61 VOLUME฀114฀฀•฀฀NO.฀2 REVIEW ARTICLE • • • Author Affiliations: Departments of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wis (Epperla); Department of Clinical Research, Marshfield Clinic Research Foundation, Marshfield, Wis (Mazza); University of Florida College of Medicine, Gainesville, Fla (Yale). Corresponding Author: Narendranath Epperla, MD, Medical College of Wisconsin, Department of Hematology and Oncology, 9200 W Wisconsin Ave, Milwaukee, WI, 53226; phone 414.805.0516; fax 414.805.0535; e-mail nepperla@mcw.edu. region will have different shades of color, reflecting differential rates of hemoglobin catabolism. Ecchymosis caused by internal condi- tions can be divided into 4 anatomical areas (Table 1). These regions are assigned an eponym associated with the physician who first described the physical finding. In this report, we review the classical signs and eponyms associated with ecchymosis that may be markers of potentially serious internal bleeding. Furthermore, these signs may be potentiated by anticoagulation therapy or qualitative and quantitative platelet abnormalities. Prompt laboratory and imag- ing studies are important to further elucidate the cause of the ecchymosis and guide appropriate intervention. It is important that, in addition to a careful physical examination, a thorough review of the patient’s medications and past medical history be conducted. DISCUSSION It was not until 1761, when Leopold Auenbrugger first described the technique of percussion, that the physical examination came into vogue. However, it did not become popular until 1808 when Jean-Nicolas Corvisart (personal physician of Napoleon) endorsed the importance of medical signs. 1 Shortly thereafter, Laennec invented the first stethoscope, expanding the horizon of physicians’ senses. 2 The latter half of the 19 th century saw steady improvement in new inventions including the ophthal- moscope (Hermann von Helmholtz, 1850), medical thermom- eter (Carl August Wunderlich, 1871), and sphygmomanometer (Riva-Rocci, 1896). Thus, physical signs gained importance and popularity by the beginning of the 20 th century. 2,3 During this time period, there was a continued rise in new inventions and discoveries, as well as the emergence of novel diagnostic tests in medicine. Conducting a complete examination with cognizant focus on physical signs remained paramount for a physician to make a diagnosis. Several books and articles were published advo- cating the importance of the physical examination and providing INTRODUCTION Ecchymosis is defined as a large area of discoloration of the skin due to extravasation of blood into the subcutaneous tissue. The term is often used interchangeably with purpura, which describes similar characteristic discoloration of the subcutaneous tissue but usually is reserved for a larger, more extensive area of involve- ment. Ecchymosis is an objective physical finding that may provide valuable clues as to its possible etiology. The causes of ecchymosis are many; however, there are certain regions where the discoloration aids in the search for the etiology. The color of the subcutaneous tissue reflects the physiologic sequences of hemoglobin catabolism and its conversion to bilirubin and hemo- siderin. Thus, the tissue progressively transforms over time from purple or black and blue to a yellow and green color and finally a brownish discoloration. It is recognized that the ecchymotic ABSTRACT Ecchymosis is a large area of discoloration caused by extravasation of blood into the subcutane- ous tissue. It is an objective physical finding that may provide valuable clues as to its possible etiology. Ecchymosis is associated with eponyms based on the physician who first described the physical findings, which can be divided into 4 anatomical categories: base of the skull, abdomi- nal wall and retroperitoneum, groin and scrotum, and lower extremity. Classic external signs and eponyms associated with ecchymosis are reviewed. Knowledge of these signs on physical examination may prove to be a useful clue directing the examiner to consider potentially serious causes of disease. Narendranath Epperla, MD; Joseph J. Mazza, MD; Steven H. Yale, MD A Review of Clinical Signs Related to Ecchymosis