing with public issues) autopsies and are performed preferably by pathologists with special training in this
field, that is, forensic pathologists.
This article explains the need for pathological investigation
after death, why and how we do autopsies, and discusses
definitions needed to understand the concepts and contexts
of where this practice sits within the field of postmortem
pathology and death investigation. Other chapters in this
section address more specific details of how and why those
investigations are done.
enough to support another persons life. After the organs

cease to function, some tissues may still be viable, again, even
well enough to function properly in another person. And some
cell types, especially fibroblasts, stem cells, or some derivatives
of tumor lines may last well beyond the life expectancy of the
living person from whom they were obtained. Although DNA
may never be considered to be a living molecule, it certainly is
capable of directing lifes functions, and may someday become
available for this purpose, obtained from organisms that died
recently or even millennia ago.
The term postmortem means after death. The postmortem
interval refers to the amount of time elapsed between when
death occurred until a given study or event begins.
Determining the Cause of Death
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Definitions of Death
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In most medical contexts, the time that a patient may be

declared dead is after he or she has sustained either irreversible
cessation of circulatory or respiratory functions (cardiopulmonary arrest) or irreversible cessation of all functions of
the entire brain, including the brainstem (brain death). In
legal arenas, especially for civil matters, the time of death is
defined as the moment of pronouncement as stated on a valid
death certificate.
In some ways, the time of death is always wrong. People can
never be declared dead until the proper medical criteria have
been met; that is, they must be dead before the declaration or
pronouncement of death is made. A prolonged resuscitative
effort may postpone the actual pronouncement of death for
several hours. In some instances, the pronouncement may be
postponed for days, as when a cadaver is maintained on life
support for possible organ donation or for compassionate
treatment of the surviving family members.
Death is even harder to define on the infraorganismic level.
All of the person does not die at the same time. After death is
declared some organs may continue to function, even well
Determining why somebody died will clearly never benefit the

deceased person, but knowing the cause of death will hopefully educate the surviving community in ways that might
prevent or delay further deaths. To improve either the quality
or length of life it is important to understand what went
wrong with those whose lives were not realized to their
expected fullest. It is also important to understand what went
right with those whose lives exceeded expectations from a
condition or situation that would otherwise have led to a
poor quality or early end of life.
From the clinical and academic perspectives, knowing why
a person died and the pathologic versus normal state of the
patients organ systems at the time of death is the ultimate
quality control of the health-care system. Assessment can be
made of the accuracies of prior diagnoses and of the efficacies
of applied therapies and treatments. This knowledge provides
not only the foundations for refining clinical management in
similar cases, but also the substrate for research on the disease
process that may lead to innovative management approaches,
entirely new therapies, and even cures.
From the legal and societal perspectives, knowing why a
person died may have relevance in keeping the rest of the
population alive and well. Although deaths due to natural
causes are mostly investigated clinically through hospital
autopsies, natural diseases that are communicable and pose
a risk for the population at large may need to be investigated
beyond the confidentialities and required permissions inherent in hospital-based investigations. If the cause of death is
not due to natural circumstances, the manner of death will be
either violent (accident, homicide, or suicide) or undetermined. In these nonnatural or uncertain causes of deaths,
there is usually a compelling public interest to investigate
the circumstances surrounding the death. Almost every legal
Pathobiology of Human Disease: A Dynamic Encyclopedia of Disease Mechanisms
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POSTMORTEM AND FORENSIC PATHOLOGY | What Is Postmortem Pathology: Why and How We Do It
jurisdiction in this country (federal, state, county, or large

municipality) has granted the authority to investigate
deaths-of-public-concern to public or governmental agencies
such as medical examiner or coroner offices. The types of
cases and details of their protocols vary considerably between
jurisdictions, but what they all have in common is that the
death investigations are done for the benefit of the public at
large they are forensic cases.
Besides the clinical/academic (hospital-based) and the legal/
public health (forensic) interests in knowing an individuals
cause of death, the surviving family members often have more
compelling reasons to know the cause of death of their loved
ones and want answers to the following questions among others:
Could I have done anything more or anything differently? Was
the death in any way preventable or treatable? Are any genetic
relatives or industrial coworkers at similar risks? Was there more
going on than what was known about during life? If any of these
questions are lingering with the family, the compassionate thing
is not to condemn the survivors to a lifetime of either doubt or
guilt, but to give them the honest answers.
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The Autopsy and Why Its Done
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The single most valuable tool for determining the cause of

