Physical evidence of torture is often revealed in a comprehensive examination of the skin. Description of skin lesions should include the following:
- Localisation (use body diagram): symmetrical, asymmetrical
- Shape: round, oval, linear, circumferential, etc
- Size: (use ruler)
- Surface: scaly, crusty, ulcerative, bullous, necrotic
- Periphery: regular or irregular, zone in the periphery
- Demarcation: sharply, poorly demarcated
- Level in relation to surrounding skin: atrophic, hypertrophic, macular
Common injuries to the skin can be classified as:
- Abrasions (or grazes)
- Contusions (commonly known as bruises)
- Lacerations (also, commonly but confusingly, known as cuts)
- Incisions (including stab wounds)
- Burns and scalds.
An abrasion is a scraping away of the superficial portions of the epidermis or destruction of the superficial layers by tangential application of force against the rough surface of the blunt object. Abrasions are more commonly observed over bony prominences or where a thin layer of skin overlies bone. When the blunt instrument scrapes off the superficial layers of the skin the surface is striped. If abrasions are deep and extend down to the dermis, capillaries may bleed, and serosanguineous fluid deposits on the surface of the skin that forms a brownish scab when it dries out. The abrasion remains moist until it forms a scab which consists of a hardened exudate. 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. The scab organizes in a few days and covers the lesions for up to a few weeks, and then it usually leaves a pink intact surface after detaching. The pink colour gradually fades, within a few months. Unless the abrasions are of full-thickness, they will heal with few remaining signs, although they can leave hyperpigmentation or hypopigmentation.
Linear abrasions are referred to as scratches. These are caused by pointed objects such as wire-ends and pins. Sometimes victims of torture may be thrown from moving vehicles so that they slide on the road, or they may be dragged out on 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.
Abrasions may show a pattern that reflects the contours of the instrument or surface that inflicted the injury. Identifiable patterns of scratches can be seen, for example, from fingernails. Elongated broad abrasions can be caused by the friction on the skin from objects such as ropes and cords. When the blunt force is directed perpendicular 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, such as a shoe print. In hanging and other asphyxiations by ligature, patterned abrasions can often be found on the neck.
A contusion or bruise is caused when blunt trauma occurs to the subcutaneous tissue resulting in rupture of blood vessels with extravasation into the neighbouring soft tissue. The continuity of the skin surface is unbroken. Contusions may be present not only in skin but also in muscles and internal organs. A haematoma is a focal collection of blood in the area of the bruise.
Contusions cause blood to leak from small blood vessels, making the area tender and sometimes boggy. If the skin and subcutaneous tissues are thin, the bruise becomes apparent relatively quickly and may take the shape of the weapon used, although this might not be obvious in darker skins. The extent and severity of a contusion are related to the amount of force applied, but more importantly vascular structure of the traumatised area affects them. Elderly people and children who have loosely supported vascular structure will bruise more easily than young adults. Many medical conditions are associated with easy bruising or purpura, including blood disorders, vascular disorders, and vitamin and other nutritional deficiencies. Certain types of medication can also impair clotting and result in more extensive bruising.
Sometimes the shape of the bruise helps to identify shape of the blunt instrument that caused the injury. 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. Ideally bruises should be photographed as soon as possible (see Medical Photography section below), before they spread or fade.
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.
Bruises change colour and fade over a period of hours and days as the blood pigments are metabolised and absorbed, but this takes a variable period 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.
Speculative judgments should be avoided in the evaluation of the nature and age of blunt traumatic lesions since a lesion may vary according to the age, sex, condition, and health of the patient, 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.
Irradiation, corticosteroids, scurvy, diabetes, hepatic cirrhosis, uraemia, denervation of the wounded area, blood loss, cold, concussion, and shock all inhibit wound healing. Wounds heal faster in young people. Bruises resolve over a variable period, ranging from days to weeks. Reddish-blue, blue or purplish-black bruises are almost certainly recent. As the extravasated red cells are destroyed, the aging bruise goes through variable colour changes of bluish-green, greenish-yellow and brown. Estimating the age of non-recent bruises is one of the most contentious areas of forensic medicine.
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). Lacerations develop easily on the protruding parts of the body since the skin is compressed between the blunt object and the bone surface under the subdermal tissues. With sufficient force, however, the skin can be torn on any portion of the body.
Incisions are caused by sharp objects like a knife, bayonet, or broken glass that produce a more or less deep, sharp and well-demarcated skin wound. The acute appearance is usually easy to distinguish from the irregular and torn appearance of lacerations. 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.
