Different types of torture can lead to different clinical features which can vary with duration, frequency, intensity, underlying medical conditions etc. With each sign or symptom, the HCP should be able to assess the likelihood of having been caused because of torture. The disability and loss of function caused by the injury should be objectively assessed and the level of recovery should also be assessed. The terminology that should be used for documentation ranging from ‘not consistent with torture’ to ‘diagnostic of’
Skin injuries
The skin should be examined for generalized disease, including nutritional deficiencies. Skin changes due to torture can include abrasions, bruises, pigmentation changes, lacerations, puncture wounds, burns from cigarettes, chemicals, scalding liquids or heated instruments, electrical injuries, incised wounds, alopecia and nail removal.
Torture lesions should be described by their localization, symmetry, shape, size, colour and surface (e.g. scaly, crusty or ulcerating), as well as their demarcation and level in relation to the surrounding skin. Clinicians should note if normal hair growth is absent or there are any areas of numbness. Lesions may be described as fresh/acute or healed. Photography is recommended whenever possible. For injury interpretation it is useful to consider if the lesion is a pigmented or depigmented lesion, a scar or contains areas of scarring.
The examination should include the entire body surface in order to detect signs of generalized skin disease, including signs of vitamin A, B and C deficiencies, pre-torture lesions or lesions inflicted by torture, such as abrasions, bruises, pigmentation changes, lacerations, puncture wounds, burns from cigarettes, chemicals, scalding liquids or heated instruments, electrical injuries, incised wounds, alopecia and nail removal.
Torture lesions should be described by their localization, symmetry, shape, size, colour and surface (e.g. scaly, crusty or ulcerating), as well as their demarcation and level in relation to the surrounding skin. Clinicians should note if normal hair growth is absent or there are any areas of numbness. Lesions may be described as fresh/acute or healed. Photography is recommended whenever possible. For injury interpretation it is useful to consider if the lesion is a pigmented or depigmented lesion, a scar or contains areas of scarring.
Speculative judgements should be avoided in the evaluation of the nature and age of traumatic lesions since a lesion may vary according to the age, sex, condition, and health of the individual, the tissue characteristics, and the severity of the trauma. Fresh and old injuries can be seen together on people who have a long history of torture.
Infection, irradiation, corticosteroids, scurvy (vitamin C deficiency), diabetes, hepatic cirrhosis, uraemia, blood loss, cold, and shock all inhibit wound healing. Wounds heal faster in young people. Bruises resolve over a variable period, ranging from days to weeks. Estimating the age of bruises is one of the most contentious areas of forensic medicine.
When the skin is injured it can respond in different ways
• Contusions (commonly known as bruises)
• Abrasions (or grazes)
• Incisions (including stab wounds)
• Lacerations (also, commonly but confusingly, known as cuts)
• Burns and scalds.
The skin can present signs of torture in several ways. These should be documented in detail and accurately. Acute lesions may present with pain, secondary infection or poor healing (this could be due to the location or due to nutritional/metabolic diseases).
The examination of the skin should include the entire body surface to detect signs of skin diseases, non-torture-related lesions and/or torture-related lesions.
With skin lesions, document the following
Location, preferably using the body diagram and indicating if they are symmetrical or asymmetrical
Shape - whether round, oval, linear, irregular etc.
Size -using a ruler or measuring tape
Color - if it is uneven, this should be described
Surface - whether inflamed, scaly, crusty, ulcerated, necrotic
Smell - Some lesions, if infected, can have a smell.
Edges - Whether regular or irregular, elevated, pigmented, inflamed
Bruises
A bruise occurs following a blow (blunt trauma) that does not break the skin, and causes rupture of blood vessels and hemorrhage into soft tissues, making the area tender and boggy. The extent and severity of the bruise depends on the amount of force applied as well as the structure and vascularity of the bruised tissue.