death is the autopsy. It is a comprehensive medical evaluation
of the body, preferably in its entirety, within the context of all
known facts and circumstances surrounding the death. Derived
from the Greek autos ( self) and op- ( see), the word
autopsy literally means to see for oneself. Although often
used synonymously with examination of the dead, the
autopsy actually encompasses much more than just that.
The necropsy may be considered the procedure to examine
the dead (nekros dead or corpse), similar to how a biopsy
is the procedure used for examinations in the living (bios life).
Just like any other medical procedure, the autopsy should
begin with the history, followed by the physical examination,
and incorporate any laboratory studies or consultations that
may be necessary. Moreover, as in most clinical situations, the
history is usually the most significant element in determining
the diagnosis; the physical exam, or here the dissection of the
body, is often corroborative; and the laboratory studies are
either confirmative or sources of greater detail and more specific additional information.
In hospital autopsies, the history is almost always derived
from the patients chart or occasionally supplemented by a brief
note or conversation from one of the treating physicians. There is
almost always a clinical working diagnosis based on the patients
presentation, prior admissions, responses to treatments, and
entire diagnostic workup and clinical course. In forensic cases,
the deaths often occur outside of the hospital and the histories
provided to the forensic pathologist are often derived from
police reports, interviews of witnesses, friends, coworkers, and
family members, and especially a thorough examination of the
scene where the death occurred, all to establish the circumstances
leading up to or causing the loss of life.
This history typically sets the focus for the autopsy dissection. Although every organ system should be thoroughly
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examined, a known or suspected general idea often dictates

the approach and techniques that might be most appropriate
for the specific case at hand. Microscopy is done when a histopathologic diagnosis is necessary, or to confirm that an allegedly normal-appearing structure is indeed diseasefree. Toxicologic testing may be required when a pharmacologic or chemical (xenobiotic) cause of death is suspected.
Radiology, photography, and specialist consultations may be
utilized as part of the autopsy to supplement the dissection in
order to better define the cause of death or to answer other
questions related to the patients medical status.
Because the body is legally the property of the next-of-kin,
they must decide on the final disposition of the remains.
Hospital autopsies are done only with the consent of the
family, and at the time they give permission for doing the
autopsy is when they can opt for return of all organs, some
organs, or none. They can specify whether samples may be
retained by the hospital for purposes of diagnosis, teaching,
and/or research. If clinicians want an autopsy performed or if
researchers need specimens, they must get consent of the family. Forensic autopsies do not require family consent, but can
be performed only if the circumstances of death fall into the
categories defined by the specific statutes of the jurisdiction
where the death occurred, usually within the scope of
compelling public interest or the need to prosecute those
involved in a major crime. Many jurisdictions have provisions
for families who object to an autopsy and might be able to
have the dissection limited to least intrusive and focused only
on the specific area(s) that justified the compelling need to do
the autopsy. In those cases, histology and toxicology are often
minimal. In no circumstances should material from forensic
cases be retained purely for teaching or research purposes,
unless written consent is obtained.
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How Autopsies Are Performed
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The purpose of doing an autopsy is to answer specific questions (see above). The methods employed to arrive at those
answers are as varied as the specific questions being asked. The
basic style of removing each organ from the body one at a time
is the Virchow method and is used most commonly in forensic
autopsy; the style of removing the entire organ bloc en masse
from the body and dissecting organ systems off the bloc is
referred to as the Rokitansky method and is used most often
in the hospital autopsy. The accompanying figure illustrates a
step-by-step illustration of a Virchow-style dissection. In no
way does it presume to be a detailed description, but it merely
highlights some of the basic steps employed in most forensic
autopsies (see Figure 1). There are also many variations that
blend certain elements of each style. The dissecting styles and
techniques employed by the prosector are much less important
than whether or not they are capable of achieving the end
result. How much microscopy is necessary is another
example of fitting the techniques to the need. For example, if
an autopsy requires several hundred microscope slides to
completely elucidate the distinction between the clinical
courses of multiple simultaneous malignant and infectious
processes, then a very large number of slides may be absolutely
justified. If, on the other hand, an autopsy is performed to
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delineate the extent of a traumatic injury in an otherwise

healthy young individual, then having no microscope slides
might not be inappropriate.
A complete autopsy is one that answers all the questions.
In the hospital autopsy, it is not infrequent that permission
is given for a restricted or limited examination (e.g., chest
only, no brain, etc.). If the familys concerns are limited to
specific organ systems or specific body regions, a partial
autopsy which does not include restricted areas may still be
quite capable of answering all of their questions. In the forensic

