Nowadays, autopsy occurs between 1 and 10 times per million words in typical modern English usage, along with other words which are considered to be distinctively educated, while not being overly technical or jargon (example nouns at a similar frequency include surveillance, assimilation and paraphrase) [29]. Since the early nineteenth century, attempts have been made to remedy the discrepancy between conflicting senses either by adding determining adjectives to the existing noun, or by substituting autopsy with another word altogether, although none have succeeded in surpassing its popularity for over a century (Fig. 1).

Google Books Ngram Viewer graphs showing how frequently the words autopsy, necropsy, post-mortem examination and necrotomy occurred in a corpus of books from 1800 to 2019 in: a English published in any country; b English published in the USA; and c English published in the UK [29]

The term postmortem examination is an example: a borrowing from Classical Latin post (“after”) and mortem, accusative of mors (“death”), attested 1834 [30]. The term is frequently shortened simply to postmortem, and may be hyphenated or unhyphenated for the sense “examination of a dead body” (although the latter is not also used for the “after death” adverb form). Knight remarks “the term ‘post-mortem examination’ is a common alternative, especially in Britain, where its meaning is never in doubt. Unfortunately, it suffers from a lack of precision about the extent of the examination, for in some countries many bodies are disposed of after external examination without dissection” [23]. However, one may argue that the word autopsy provides even less information about the content of the examination, given its original sense “self-inspection of something without touching it” and current polysemy. Knight observed the relative popularity of postmortem examination over autopsy in Britain; use of the former was preferred between the 1830s and 1930s in British English compared with American English texts, as represented by Fig. 1. Substitutions of autopsy for postmortem examination were common: the 1885 English translation of Virchow’s Die Sections-Technik preferred the term postmortem examination over autopsy, and similarly Hektoen in his 1894 The Technique of Post-mortem Examination [31]. Nowadays in the United Kingdom, statutory and regulatory bodies tend to either offer vague, overarching definitions for autopsy, or replace it altogether with postmortem examination, as has been the case with recently amended Home Office publications [32]. UK Government legislation makes no reference to the autopsy, and instead refers only to postmortem examinations. This is epitomised by Acts governing activities involving human tissue [33, 34], and those involving the authorisation of postmortem examinations by judicial officers [35, 36].

A contributor to JAMA’s 23rd issue in 1901 poses a dilemma presented to the US Circuit Court in Kentucky, illustrating the importance of accurate language in these circumstances [37]: when a person taking out a life insurance policy permits a medical advisor to examine the body after death, does this give the company the right to make an invasive postmortem examination? Indeed, the court “did not think that any ordinary person would suppose that they were agreeing to what would have been much more clearly expressed by the word ‘autopsy’ or by the word ‘dissect’… While an autopsy, generally speaking, always includes an examination, the court does not think that an examination always includes an autopsy”.

Another term that overtook postmortem examination in popularity from the 1910s was necropsy (attested 1842), which was formed in English by compounding necro- (“death”) and -opsy (“visual inspection”); probably modelled on the aforementioned French nécropsie [38]. Pepper’s Medical Etymology describes necropsy simply as “a better term than autopsy” [8]. Knight writes “though ‘necropsy’ is semantically the most accurate description of the investigative dissection of a dead body, the word ‘autopsy’ is used so extensively that there is now no ambiguity about its meaning” [23]. Necropsy is also considered a more general term without reference to species [5]. Autopsy in its early sense “self-inspection” led many to believe that the frame of reference for “self” was “ourselves”; i.e. our own species, humans. As such, the postmortem examination of a non-human was proscribed from using the term and instead designated a necropsy. However, the current meaning of necropsy is subject to similar criticism as autopsy: strictly, the word portrays “inspection of a dead body”, but is more often used in the context “dissection of a dead body”. In contrast to its English interpretation, Greek forensic practitioners use their νεκροψία to denote an observation of the intact (not yet dissected) deceased [3]. In Greece, the necropsy would be considered synonymous with the non-invasive or external-only postmortem examination. Necrotomy is a compound of necro- (“death”) and -otomy (“dissection”), and is seldom used in English [39]. The Greek equivalent νεκροτομία is used to denote “dissection of a dead body”, and is considered synonymous with the invasive or internal postmortem examination [3].

Several other modern words now use the autopsy root to describe various forms of postmortem examination, and their quantity reflects the sheer variability in procedures. The least invasive is the so-called verbal autopsy (“a method used to ascertain the cause of a death based on an interview with next of kin or other caregivers”); a juxtaposition, given that no examination of the body is actually undertaken, and which Burton suggests would be better represented by postmortem clinical case review [40, 41]. Pathological examinations have embraced new technologies, and non-invasive postmortem examinations are often supplemented with various imaging modalities. The so-called virtopsy is a portmanteau of virtual and autopsy, and is a trademark registered to Dirnhofer; the former head of the Institute of Forensic Medicine at the University of Bern, Switzerland [42]. A similar buzzword echopsy describes a modified needle autopsy technique with ultrasonography [43]. Where a postmortem examination does not provide a satisfactory answer for the cause of death, the term negative autopsy is sometimes used. The use of genetic analytic techniques to determine the cause of death in these unexplained cases is represented by the term molecular autopsy; first proposed 20 years ago [44].

Indications for postmortem procedures also vary. In England and Wales, there are two fundamental types of postmortem examination: hospital and coronial (usually subdivided into routine coronial and forensic cases). The hospital invasive postmortem examination rate was 0.51% of all deaths in England and 0.65% of all deaths in Wales in 2013 [45]. Routine coronial and forensic invasive postmortem examinations were performed in 16% and 0.8% of deaths in the same year, respectively [46]. Confusingly, the vast majority of postmortem examinations instructed by the coroner are performed in a hospital mortuary by histopathologists who are also employed by the National Health Service. The term coronial strictly means “relating to a coroner”, and therefore any postmortem examination authorised by a coroner is, in essence, coronial. However, in England and Wales, coronial cases tend to refer to those that are not forensic. The word forensic derives from Classical Latin forēnsis (“of or belonging to the Forum; of or connected with the law courts”) and its current definition has largely retained this meaning (“of, relating to, or associated with proceedings in a court of law”) [47]. According to this definition, one would expect the forensic postmortem examination to automatically describe any qualifying coroner-requested procedure, as is the case in almost every other country with an established forensic pathology service, including Scotland (the Procurator Fiscal distinguishes between those cases likely to progress to court and those not, named according to the statutory requirement for corroboration in Scots law: one-doctor or two-doctor postmortem examinations) [48]. In England and Wales, the routine coronial and forensic postmortem examinations are distinguished by the cost to the coroner, requirement for a Home Office registered forensic pathologist to perform the procedure, and a higher level of scrutiny with the expectation that the case will be heard in court.

To complicate things further, hospital postmortem examinations are sometimes referred to as consented, and their coronial counterpart as non-consented, given that informed consent is not mandatory in coronial cases. However, families must be notified and will likely be counselled on the advantages and disadvantages of a postmortem examination as applied to an individual case, and may be asked for their “consent” in the sense that the coroner should pay appropriate respect to families’ held religious and cultural wishes with regards to the treatment of the deceased body.