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Forensic Medicine: "We are not just dealing with dead bodies“
Professor Stefanie Ritz-Timme; © private
It’s well-known that reality and fiction sometimes are much farther apart than you would think. Popular US crime drama series have long since shown us that and sketch a smart image of the job of forensic pathologists: they perform autopsies, identify and solve homicide cases like clockwork. Everyday life in a forensic medical Institute though is reflected to a lesser extent in this case.
MEDICA.de spoke with Professor Ritz-Timme, Director of the Institute of Forensic Medicine at the Düsseldorf University Hospital and Dean of the Medical Faculty at the Heinrich Heine University Düsseldorf about the kind of duties and responsibilities she really deals with day-to-day.
MEDICA.de: Professor Ritz-Timme, forensic medicine and pathology are often confused with one another. In what way does forensic medicine distinguish itself from pathology?
Stefanie Ritz-Timme: Both subjects are very different from each other. They get mixed up, because forensic medicine in the Anglo-American region is referred to as “forensic pathology“. In the discourse or in the German translation the term “forensic” is omitted, which is why the remaining term “pathology“ is equated with pathology. The only connection between the two subjects is in that they both deal with causes of death. There is one big distinction though. Pathologists perform autopsies on people which died in hospitals. The focus here is the question of quality assurance in medicine. Forensic pathologists perform autopsies on people, which passed away under unclear circumstances. It is imperative for them to answer the crucial forensic medical question of whether somebody died a natural or unnatural death.
There is another important difference: forensic medicine is not just dealing with dead bodies, but also with other topics from the fringe area between legal questions and medical background. Forensic pathologists are also important contact persons for victims of violence, who survive a violent crime and then need medical and psychosocial support. Forensic medicine also deals with paternity tests, blood alcohol regulations or toxicity analysis and many other topics. The subject area covers a very broad spectrum.
MEDICA.de: How many death cases or other assessments of injuries on surviving victims of violence do you approximately investigate per year at your Institute?
Ritz-Timme: We autopsy about 500 deceased people per year and daily examine living persons who were victims of violence. This takes place partly in our own outreach clinic in Düsseldorf, but also in part on a consulting basis in nearby hospitals, which are sought out by patients with injuries that require treatment. If for instance a woman was raped, this patient must have a gynecological exam. This may take place in a gynecological clinic. During the exam many clinical questions need to be answered which not only pertain to the injuries, but also for instance concern the issue of getting infected with diseases that can be sexually transmitted. It makes sense if our associates visit the patient at her chosen clinic and examine her together with a gynecologist. This way the patient does not unnecessarily have to be burdened with several trips and only needs to tell the experts about this emotionally draining crime one time.
The number of cases of course also depends on how many orders the public prosecution department issues. The public prosecution department proceeds very carefully in these cases. Generally, the need for clarification by law enforcement agencies is very big.
MEDICA.de: Have you noticed a rise in forensic investigations in recent years?
Ritz-Timme: We have an increasing number of cases we investigate. This does not necessarily mean that there is more crime. We often notice that society simply has become more sensitive. Especially the number of surviving victims of violence that we see is continuously increasing. This is primarily due to the fact that victims can take advantage of special support services from us. We don’t just look at the person that is sent to us by the police, but we also examine and analyze injuries of people that don’t want to directly notify the police after they have been subjected to violence. In the event that these victims would like to press charges against the perpetrator later on, we document the diagnostic findings and secure the evidence, so the victims can protect themselves. This service is very “low-threshold“, because we are discreet and in this case comply with our medical confidentiality. More specifically this means: the victim that comes to us is in charge of the proceedings. The reason this is low-threshold is because we meet the subjective wishes of the person. The service is consequently very well used.
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Institute of Forensic Medicine
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MEDICA.de:What are the most frequent medical and also scientific methods with which you can uncover unnatural causes of death? How are the identity of a deceased person, the time of death and other important information determined?
Ritz-Timme:We work according to the rules of classic forensic medicine. At first an autopsy is performed on the deceased person. In specific indications we also work with imaging procedures. This could mean computer tomography (CT) or classic x-ray technique. With imaging we gather important additional medical findings. However, an autopsy cannot be replaced by an imaging procedure.