setting, however, where culpability for the death is often the
issue, alternative hypotheses may be offered for the cause or
contributory cause of death. It is therefore incumbent upon the
forensic pathologist to unequivocally rule out all other possible causes of death and not have restrictions or limitations on
what may be examined during the autopsy. An adage in the
forensic setting is that partial autopsies yield partial answers.
Exceptions, of course, are always possible.
Figure 1 After thorough review of the history and careful inspection and documentation of the external features and therapies, 1. the internal
examination commences with the Y-shaped standard incision, or modification necessary to accommodate the specific body habitus. 2. The skin is
reflected to expose the chest and abdomen. 3. The chest plate is reflected to expose the thoracic organs in situ. 4. The pericardium is opened and
its contents examined. 5. After checking the pulmonary arteries for thromboembolism, the inferior vena cava is incised, and the heart is reflected
cephalad and freed of all its attachments. 6. Each lung is held at its hilum, reflected outwards, and removed.
(continued)

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Figure 1contd
7. The empty chest cage is then examined. 8. The ligament of Treitz is identified and all mesenteric attachments are incised
distally from there as close to the bowel as possible. 9. The bowels are then removed from proximal ileum to sigmo-rectal junction (it is usually
opened transversely through its entire length and rinsed gently for later inspection). 10. The gallbladder can be removed, dissected, and have its
contents sent for analysis, if indicated. 11. The liver is then removed by cutting at the porta hepatis and freeing up from the diaphragmatic
attachments. 12. The spleen is identified and removed.
(continued)
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Other distinctions between hospital and forensic autopsies

have more to do with the differences in the reasons why each
autopsy is being performed. Although the fundamental questions may be identical, the approach to those answers and
legal constraints may be very different. Some of the similarities and differences are cataloged in table form in Dolinak.

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The Focus of Clinical (Hospital) Versus Forensic

Autopsies
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In some ways, the hospital autopsy may be considered an

extension of surgical pathology, where the specimen is the
entire body. Directed questions almost always involve the
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Figure 1contd
13. The stomach is freed from just distal to the pyloric sphincter, reflected cephalad, and kept attached to the esophagus.
14. The stomach and esophagus are then removed by cutting just below the neck. 15. The adrenal glands can now be identified, removed if necessary
to be weighed, or sectioned in situ, examined, and sampled for histology (if necessary). 16. The duodenum is now identified, 17. opened, and
examined for biliary or pancreatic ductal pathology. 18. The pancreas can now be identified,
(continued)

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Figure 1contd
19. removed if necessary to be weighed, or sectioned in situ, examined, and sampled for histology (if necessary). 20.
The kidneys are examined in situ, 21. stripped from their capsules while still attached, 22. and then removed with an appropriate length of ureters.
The remaining abdominal soft tissue and diaphragm are removed. 23. The aorta is now opened and examined. 24. The pelvic organs with attached
colon are freed up from the retropubic space (of Retzius) and retrocolic fascia and then cut just proximal to the anus. At this point in a male
cadaver, the testes would be removed through a widened incision at the inguinal canal.
(continued)
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nature and extent of disease, treatment, local and systemic

adverse effects, and usually the clinical reason for death. The
forensic autopsy deals with these identical problems, but usually when there is some ambiguity or reason to believe that
there was involvement by other-than-natural causes or contributions to death.
Of almost equal importance in the forensic autopsy is not
just whether these other-than-natural elements were involved,
but how they were involved. This area of forensic pathology
specialty is referred to as wound interpretation. For example, in

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a clinical setting, the path of a perforating (through-andthrough) gunshot wound must be understood in order to surgically treat the patient, and the direction that the bullet traveled
is almost never of significance. In the forensic autopsy, the
trajectory (or direction) that the bullet traveled could explain
the physical relationships between the victim and the possible
shooter. In a similar way, the forensic autopsy pathologist must
elaborate on whether the gun was fired from within certain
identifiable ranges. Knowing which bullet wound marked the
entrance into the body versus which was the exit wound from
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Figure 1contd
25. The empty chest, abdomen, and pelvis are examined for skeletal defects; here the iliopsoas muscles have also been
removed looking for retropsoas pathology. 26. Attention is now brought to the head where the scalp is incised near the occiput between the two
mastoid processes. 27. The scalp is reflected forward over the face and slightly backward over the neck and the skull is sawed circumferentially in
an approximately coronal plane. 28. The anterior skull is raised and pivoted backward to expose the top of the brain; here the hand is inserted in
the epidural space in order to keep the dura mater on the brain and not adherent to the skull.
(continued)
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the body, or whether the gun was within inches versus feet away
from the victim is paramount in the forensic setting.
Similarly, wound interpretation can be applied to other
forms of trauma such as sharp injuries (cuts and stabs), blunt
trauma (abrasions, contusions, and lacerations), and general
identification of patterned injuries. The forensic pathologist
must also be knowledgeable in the interpretation of injuries
due to thermal effects (heat and cold), electricity, baro-trauma,
ionizing radiation, chemical trauma, and combinations of all
of these. Often, knowing why the person died is fairly obvious,

