Ecchymoses are more easily produced in the young, the aged, and in females, also in the case of such general diseases as scurvy, purpura, hemophilia, etc. In fact, in the last three classes they may occur spontaneously. This fact should never be lost sight of, as the attempt may be made to explain a traumatic ecchymosis in this way. The diagnosis between the traumatic variety and such cases of spontaneous ecchymoses is, in general, easy, for in the latter case their number, form, size, and occurrence on parts little exposed to injury and on the mucous membranes, as well as the general symptoms of the disease, leave little or no room for doubt.
From an oblique or glancing blow a considerable area of skin may be stripped up from its deep attachments forming a cavity which may be filled by a clear serous fluid alone, or with some admixture of blood. These cases have been studied especially by Morel Lavallée and Leser, and the fluid has been thought to be lymphatic in origin, hence the name “lymphorrhagia.” Carriage accidents, especially where the wheels do not pass directly but obliquely across or merely graze the body, are especially liable to show this form of extravasation, which is thought to be more common than is generally supposed, being often obscured by a small quantity of blood.
Fig. 8.—Linear Wound with Nearly Clean-Cut Edges, with Strands of Tissue bridging across at the Bottom and caused by a Fall on the Head on a Smooth Surface.
Contused Wounds.—If with the contusion we have a solution of continuity of the skin, then we have a contused wound. This may sometimes resemble an incised wound if the weapon has marked angles or edges, as a hammer, or, as we have already seen, in wounds of the scalp or eyebrow (Fig. 8). Careful examination, however, by a small lens if necessary, is sufficient to distinguish them if they are fresh. If they are four or five days old and have begun to granulate, it may be impossible to distinguish them. Contused wounds present on examination small tears on the edges which are widely separated and more or less extensively ecchymosed. Contused wounds are often irregular, and have thickened or swollen and ragged borders. They may, like simple contusions, show by their shape the form of the instrument which caused them. In contused wounds, unless they be perfectly aseptic, we usually find sloughing of the contused, necrotic tissues. This leaves a cavity to be filled up by granulation like wounds with loss of substance. They therefore often present large cicatrices which may be mistaken for those of ulcers. In contused wounds the bone may sometimes show the impression of the instrument causing the wound.
A variety of contused wounds is that where the wound of the skin consists merely of an erosion or excoriation with an ecchymosis beneath. The wound may reproduce the shape of the weapon, i.e., finger-nails, etc. After death the skin becomes brownish-yellow, hard, and dry, and then they are called by the French “plaques parcheminées.” They are distinguished, as a rule, from those produced after death, by the ecchymosis beneath.
Lacerated wounds resemble contused wounds very closely, but are not ecchymosed to any considerable extent. The solution of continuity is sometimes very extensive and irregular, and may present several flaps. The bone or bones are often fractured at the same time. They seldom bleed much. The course of repair resembles that of contused wounds as a rule. The prognosis is variable, for there may be slow and extensive cicatrization and impairment of function, etc. These wounds usually result from machinery accidents and accidental tears, etc. They are therefore seldom the occasion of criminal proceedings but more often of a civil suit, and thus require medical examination.
The injury which causes a contusion or contused wound may not infrequently produce effects far more serious and more or less remote from the contusion. Some of these effects it may be well to particularize. Blows on the abdomen are sometimes quickly followed by death without visible lesion to account for it. That authentic examples of this exist has been denied by Lutaud, except for cases of rapid death following contusions of the abdomen which had caused extensive rupture of the viscera and abundant hemorrhage. But Vibert gives two cases from his own experience, which are as follows:
A young man, twenty years old, received a kick in the stomach at a public ball. Numerous witnesses of the scene testified that he only received this one blow. The man collapsed immediately and died in a few minutes. On autopsy nothing was found but two small ecchymotic spots in the peritoneum covering the intestine, the largest not the size of a bean.