During a forensic autopsy the entire body is being meticulously externally examined− from the tip of the nose all the way to the toenails. Even almost unrecognizable scratches are documented, which would barely catch someone’s eye at a hospital. But precisely such smaller injuries could potentially be important to reconstruct events. The interior body examination, this meaning the autopsy of cranial-, chest- and abdominal cavity of the body, is also done in the same meticulous manner. This physical examination is performed by skilled morphologists, who precisely document all medical findings. Not until all facts have been gathered, can an overall picture on the causation of events that lead to death be puzzled together. Often we are able to piece the jigsaw puzzle together right after the autopsy. At the end the result is either the assumption of a natural death, like for instance a heart attack, or consequently an unnatural death. If according to the investigation the deceased for example committed suicide and the autopsy results confirm this, it might be that the public prosecutor considers the case closed. Yet it is also possible that at the end of an autopsy there are many questions left unanswered, because you were not able to determine a cause of death for instance based on just looking at the medical findings. If then for example there is suspected poisoning, the person performing the autopsy for the public prosecution department can suggest further investigations.
MEDICA.de: Can you always determine time of death, the identity of the victim or cause of death? In which cases is this particularly difficult?
Ritz-Timme: We can establish the time of death during the early postmortem time interval, the first hours after death, relatively well. We base this on specific parameters that can be directly collected at the location where the dead body is found. Body temperature, livor mortis condition and rigor mortis are important for example. And there are other, specific parameters such as the excitability of mimic muscles using electrical stimulation. The sooner you perform these examinations at the dead body’s location, the more accurate you can determine time of death. And the further the point in time of examining the dead body is from the time of death, the harder it becomes – for instance if a corpse already exhibits signs of putrefaction. For maggot infestation the so-called forensic entomology takes effect. Specialized biologists examine the maggots that populated the dead body. Based on the degree of development of these animals, experts in parts draw very good conclusions on the time of death.
A clarification on whether murder or homicide caused this unnatural death is a legal issue. The attorney draws on the findings we gather. These findings are clear-cut in many cases, in other cases less so.
If this is a homicide where the Federal Bureau of Investigation does not know the identity of the deceased, it barely has a way to find investigative leads. We can resort to a comprehensive repertoire of methods for identification. Besides gender and body height, age is the most important target variable to identify an unknown dead body. It has a high discrimination value for identifying an unknown dead person, which is why it is so important. In Düsseldorf for example we have established one of the most accurate procedures, a biochemical method. This procedure is based on the racemization rate of aspartic acid. Here we take a look at the age-related changes of amino acids. These can be compared to an inner clock: because the older a person gets, the higher the concentration of a specific amino acid is – and we can measure it. However, this is quite an elaborate and relatively expensive procedure. That’s why it is primarily used in cases that cannot be solved using other procedures. If there is a suspicion on who the dead person might be, we have great ways to compare, for instance using molecular genetic methods. Very suitable are also simple odontostomatological procedures, meaning comparing dental records.
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MEDICA.de: You also take on a social duty and public responsibility, respectively, by often working under order of the public prosecutor during a criminal trial. How can you describe this progress of work and what is important here?
Ritz-Timme: If there is a case of death that’s unexplained and the first examining doctor suspects an unnatural death or if it is obviously an unnatural death, this is reported to the police. A preliminary death investigation is then initiated. At its end is a homicide investigation report, which the police forward to the public prosecution department. The public prosecutor in charge then decides whether he wants to consider an autopsy: if applicable, a judge then needs to order an autopsy. If such an order is issued, a forensic autopsy is performed on the dead body. The public prosecution department then is in charge of the proceedings. After the autopsy we write a detailed autopsy record. At the end is a preliminary expert opinion in which the expert performing the autopsy preliminarily evaluates the case. Depending on the result of the autopsy, the public prosecution department decides whether further examinations are ordered or whether the case is now closed.