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but knowing how the person died is critical in preventing

future deaths.
After the Autopsy
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The final report should reflect the sum total of all the components that go into the autopsy. The historical facts may be
attached or summarized; the gross and microscopical descriptions are detailed in an objective manner; and laboratory
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Figure 1contd
29. Removal of the skull top now reveals the brain and dura in situ. 30. The optic nerves, pituitary stalk, and associated
vessels and nerves are cut; the temporal lobes are bluntly teased out of the middle cranial fossae and all the remaining cranial nerves are severed.
31. The cerebellar tentorii are cut and as the brain is gently reflected slightly backward, the scalpel is inserted deep into the spinal canal and the
cord is transected. 32. The occipital dura is cut and the brain is removed.
(continued)
reports, special studies, and consultant reports are attached.

The final diagnosis or cause of death should be the only
subjective statement(s) in the document. In this way, the signer
of the autopsy presents all the facts seen by him or her and then
states an opinion (the diagnosis) as the conclusion based on

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those facts. A long scholarly discussion (epicrisis) or brief

commentary note may or may not be included. The final
autopsy report may not be released for days, weeks, or even
months, depending on the complexity of the case and possible
need for more information or testing.
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Figure 1contd
33. The pituitary gland is removed. 34. The remaining dura is stripped and the skull is examined for pathology and trauma.
35. Lastly, attention is focused on the neck for a careful and methodical layered dissection of the strap muscles and adjacent soft tissue from the
hyoid bone to the carina. 36. The thyroid gland is examined and dissected off the now-skeletonized trachea. The hyoid bone may be separated
from the suprahyoid musculature to be removed with the trachea bloc, or remain attached to the tongue to be removed as one continuous
specimen from the tongue to the carina. They are done separately in this illustration.
(continued)
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The quality of the autopsy will therefore be determined in

part by the nature, amount, and validity of the material seen, as
well as the perspective of the seer. (Recall The eye does not see
what the mind does not know!) If new information becomes
available after the autopsy report has been completed, an
amended final report may be issued. Often other experts may
review the same material, have other interpretations or opinions
of the findings, and come to different conclusions.
In order for the body and remains to be buried or cremated,
a certificate of death must be issued that contains all the demographic and personal data required by the local jurisdiction as

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well as the medical cause of death. The person who performs the
autopsy is almost always responsible for filling out the medical
cause of death section. In hospital autopsies, where death
usually results from natural causes, the cause of death is usually
confirmed or determined at the conclusion of the dissection. A
death certificate can be issued at that time in order to release the
body and the autopsy report may be issued much later with the
finer details of the pathological processes. In forensic cases, the
cause of death is not always obvious after the dissection and
frequently a temporary death certificate is issued in order to
expedite the funeral. In forensic cases, the manner of death
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Figure 1contd
37. The prevertebral fascia is separated and the trachea bloc (with the cervical esophagus) is removed from the epiglottis
to its terminus. 38. The tongue is removed by severing the glottic attachments to the chin, inserting the palmar aspect of two or three fingers up
through the incision, flexing the fingers around the tongue, and 39. delivering the specimen through the neck. 40. All removed organs are now
weighed (if necessary), opened, and examined as if on a surgical pathology bench; photographed if documentation is necessary; and sampled for
histology, toxicology, microbiology, or whatever else is necessary (here the heart is found to have myxomatous changes on the mitral valve).
(continued)
must also be determined and this too is not often obvious at the
completion of the dissection. In either of these cases, the cause
or manner or both might be listed as pending further studies
on the death certificate and a final, or amended, death certificate
is reissued after the studies are completed.