If the skin and subcutaneous tissues are thin, the bruise becomes apparent relatively quickly and may take the shape of the inflicting instrument used, although this might not be obvious in darker skins. For example, a blow from a baton or heavy stick often leaves two parallel lines of bruising (tramline bruising) caused by the blood being pushed sideways by the contact. The shape of the object may be inferred from the shape of the bruise. The colour of a bruise does not assist in assessing age of injury.
The perception of bruise colour varies according to skin tone and cannot be determined accurately from images. In some skin types, bruising can lead to hyperpigmentation, which can last several years. Bruises that develop in deeper subcutaneous tissues may not appear until several days after injury, when the extravasated blood has reached the surface. Ideally bruises should be photographed as soon as possible, before they spread or fade. Some bruises may become better defined after some time in which case person may need to be examined again.
When the bruise is deep the blood tracks slowly to the surface, and it may be several hours or even days before anything is visible. It is often helpful in such cases to re-examine the patient a day or two later. In such cases the extravasated blood (blood that has been lost from the vessels) follows tissue planes and may emerge some distance from the original injury, and is unlikely to be tender. For example, bruising of any part of the face may appear below the eye. Thus the site of the bruise is not the site of the injury, but the size of the bruise could be evidence of the force of the blow. This should be made clear in any report.
They occur more readily in areas of thin skin overlying bone or in fatty areas. Many medical conditions, including vitamin and other nutritional deficiencies, age and medication may be associated with easy bruising or purpura. Dietary deficiencies of, for example, vitamin C (scurvy), can cause spontaneous and widespread bruising. This may be evidence of neglect of detainees. Extensive bruising not explained by the history should, if possible, be investigated in case it is the consequence of a disease.
In older people and those on certain types of medication, clotting is impaired and bruising is much larger than usual. This is particularly the case in those areas where the skin is loose. In these patients, for example, a minor injury on the neck can result in a large bruise. Bruises change colour and fade over a period of hours and days as the blood pigments are metabolised and absorbed, but this takes a different amount of time in different parts of the body following a single incident. However, if there are bruises at different stages of resolution in the same place, this could support allegations of repeated assaults over several days.
The absence of a bruise or abrasion, however, does not indicate that there was no blunt force to that area. In cases of an allegation but an absence of a bruise, the victim should be re-examined after several days.vIt should be taken into consideration that the final position and shape of bruises may bear no relationship to the original trauma and that some lesions may have faded by the time of re-examination.
Permanent changes in the skin due to blunt trauma are non-specific and usually without diagnostic significance. Prolonged application of tight ligatures may result in characteristic findings, including a linear zone extending circularly around the arm or leg, usually at the wrist or ankle, containing few hairs or hair follicles, a form of cicatricial alopecia.These findings are relatively rare, however; it is more common to see short, linear, narrow scars over the bony sides of the wrists from handcuff abrasions, especially in situations in which the person has been beaten while suspended by handcuffs. These findings may be diagnostic of the alleged torture or ill‑treatment as there are no other skin diseases or injuries that could account for such findings. Ligature injuries will depend on the tightness of the ligature, the nature of the ligature used, and the force applied, such as twisting of handcuffs or suspension and beating while handcuffed.
Abrasions
Abrasions are caused either by a blow with a blunt object or a fall onto a rough surface. Parts of the epidermis are rubbed away, sometimes in lines showing the direction of the impact. They are more likely to occur if the superficial tissues are thin, for example, over a bone.Acute abrasions resulting from superficial scraping lesions of the skin may appear as scratches, brush burn type lesions or larger scraped lesions. At times, acute abrasions may show a pattern that reflects the contours of the instrument or surface that inflicted the injury. Repeated or deep abrasions may create areas of hypo or hyperpigmentation, depending on skin type. This occurs on the inside of the wrists if the hands have been tied together tightly.
During the two or three days following the injury, abrasions produce fluid that crusts over. This makes them very susceptible to infection, which delays and distorts the healing process. Unless the abrasions are full-thickness, they will heal with few remaining signs, although they can leave hyperpigmentation or hypopigmentation.
