Bruises and scars on the scalp may be difficult to find, especially if the hair is thick. Bruises will usually be tender to touch. Head trauma a very common outcome of torture and even repetitive minor head trauma can cause permanent damage to the brain. This in turn can lead to neurological deficits. Some survivors of torture may report losing consciousness during periods of time, in which case, the presence of a reliable witness would help in documentation. Loss of consciousness can occur because of direct blows to the head, post-traumatic epilepsy, asphyxiation, pain and exhaustion, excessive loss of blood internally or externally or any combination of this. After having been hit on the head, many complain of persistent or recurrent headaches. There could be areas of hyperaesthesia on the scalp (extreme sensitivity of the nerves) and thickening of the scalp due to scar tissue. This can be palpated by running the fingers along the scalp.
Violent shaking of the upper body, as can happen with a child or a small made person, can leave severe headaches and cognitive changes. Even though no external injuries may be identifiable, internally, it can manifest as cerebral edema or sub-dural bleeding. After severe head injury, there may be concussive convulsions but may not necessarily lead to epilepsy. Convulsions in the first week after severe head injury tend to be tonic-clonic, can recur for a year or more, but are not generally lifelong. If the injuries, specifically in the temporal area, do cause brain damage, then they are likely to develop complex partial seizures, months or years after the incident, making history very important in proper management and for documentation. More than 90% cases of complex partial seizures start with an aura, with concurrent automatic movements (like lip smacking) and followed by absence that can last for up to 2 minutes, followed by a few minutes of disorientation. This has to be differentiated from Post Traumatic Stress Disorder (PTSD) symptoms where the person can be roused and doesn’t completely lose consciousness.
Survivors of torture rarely have an accurate account of their head injuries, and unless they have an external reference, they cannot know for how long they were unconscious. One problem with attributing epilepsy to head trauma is that there is rarely any information about the individual’s neurological state prior to the incident.
It is essential in possible cases of neck compression or strangulation that all areas of the eyes, skin and mucosa (including inside the mouth, the eyelids, the palate and the uvula, and the skin of the scalp) above the level of compression are examined with a good light to identify any localized areas of petechiae. It is important to identify petechiae at an early stage as they fade and disappear within 24 hours or so. In cases of manual strangulation or neck compression petechiae may be florid and may coalesce to form larger bruises. There may also be difficulty breathing, ptosis or facial nerve palsy. Late complications include aspiration pneumonia, pulmonary oedema and seizures.
Where strangulation by ligature or hand has been attempted, potential findings include:
(a) No injury seen;
(b) Pain or tenderness – at site of application of force with no visible injury on swallowing or on neck movement;
(c) Reddening (erythema), which may resolve after a few hours;
(d) Skin bruising, abrasions or swelling at the point of compression – for example, at sites of finger/thumb/ligature application – this may appear early or later and persist for days;
(e) Pinpoint bruising (petechiae) above the site of compression;
(f) Damage to the larynx – thyroid cartilage (voicebox) – causing hoarseness and/or hyoid bone (bone at base of neck);
(g) Scratches to neck
(h) Damage to mucosa of the mouth and tongue due to direct pressure on teeth internally and swelling of the tongue;
(i) Bleeding from mucosa where the intravenous pressure has been raised – for example, from the nose and ears;
(j) Additional non-specific features that may rarely be present include frank hemorrhage from orifices such as the nose and ear and spontaneous evacuation of feces and urine. These may appear alone or in combination.
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