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Causes and Manners of Death
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Most simply put, the cause of death is the etiologically specific

disease or injury responsible for initiating the lethal sequence
of events. The format of the death certificate asks for the
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Figure 1contd
41. After the prosector has taken all samples for testing or retention, the remaining organs are returned to the cadaver
and all skin incisions are sutured closed. 42. This last picture compares the appearance of the cadaver before and after the autopsy. A funeral
ceremony with an open casket and full facial view is absolutely possible after a routine autopsy with complete examination of the head and neck.
Note: This sequence is by no means meant to be an all-inclusive description of an autopsy. It is one variation of several techniques, and does
not include special procedures often used but not routinely necessary.
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sequence of causality of medical conditions that lead up to the

final event. The first line asks for the mechanism of death,
which is due to or a consequence of the immediate cause of
death stated on the next line, which is due to or a consequence of the proximate or underlying cause of death, which
must always be the bottom-most line.
The mechanism of death is the alterations of physiology
and biochemistry whereby the cause exerts its lethal effects.
Mechanisms of death (e.g., sepsis, cardiac arrhythmia, congestive heart failure, disseminated intravascular coagulopathy,
asphyxiation, or exsanguination) are never etiologically specific and should never be designated as the cause of death.
The immediate cause of death is the terminal disease,
injury, medical complication, or pathophysiologic condition
resulting from the underlying cause or circumstance and
directly preceding death. It is usually the most acute condition
that is being treated clinically. The underlying cause of death
and the immediate cause may either exist simultaneously or be
separated by variable spans of time. The immediate cause of
death need not be an etiologically specific disease or injury
(e.g., pneumonia, or decubitus ulcers).
The underlying or proximate cause of death is that which
in a natural and continuous sequence, unbroken by any efficient intervening cause, produces the end result and without
which the end result would not have occurred. The underlying

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cause of death should always be an etiologically specific disease or injury (when known).
The death certificate also provides the certifier with an option
of adding a contributory cause of death. If this is filled in, it
should be only for significant disease(s), injuries, or pathophysiologic condition(s) that existed at the time of death and
that may have fatal potential, but did not lead to or result in the
underlying cause of death. In natural deaths, it may represent
comorbid conditions that likely took years off the patients life.
An example might be someone who dies of hypertensive cardiovascular disease (the proximate cause) and is markedly
obese; the obesity may be included as a contributory cause.
After the cause of death is stated on the death certificate, the
manner of death must be filled in. This is an explanation of
how the cause of death arose, and can be either natural or
violent. Natural deaths are defined as those that are caused
exclusively (100%) by disease and are most often the type of
cases that are autopsied in the hospitals. If an injury (physical
or chemical) contributes to death, no matter how minor the
contribution, the fatality cannot be classified as natural and
usually requires either consultation with or referral of the case
to the medical examiner or coroner. Violent deaths may be
subclassified as accident, homicide, or suicide. The manner of
death may also be categorized as undetermined when the
circumstances and findings leave reasonable doubt about the
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classification. Further discussions of the categorization process

for the manner of death are available in many texts on forensic
pathology and death investigation; it will not be discussed
further here.
At this point, the critical reader may wish to refer to an
article by Joseph Davis titled Why Did He Die? He Wasnt
Supposed To!, which discusses the concept of how the cause
of death does not really explain why the person died.
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Other Reasons to Do an Autopsy
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Hospital Deaths
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Although a major function of the autopsy is to determine the

cause of death (and manner of death in forensic cases), there is a
wealth of other information that can come from a thorough
postmortem examination. The quality and quantity of this
information is limited only by the nature of the questions that
are being asked and by the skills and creativity of the prosector.
In the hospital autopsy, questions by the clinical staff might
be focused around the therapy and medical management.
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In research-oriented centers, and with proper family authorizations, tissue from autopsy might be taken for laboratory studies.
These specimens may be the pathological entity responsible for
the mortality or perfectly normal tissue that may be needed as
control material for studies of other processes.
In teaching-oriented centers, and again with proper family
authorizations, highly specialized clinical techniques or surgical approaches may be better perfected with the use of cadaveric material.
The autopsy can also serve administrative purposes in the
hospital as the ultimate quality control for clinical services and
can provide legislators and health policy makers with data
necessary for more equitable distributions of limited public
resources. Although errors may be a more common problem
in the ambulatory care setting, 9% of patients admitted to a
hospital are harmed by an error and 7% of these are fatal.
Medical errors cause tens of thousands of deaths each year
that could be prevented by known techniques and technology.
In 1999, the Institute of Medicine estimated that all errors, even
nonfatal, accounted for $17$29 billion in domestic health
care expenditure. In 2009, the error rate had not declined.
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Was the working diagnosis correct? If so, or partially so, or

even if not, would it have made a difference? How could it
have been better?
Was the choice of therapy appropriate? Were the limits of
the therapeutic agents exhausted? Would a different therapeutic approach have made a difference?
Was the extent of disease accurately appreciated? If not, why
might it have been underestimated? How could it have
been better?
Was the cause of death an entity which has genetic implications for surviving family members? Are there tests or
counselors available for them?
If the cause of death was of an infectious etiology, are there
risks for the hospital staff members in attendance? Are there
risks for the population at large? Do centers for disease
control or local public health agencies need to be notified?