Abrasions may show a pattern that reflects the contours of the instrument or surface that inflicted the injury. For example, ropes can cause abrasions wider than the rope itself. When the blunt force is directed perpendicularly to the skin over the bony prominences, it will generally crush the skin at that point. Sometimes, if there is anything between the object and the skin, its imprint may be observed on the skin. In hanging and other asphyxiation by ligature, patterned abrasions can sometimes be found on the neck.
Sometimes, survivors of torture may be thrown from moving vehicles so that they slide on the road, or they may be dragged along the ground during arrest or capture. In these cases, extensive abrasions may be seen, and particles of dirt, sand, etc. will predispose the abrasion to infection. The same particles may become embedded in the skin and leave a sort of ‘tattoo’ effect that can persist for years. Scratches are caused by sharp objects that produce superficial linear cuts. Identifiable patterns of scratches can be seen, for example, from fingernails.
Incisions
Incisions are caused by sharp objects like broken bottles, knives and blades that produce a more or less deep, sharp and well-demarcated skin wound. They must be differentiated from lacerations in which the skin is torn. The term ‘cut’ should never be used in a report, as colloquially the term usually means a laceration.
Incisional wounds have clearly defined edges and, on close inspection, it may be possible to see that hairs have been cut. There are no tissue bridges. Sometimes the wound can be jagged, suggesting that it was not caused by a single stroke. However, because the skin stretches as it is cut, the size of the wound is not necessarily related to the size of the implement used.
Small wounds and those that are supported by surrounding tissues heal at the surface, and they may be difficult to see after only a few days. If the wound is in a part of the skin that is not supported, it will gape. Unless it is sutured or otherwise closed, it will heal from inside.
Stab wounds are incisions that are deeper than they are wide. They should be examined carefully because of the risk of damage to deeper structures.
Lacerations
Lacerations are caused by a tangential force such as a blow or a fall and produce tears of the skin. The wound edges tend to be irregular, and often any may be bruised or/and abraded. There might be tissue bridges (where the skin has not separated along the entire length of the wound).
Burns and scalds
Burns are usually caused by dry heat, but the skin can also be scalded with very hot liquids or burnt with chemicals. Burning is the form of torture that most frequently leaves permanent changes in the skin.
The shape of the lesion can sometimes, but not always, reveal the shape of the object that caused the burn. The damage caused by heat is proportional to the temperature and the duration of exposure.
Burns are classified into three degrees, according to severity.
In superficial (first degree) burns there is no permanent damage to the epidermis. They present as a reddening of the skin
In partial thickness (second degree) burns some of the epidermis is destroyed and there may also be damage to deeper tissues. They present as moist, red, blistered lesions and are normally very painful
In full thickness (third degree) burns there is complete destruction of the epidermis and significant damage to deeper tissues. They may not be as painful as partial thickness burns. If the burns are widespread, there is usually death from shock and fluid loss.
Cigarettes are commonly used by torturers to inflict pain. Most cigarette burns are superficial and fade over a few hours to a few days. They tend to be circular, and have a diameter from 5-10 mm up to 1 cm. They cause an erythematous (reddening of the skin) and an oedematous circle that can blister.
Deeper burns are caused when the lit cigarette is pressed against the skin for a long time. When this happens the lesion is deeper and there might be a full thickness burn in the centre surrounded by blisters. If the cigarette is rubbed in, it leaves a larger and more irregular lesion.
Burns from hot objects tend to take the shape of the surface that caused the burn. The wound contracts as it heals, so the lesion may be smaller than the object. Liquids flow on contact with the skin, and this can leave a distinctive pattern reflecting the survivor’s posture at the time of the incident. Scalds lose heat rapidly so the resulting lesion diminishes away from the point of first contact, whereas chemical burns are often more extensive. A number of lesions from scalding in different parts of the body are suggestive of torture. A single burn might be caused by torture but could also be due to an accident either at work or otherwise. A good occupational history is paramount.