Usually further investigations are ordered in homicide cases —like for instance histological examinations. With these procedures forensic pathologists can detect for example how old wounds are, whether the victim died immediately after receiving the injury or was sick. Upon completion of these types of further examinations we write a conclusive homicide investigation expertise. This forms an important basis for the further investigations by the public prosecution department. If the case is finally solved and it gets to a trial within criminal proceedings, forensic pathologists are summoned as experts and present their autopsy results and conclusions. They are available for questions by the court during the entire court case.
MEDICA.de: However, it is not just about examining death cases, but also about examining surviving victims of violence. What kind of actions are you taking there?
Ritz-Timme: It always depends on the context. If for instance somebody was the victim of violence and the police are already involved, the police escort the victims and bring him/her to us. On behalf of the police we then examine the injuries, document and describe them and answer their questions. One typical question of the police is for example: “Do the injuries match the descriptions the victim is giving? “ These people are not only physically but also mentally traumatized, in some instances they had to endure tremendous agony while fearing death. This is why we also view our care mission as part of the public health service of the University Hospital in comprehensively counseling these affected persons, being there for them and to place them with other counseling services. We are integrated into a well-structured network of many clinics for victims of violence. For acute crisis intervention in Düsseldorf we can draw upon the services of our psychosomatic medicine doctors and psychiatrists. We usually refer the concerned women to local women’s counseling services because we know that they receive excellent care there. And vice versa the women’s counseling services also refer women with injuries to us.
We also examine persons who for the time being do not want to notify the police and would like to wait. At the same time though they also want to make sure that they have good backup. They receive counseling- and therapy services. We then store the findings we gather for them, also photos and evidence we detect here at the Forensic Institute. We treat this very discreetly, the concerned person only receives a medical certificate from us which also shows our contact information in case they want to press charges later. By now we have seen that many affected people take advantage of this opportunity and file charges after some time has passed.
MEDICA.de:Do patients also come to you directly or does the family doctor mostly seek your advice?
Ritz-Timme: In part the concerned people come to us through the police and partly they come straight to us, particularly because our services are well-known. Many patients also come to us from our own clinics. For example we work closely with trauma surgery and gynecology here at the Düsseldorf University Hospital. In addition we are connected to a network of family doctors who refer patients to us. At the same time these family doctors are also trained by us. We teach them for instance how to document injuries and evidence so it can stand up in court. For the person concerned, it is a great relief if all examinations can take place in one location. If the family doctor’s office has questions about the examinations or medical findings, we gladly offer counseling.
MEDICA.de: Within the scope of a scientific EU project you oversee the development of a safe procedure that pertains to estimating the age of children on photos. Unfortunately, this is becoming more and more important. How does this work?
Ritz-Timme: Estimating the age of children on photos serves to answer the question whether the pictures depict child pornography or not. So far one particularly analyzes what kind of signs of external sexual developments can be identified. Puberty however runs through different age stages, there are early and late bloomers and in different ethnic groups, puberty also begins at different times. To determine the exact age this way is very difficult. For the most part this is just an approximate age diagnosis.
Our new approach is based on the development of a child’s face. We have researched this development in a large anthropological and forensic project. Apparently this development is genetically well regulated and proceeds regularly. For starters we learned how we can reconstruct this development. We came up with the idea of wanting to design this method more objectively by recording child face proportion with the aid of a computer. With the help of an algorithm the faces should get assigned to a specific age category through their proportions. We were then able to implement this idea with an industry partner, a software company. We managed to develop a software prototype that in an automated way finds the faces and assigns the photos to age categories. This works well, but still needs to be validated.
MEDICA.de: Forensic Medicine is more a matter of the German federal regions. How are the individual forensic medicine institutes cross-linked among each other?
Ritz-Timme: We have a joint scientific association for forensic medicine that hosts conferences on a regular basis. There also is a publication for this association. There are not many forensic pathologists in Germany; in essence all forensic experts know each other. The exchange between the individual institutions is quite possible, because everybody knows the specialization of the other person. This is especially helpful if you handle cases that involve specific questions. If you do not have a certain specialization at your own institute, you can get advice from another forensic institute or you refer the ordering party to your colleagues.
The interview was conducted by Diana Posth and translated by Elena O’Meara