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Almost every aspect of the health-care system is reliant on

sound medical and scientific interpretations of the pathologic
findings on the body. Often the ability to prevent further
deaths, or to treat similar conditions more efficiently or more
economically, is dependent on the correct interpretations of a
complete autopsy.
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Forensic Cases
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In the forensic autopsy, the primary goal is usually to determine the cause and manner of death. But other questions may
be asked, and often the ability to answer those questions will
be determined by whether a given office has the statutory
authority to accept jurisdiction of that type of case. Most of
the time, when a death is unexpected, not due to natural
circumstances, or in any way unusual, suspicious, of potential
public health concern, or possibly the result of criminal activity, authority is granted to the appropriate agency (medical
examiner or coroner) to investigate the circumstances surrounding that type of death and includes the performance of
a forensic autopsy if deemed necessary.
In the chapter on The forensic postmortem examination
and the medicolegal autopsy from his classic 1970s text The
Pathology of Homicide, Lester Adelson wrote that when the
pathologist performs an autopsy investigated under medicolegal auspices, the efforts must be directed to find the answers to
six questions. The question-and-answer exercise, or dialog
with the dead, is the pathologists interrogation of the cadaver,
asking specifically (1) Who are you? (2) When did you die?
(3) Where did you die? (4) Why did you die? (5) What happened? and if it is a homicide (6) Who did it?
The first three questions (who, when, and where) are almost
never an issue in an autopsy performed at the hospital on a death
due to natural causes. But in the forensic setting, identity, timing,
and location of the body at death may make the difference in
assigning culpability or substantiating an alibi of a suspected
perpetrator. The next two questions (why and what happened)
are essentially asking the cause and the manner of death.
The last question (who did it) is answered by interpreting
the injuries both the lethal and the incidental ones in
an attempt to recreate the terminal events and physical relationships of the victim to the surrounding environment and/or
perpetrator(s).
The criminal justice system and the health-care system rely
on sound medical and scientific interpretations of the pathologic findings on the body. Often the ability to prevent further
deaths is dependent on the correct interpretations of a complete autopsy.
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Public Health Concerns
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Often the first indication of an epidemic is the increase in the

number of deaths from infectious agents. Isolating and characterizing the organism, describing the extent of disease, and
otherwise identifying the pathogenetic process is another
major function of the forensic autopsy.
Besides infectious agents there are many toxicologic etiologies of death that can put the public at risk. Whether it is an
excess of carbon monoxide (or other oxygen-depriving gas) in
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a confined work area or a chemical contaminant, a toxicologic

examination of the decedents organs or bodily fluids can often
identify the offending agent.
Usually cases of public health concern are within the jurisdiction of the medical examiner under the authorities of investigating deaths that pose imminent threat or risk to the public.
The circumstances of these deaths need to be investigated,
usually by professionally trained death investigators who are
not normally associated with hospitals. The necessity for doing
these autopsies preempts the familys wishes to possibly
decline consent for a hospital autopsy.
s0070
For the Future
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It is a tenet of education and society at large that we provide for

the benefit and improvement of future generations. Unfortunately, it is often impossible to know exactly what they will
need, because the technology that they will be using has not yet
been invented. It is clear, however, that if any retrospective
study is to be done, regardless of the technology employed, a
substrate for analysis must be available. Some pathology
departments have maintained autopsy material for decades as
either glass microscope slides or wet (formalin-bathed) tissue.
Some of that material is now capable of being reexamined with
technologies that were not conceived of when the samples
were taken. Tumors come to mind immediately when one
thinks of possibly reanalyzing pathologic samples in the future
with probes or methods not available today. But what about
the nonpathologic material (e.g., blood, liver, heart, and
brain from trauma victims who are in otherwise perfect
health)? Perhaps their offspring will need to know whether
they are potential carriers of some genetic anomaly. Perhaps
the future centers for disease control will need to know the
prevalence of antibody in the population of a generation ago,
or need to compare the previous generations (our) levels of
proteins, elements, environmental chemicals, or who-knowswhat that might be linked to some future entity. Whether it is a
DNA-card with a blood spot, cryopreserved tissue sample, or
whatever else, the best practice of preservation today should
dictate that some banking of all this potential data be made
available for future analysis.
s0075
Limitations of the Autopsy
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Limitations of diagnoses and interpretations of autopsy findings