Burning with cigarettes, hot instruments or hot fluids leaves acute burns of varying degrees. Burning is the form of torture that most frequently leaves scars, often of diagnostic value. Cigarette burns often leave 5-10 mm large, circular and macular scars with a depigmented centre and a hyperpigmented, relatively indistinct periphery.1 Burning via the transfer of larger amounts of energy to the skin than those transferred when stubbing a cigarette on the skin often produces markedly atrophic scars. They present a narrow, regular, hyperpigmented or hypertrophic periphery, originating from the inflammatory zone, which surrounds the necrotic tissue in the acute phase. While their shape reflects the shape of the instrument used, their size relates to the amount of energy transferred to the skin. Following alleged torture from burning on several areas of the skin with a heated, circular metal rod the size of a cigarette, mostly circular scars with an atrophic centre and a regular, narrow, hyperpigmented or hypertrophic zone in the periphery can be observed. Burns on the nails leads to striped, thin, deformed nails which can also be broken.
Bites
They tend to be a mixture of laceration and crush injury. Human bites, especially those that are sexual in nature, can show petechiae from sucking. Petechiae are obvious in the twenty-four hours following the assault. The marks from human bites have a semicircular shape and appear blunt. Animal bites cause deeper and sharper wounds. It is important to look for lacerations caused by the claws
Blunt trauma
Blunt trauma may leave contusions or lacerations with extravasation of blood into the skin and subcutaneous tissue, and leave ecchymoses, contusions or lacerations, in some cases reflecting the shape of the instrument used, e.g. from beating with a stick.
Blunt trauma often leaves no or uncharacteristic scars. Flogging or beating with canes or truncheons may, however, leave characteristic scars, e.g. asymmetric, linear, straight or curved or “tramline”-shaped scars, showing a pattern of external infliction. The hemorrhagic areas can move down over the next few days.
Deep tissue bruises may not be visible on surface and only tenderness may be present. blunt injuries can change colour from dark red, to purple to brown or green or yellow followed by hyperpigmentation or disappearance. The scars may be hypertrophic with a narrow, regular, hyperpigmented area in the periphery, representing the inflammatory zone appear- ing around necrotic tissue in the acute phase.
Prolonged application of tight ligatures may leave a linear zone extending circularly around the arm or leg. Blunt trauma on feet (falanga) (described later in Section……)can leave contusions in the arch of the feet and swelling.
Scars
Various forms of physical torture like electric shock, burns (with cigarettes, instruments, scalding liquids, caustic substances), crush or penetrating injuries, stab wounds, amputations, surgical removal of organs etc. can cause scarring. Physical torture can leave scars which can become more difficult to interpret with time. They should be examined in good light and scar area measured. Scars should be documented in terms of size, shape, location (in relation to the closest anatomical landmark), color, contours, associated infection or tenderness, whether raised or flat, pigmentation,
Scars can be a form of medico-legal evidence even months or years after the incidents. The nature of scar can be affected by whether it had been infected or not, if there was repeated trauma in the same area, association with malnutrition etc. A detailed history can corroborate allegations of torture. It can also give an idea of whether healthcare services were adequate and quality of nutrition during the time of healing of the wound. Comparing photos of wounds when they occur with later scar formation can give clues to the nature of the injury.
Full thickness wounds (those that go through the epidermis) heal in one of two ways. When the wound is small and the edges are opposed, it heals from the top down (by primary intention). This tends to leave a small, tidy scar. Pockets of infection inside can become abscesses.
If this process cannot occur, especially if the wound gapes, it heals from below (by secondary intention). This is a slow process and prone to infection, and will leave a wide scar. When the original wound was straight, and especially if it was an incision, the scar tends to be symmetrical, with curved edges, and is widest at the middle (a biconvex scar). Pain and secondary infection can occur if lesions are located in areas of venous or arterial insufficiency. If close to a joint, they can induce contracture, decreased mobility of joint and pain.