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 a form of torture that 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. Sometimes third-degree burns are seen with complete destruction of all layers of the skin. The shape of the lesions may or may not reflect the shape of object that caused the thermal injury. 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, have a diameter of 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 longer 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. The cigarette fire has a conical structure and its intensity may vary on different parts of the surface. Sometimes there is indistinct blister formation and the lesion is deeper in one part, with blisters partially or totally surrounding it. There may be complete disruption of the epidermis and most of the basal layer.
Electric burns usually consist of a red brown circular lesion, 1 – 3 mm in diameter, usually without inflammation, and may result in a hyperpigmented scar. The skin surfaces involved must be examined carefully because the lesions are often not easily discernible.
Electrical burns may produce specific histologic changes, but these are not always present, and the absence of such changes in no way mitigates against the lesion being an electrical burn. The decision must be made on a case by case basis as to whether or not the pain and discomfort associated with a skin biopsy can be justified by the potential results of the procedure.
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.
Many lesions comprise areas of different types of wounds. For example, as noted above, many lacerations are bruised and abraded at their edges. Wounds caused by broken glass may be a mixture of incision and laceration.
Bites 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.
It is often the case that a health professional will see a survivor of torture months or years after the incidents. In such cases the wounds are likely to have healed to a greater or lesser extent. Healing is influenced and often impaired by many factors that can be present in places of detention including persistent, untreated infection; repeated trauma to the same area; and malnutrition. When faced with the examination of old injuries, it is thus important to obtain a detailed history from the individual of the acute appearance of the injury, any treatment received (such as sutures, antibiotics) and a description of how the wound healed and in what time frame. Such descriptions from a lay person may in themselves assist in corroborating allegations since they may indicate medical phenomena that a lay person would not usually be aware of. Such a description of wound healing may also reveal elements of the detention which are also deliberately neglected, such as:
- Inadequate healthcare provision
- Poor toilet and washing facilities
- Insufficient or nutritionally incomplete diet.
The commonest physical finding following the late examination of survivors of torture is scarring. Most scars are nonspecific, but some individual scars can be helpful in supporting a history of torture, as can the pattern of scarring. Occasionally the individual will have photographs of the acute lesions, and these can be very helpful in giving an opinion on the cause of the late signs. However, before citing such photographs in an expert report, it is essential to be certain of the date of the photographs, and that they really are of that individual.
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).
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 and other causes. All scars should be documented, including those that the individual feels were caused in incidents other than torture.
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.
Sometimes scars are self-inflicted in order to support a weak medico-legal case, but these are often apparent. Generally they are superficial and within easy reach of the dominant hand.
Small regular patterns of scarring, particularly but not exclusively in Africans, could either be tribal marking or caused by traditional healers. The former are generally on the face. The latter tend to be multiple, symmetrical, and around painful parts of the body. However, some torturers may also produce small symmetrical patterns of scarring.
Bullet wounds are rarely caused during torture but may be caused prior to arrest or during escape (sometimes security forces stage escapes before shooting detainees). Generally, as a bullet enters the body it leaves a small, regular wound, but as it leaves the wound is much larger and more ragged. The appearance depends on the distance from the weapon and its type. If there is an entry wound but no exit wound, it may be appropriate to arrange an X-ray to find out if the bullet is still in the body. A photograph or, if a camera is not available, a drawing of the wounds might be helpful if an expert opinion needs to be sought.
Small wounds to the backs of the hands can be caused by punching or being hit. Wounds on the backs of the forearm could be defence injuries. The inside of the non-dominant forearm is the usual location of self-inflicted wounds. Superficial abrasions or reddening around the wrists could have been caused by tight handcuffs or cords. At a later stage there is often hair loss and there may be hyperpigmentation.
Finger and toe nails can be extracted or crushed during torture, but the late appearance is normally indistinguishable from infection or innocent trauma. Vaccination scars should be noted to ensure they are not attributed to ill-treatment.
Scars on the knees and shins are common in many people, especially those who have played contact sports. Thus lesions in this part of the body can rarely be significant, though they might be consistent with allegations of torture. Additionally, tropical ulcers in childhood can leave large, irregular scars primarily around the lower legs. Lesions on the upper thighs and particularly those inside the thighs are much more important, as they are less likely to be the result of disease or accidental causes.
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.
Hyperpigmentation can follow inflammation in darker skins, irrespective of the cause. It is not seen in pale skins, nor in very dark skins. 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 striae distensae (see below) commonly referred to as “stretch marks.”
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).
Striae distensae (stretch marks) are most common on the abdomen (especially after pregnancy), the lower back, the upper thighs, and around the axillae. They are hypopigmented lines in which the skin might be folded. They must not be confused with scars from whipping. In striae, the skin is intact. They can be evidence of significant weight loss, for example in detention.