are due either to the nature of the cause of death (i.e., whether or
not there is a demonstrable anatomical or toxicological
substrate) or to changes that occur after death from biological,
chemical, and physical processes (postmortem artifacts).
Many of these postmortem artifacts are well known and
well documented; many are not. The ideal autopsy would
occur immediately after life ceases, hoping that the findings
in the cadaver are representative of the person at the moment
death occurred. For practical reasons, the autopsy rarely occurs
before 1224 h post mortem, and quite frequently may be days
to even months or years if the body was not discovered soon
after death. Refrigeration may retard many of the biologic and
some of the chemical processes that create postmortem artifacts, but there are great variations between when the body was
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placed in the refrigerator, how quickly the body will cool down
(size and fat content of the cadaver), and relative humidity
within the cooling system. Some organs and tissues are fairly
stable for a relatively prolonged interval; some are not, especially those requiring microscopic analysis of fine nuclear
details. Some chemical agents (therapeutic or otherwise) are
stable, while others break down quickly; some stay where they
were, while others redistribute by diffusion from their sites of
origin to places where they would not have been during life.
Many sources, especially forensic pathology texts, address
these issues in great detail; they are mentioned only briefly here
to make the reader aware of possible confounders in the interpretation of some autopsy findings. Knowledge of how postmortem artifacts can affect the data will not only prevent
overdiagnosis or misdiagnosis, but will enable validation of
some diagnoses made in cadavers that have been exhumed
from graves decades after burial or even remains that have
been mummified for thousands of years.
In general, though, an autopsy is an excellent tool for the
diagnosis of pathologic conditions surrounding the time of
death, provided that the interpretations are made within the
proper context. If the lesion(s) fall into the category of anatomical derangements, the autopsy can be an excellent tool for
making the diagnosis. If the pathology is due to infectious
etiology, exposure to toxic substances, or occasionally deprivation of necessary substances, the autopsy can be a very good
tool to determine the cause of death, provided that the anatomical findings are consistent and the substance(s) to be
tested can be done so reliably. If the derangements are metabolic or genetic, the traditional autopsy might provide some
clue to the lesion only if there are anatomic or testable chemical correlates associated with the lesion. When the cause of
death is due to an acute physiologic derangement, the traditional autopsy contributes less to the determination of the
cause of death. When the autopsy results are negative, there
is still a wealth of useful information in having eliminated the
possibilities of all fatal processes that have either anatomical
findings or testable metabolic derangements. This may also
prompt a revisit to the scene of death where a heightened
awareness may now disclose the presence of a potential electrocution, oxygen deprivation, or other cause of death not necessarily demonstrable from the anatomic and toxicologic autopsy.
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Conclusion
s0080
The purpose of an autopsy is to state the facts of the death and

serve the living.
The unfortunate reality is that the number of hospital-based
autopsies has been declining precipitously for many decades,
and they are now not even performed to any degree other than
in a few academically oriented institutions. The forensic autopsies vary enormously in quality due to the lack of enforceable
standards, dearth of public resources, and underfunding of
training programs.
The way to promote the extent and quality of life and to
reduce the pathologies from both medical and societal perspectives is to better comprehend and study pathology after
death. Everyone is familiar with the expression you only live
once. What people fail to consider is that much of the length
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14
and quality of that life is a direct result of the advances made in

medicine by the study of postmortem pathology. The corollary
to that expression might be you only die once. Lets not waste
this one opportunity to pay back our predecessors by promoting the length and quality of life for the next generation as they
did for us.
See also: Postmortem and Forensic Pathology: The Importance

of the Autopsy: Illustrative Cases (6702); Toxicology in Post-mortem
Pathology (6704); The Negative Autopsy (6705); Forensic Radiology
(6706); Genetics and the Molecular Autopsy (6707)
Further Reading
Adelson, L.A., 1974. The Pathology of Homicide [A Vade Mecum for Pathologist,
Prosecutor, and Defense Cousel]. Charles C Thomas Publisher, Springfield, IL.
Davis, J.H., 2011. Why did he die? He wasnt supposed to. Acad. Forensic. Pathol. 4,
386391.
deVries, 2008. Qual. Saf. Health Care 17, 216223.