The number, position and size of lesions may indicate other aspects of the conditions in which the individual was detained. For example, if the floor of a cell is flooded for any reason, and there is no access to a toilet so that the person has to urinate and defecate in the cell, the detainees will have to sit or stand in dilute sewage. In these circumstances, minor wounds, whether caused by assault or accident, may well become infected and can leave many small scars around the lower legs or buttocks. These must be differentiated from lesions left by childhood skin infections. All scars should be documented, including those that the individual is clear were caused in incidents other than torture. If those detained in certain centres have far more such lesions than other individuals from the same social background, this should be documented.
If a scar has suture marks around it, this should be documented, as this demonstrates that medical care was given. Equally it should also be noted if there are scars from wounds that have clearly not received medical attention, or have been seriously infected. Scars from surgery should also be noted, especially if it is alleged to be associated with torture, for example the removal of a ruptured spleen. Self inflicted scars are superficial and within easy reach of the dominant hand.
Keloids are scars that exceed the boundaries of the original wound. They are much more common in some skin types than others. The exact pathogenesis is unclear, but the tendency to them is probably inherited. Those who have a tendency to keloid will probably have several thickened scars on their bodies. Thus such scars are more difficult to attribute to specific allegations of torture.Sharp trauma, caused by the use of razor blades, knives etc. leave recognizable scars.
Cigarette burns often leave 5-10 mm large, circular and macular scars with a depigmented centre and a hyperpigmented, relatively indistinct periphery. Burning with heated metal rods can leave circular scars with atrophic centres and hyperpigmented or hypertrophic zone in the periphery.
Corrosive injuries by acid can cause linear scars with depigmented centre and hyperpigmented periphery. The path of the liquid running down the body can also show features of corrosive injury.
Scars seldom inconvenience the patient but can cause distress for cosmetic or psychological reasons because they can be a constant reminder of the torture.
Post-inflammatory hyperpigmentation
Hyperpigmentation can follow inflammation. The hyperpigmentation retains the shape of the original inflammation, which can be important forensically. For example, classic tramline bruising (e.g. parallel lines of bruising following a blow from a baton or similar object) or inflammation from burns can leave distinctive patterns of hyperpigmentation. The increased pigmentation can last for between five and ten years.
Whipping can sometimes leave lines of hyperpigmentation, especially in darker skin. These lesions are rarely confused with stria which are caused by sudden gain or loss of weight, so are also seen in some former detainees. They tend to be irregular rather than linear, and have a well-recognised distribution.
Less regular patterns of hyperpigmentation are seen following abrasions, again particularly in darker skins. Tight ropes or handcuffs may leave marks around the wrists, and marks following rope burns can be seen elsewhere on the body where the individual has been tied up or suspended. These are rarely pathognomonic individually, but the locations and distribution of the marks can support the history of torture.
As hyperpigmentation can follow any inflammation, any other cause of inflammation can cause a similar pattern. For example, lines of increased pigmentation that follow an irritant dermatitis from contact with plant stems can be mistaken for similar lines following whipping (although it is not unknown for victims to be whipped with irritant plant stems as a form of ill-treatment).
Hematoma
This can occur following blunt trauma. Blows with rods or sticks or lathis can leave two parallel lines (tramline bruises) or asymmetric, linear, straight or curved scars. The scars may be hypertrophic with a nar- row, regular, hyperpigmented area in the periphery, representing “arrowline” bruises or an inflammatory zone appearing around necrotic tissue in the acute phase. Hemorrhagic areas often move down the body during the following days. The color can change from dark red to dusky purple, to brown to green etc. Deep tissue bruises may not be visible on the surface of the skin particularly in dark skinned individuals. Prolonged application of tight ligatures may leave a linear zone extending circularly around the arm or leg.
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