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V. PHYSICAL EVIDENCE OF TORTURE AND ILL-TREATMENT ISTANBUL PROTOCOL

later examination that may be distinctive. Regular not always of serious dimensions, cortical atrophy
patterns of small incisional scars could be due to and diffuse axonal damage can be expected. In cases
traditional healers. 431 If pepper or other noxious of trauma caused by falls, contrecoup (location in
substances are applied to open wounds, the scars opposition to the trauma) lesions of the brain may
may become hypertrophic. Juju ritual scars may be observed, whereas in cases of direct trauma,
have pigment, such as soot, rubbed in to them. contusions of the brain may be observed directly under
the region in which the trauma was inflicted. Scalp
434. Clinicians may be asked to estimate the age of scars. bruises are frequently invisible externally unless there
It is unlikely that much can be said unless a wound is swelling. Bruises may be difficult to see in dark-
appears very recent with redness and crusting. During skinned individuals, but will be tender upon palpation.
the process of wound healing the initial crusting is Estimates of a period of loss of consciousness following
followed by scar tissue formation, which appears red head injury are unlikely to be accurate as a person
at first and gradually becomes paler and flatter. Scar may suffer a period of peri-traumatic amnesia.
redness is variable and influenced by factors other
than the elapse of time, including skin tone. The time 437. Having been exposed to blows to the head, a torture
taken for a scar to evolve from the acute form to survivor may complain acutely of pain, dizziness,
the flat pale mature form is variable, depending on nausea, vomiting and visual disturbance. Chronically,
multiple factors, including trauma to wound edges, there may be persistent headaches dizziness and
depth of wound, infection, wound closure method, memory or other cognitive deficits. There may be
a “dirty” or clean wound, access to wound hygiene, seizure disorders. The pain may be somatic or may
the position on the body, tension on and movement be referred from the neck. The victim may report
of the wound, nutrition, chronic disease, pressure pain when touched in that region, and diffuse or
and friction of clothing. Some wounds (e.g. cigarette local fullness or increased firmness may be observed
burns) may be intensely itchy during healing, leading by means of palpation of the scalp. Scars can be
to a habit of scratching or rubbing them, which may observed in cases in which there have been lacerations
leave them red or pink long after other wounds have of the scalp. Acutely after head trauma, headaches
become quiescent. For these reasons, scars caused may be the initial symptom of an expanding
at the same time and by the same mode of injury subdural haematoma. They may be associated
may heal at different rates. While it is not usually with the acute onset of mental status changes and
possible therefore to give an exact opinion on the a CT scan must be performed urgently. Soft tissue
date of a lesion, it may be possible to state that the swelling or haemorrhage will usually be detected by
appearance is in keeping with the timeline stated. CT or MRI. It may also be appropriate to arrange
psychological or neuropsychological assessments (see
(b) Fractures paras. 549–565). Late effects of brain injury can be
detected with specialized radiological techniques.
435. Fractures produce a loss of bone integrity due to Minor traumatic brain injury, even without loss of
the effect of a blunt mechanical force on various consciousness, may affect memory and concentration
vector planes. A direct fracture occurs at the site of in the short and long term. Brain injury from
impact or the site at which the force was applied. asphyxia torture may also lead to cognitive deficit.
The location, contour and other characteristics of
a fracture reflect the nature and direction of the 438. Violent shaking as a form of torture may produce
applied force. It is sometimes possible to distinguish cerebral injury without leaving any external
a fracture inflicted through accidental injury by the marks, although bruises may be present on the
radiological appearance of the fracture. Radiological upper chest or shoulders where victims or their
dating of relatively recent fractures should be clothing has been grabbed. At its most extreme,
done by an experienced trauma radiologist. shaking can produce injuries identical to those seen
in the shaken baby syndrome: cerebral oedema,
(c) Head trauma subdural haematoma and retinal haemorrhages.
More commonly, victims complain of recurrent
436. Head trauma is one of the most common forms of headaches, disorientation or mental status changes.
torture. In cases of recurring head trauma, even if Shaking episodes are usually brief, only a few

431 Ibid.

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