Title Name: PATD
Dolinak, D., Matches, E.W., Lew, E., 2005. Forensic Pathology: Principles and Practice.
Elsevier, Amsterdam.
Hall, J., 2009. First, make no mistake. Op-Ed contributions to the New York Times 28
July 2009.
Institute of Medicine, 2000. To Err Is Human:Building a safer health system, 112.
Spitz, W.U., 2006. Spitz and Fishers Medicolegal Investigation of Death, Guidelines for
the Application of Pathology to Crime Investigation, fourth ed. Charles C Thomas,
Springfield, IL.
Relevant Websites
http://www.ascp.org American Society for Clinical Pathology (ASCP). Policy
Statement: Autopsy (Policy Number 91-01).
http://www.cap.org College of American Pathologists (CAP), Northfield, IL. Autopsy
Performance and Reporting, second ed. (2003).
http://www.cdc.gov Medical Examiners and Coroners Handbook on Death
Registration.
https://netforum.avectra.com The National Association of Medical Examiners (NAME),
St. Louis, MO.
PATD: 06701
Non-Print Items
Abstract:
This article introduces the topics of what pathology can offer to the medical community (academic, clinical, and research), the legal community,
surviving family members, and the general public welfare by investigating the circumstances of death. The concept of death is defined as are the
meanings of cause and manner of death and how we make those determinations. The autopsy is explained in detail: what it is, the primary reasons
for doing it, what are its components, variations on how it is done, and the impacts it may have on academic/clinical practice or the criminal justice
system. When autopsies are done in hospitals and when they are done in forensic settings are also discussed, as well as the advantages and inherent
limitations of each. An illustrative example of one type of prosection is included. Additional reasons for postmortem pathology are discussed in
terms of hospital cases, forensic cases, public health issues, and what might be done for the direct benefit of future generations. Some of the
limitations of the autopsy and validity of the diagnoses are explored, especially in terms of postmortem artifacts.
Keywords: Artifacts; Autopsy; Cause of, investigation of, manner of, time of death; Coroner; Forensic: Autopsy, Pathologist; Medical examiner;
Postmortem; Wound interpretation
Author and Co-author Contact Information:

Mark Flomenbaum, MD, PhD
Deputy Chief Medical Examiner
37 State House Station
Augusta
Maine 04333-0037
USA
Tel.: 1-203-451-1336
E-mail: Mark.Flomenbaum@Maine.gov
Biographical Sketch
After completing his anatomical and cardiovascular pathology training at Brigham & Womens Hospital,
Dr Flomenbaum pursued his Forensic Pathology career in New York City, Massachusetts, and now in
Maine. He maintains academic affiliations with Harvard Medical School, MIT, and Boston Medical School
where he has directed several courses in pathology and lectures frequently. Dr. Flomenbaum is also active
in the educational missions of the National Association of Medical Examiners and the American Academy
of Forensic Sciences.

The How of The Forensic Autopsy

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To protect the rights of the author(s) and publisher we inform you that this PDF is an uncorrected proof for

What Is Postmortem Pathology: Why and How We Do It

This section addresses issues concerned with the diagnoses of

enough to support another persons life. After the organs

Determining the Cause of Death

In most medical contexts, the time that a patient may be

Determining why somebody died will clearly never benefit the

Pathobiology of Human Disease: A Dynamic Encyclopedia of Disease Mechanisms

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jurisdiction in this country (federal, state, county, or large

The Autopsy and Why Its Done

The single most valuable tool for determining the cause of

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examined, a known or suspected general idea often dictates

How Autopsies Are Performed

delineate the extent of a traumatic injury in an otherwise

quite capable of answering all of their questions. In the forensic

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Other distinctions between hospital and forensic autopsies

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The Focus of Clinical (Hospital) Versus Forensic

In some ways, the hospital autopsy may be considered an

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nature and extent of disease, treatment, local and systemic

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but knowing how the person died is critical in preventing

After the Autopsy

reports, special studies, and consultant reports are attached.

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those facts. A long scholarly discussion (epicrisis) or brief

The quality of the autopsy will therefore be determined in

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Causes and Manners of Death

Most simply put, the cause of death is the etiologically specific

sequence of causality of medical conditions that lead up to the

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classification. Further discussions of the categorization process

Other Reasons to Do an Autopsy

Although a major function of the autopsy is to determine the

Was the working diagnosis correct? If so, or partially so, or

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Almost every aspect of the health-care system is reliant on

Public Health Concerns

Often the first indication of an epidemic is the increase in the

a confined work area or a chemical contaminant, a toxicologic

For the Future

It is a tenet of education and society at large that we provide for

Limitations of the Autopsy

Limitations of diagnoses and interpretations of autopsy findings