Int J Legal Med (2016) 130:1599–1601
DOI 10.1007/s00414-016-1386-4
CASE REPORT
The truth lies within: the reconstructive value of inner livores
in a homicide case
Eva Brenčičová 1 & Manuela Baglivo 1 & Nicole Schwendener 1 & Christian Schyma 1 &
Christian Jackowski 1
Received: 7 April 2016 / Accepted: 3 May 2016 / Published online: 12 May 2016
# Springer-Verlag Berlin Heidelberg 2016
Abstract Through the widespread use of postmortem
computed tomography, inner livores of the lungs have
become a frequently observed phenomenon in the field
of forensic medicine. Yet their time-dependent develop-
ment, notably in comparison with the widely studied ex-
ternal livores, remains poorly understood. We present a
unique homicide case where the victim was discovered
in supine position with correspondent external livores
fixed exclusively on the rear side. Yet upon postmortem
computed tomography, the victim presented pronounced
inner livores within the depending dorsal areas of both
lungs but also vertical sedimentation levels solely within
the right lung, suggesting an initial right-hand side posi-
tion and a postmortem re-positioning of the body.
Interestingly, this was consistent with tangible hints of
postmortem manipulation on-site. It is likely that this re-
positioning occurred sometime during the early postmor-
tem interval (<6 h) as the external livores have completely
rearranged to the final supine position. The presented case
suggests different development patterns of inner and outer
livores, highlighting the necessity for controlled studies
that explore the formation and fixation processes of livor
mortis in internal organs. A better understanding of these
issues can prove useful in forensic examinations.
Keywords Livor mortis . Inner livores . Postmortem
imaging . Early postmortem interval . Homicide
* Eva Brenčičová
eva.brencicova@irm.unibe.ch
1
Institute of Forensic Medicine, University of Bern, Bühlstrasse 20,
3012 Bern, Switzerland
Case history
Scene findings
The corpse of a 74-year-old man was discovered in his single-
family detached house. The scene was immediately recog-
nized as one of a violent case of a homicide. The body was
found on the ground floor in supine position. The legs of the
victim were extended, with the left leg folded over the right
leg. The trousers were stained with blood on the front side
(Fig. 1a). To the right of the corpse was a large pool of dried
blood, which showed, approximately 20 cm to the right of the
head of the corpse, an area with only a thin film of dried blood
on the floor. In the same area, brain tissue was found (Fig. 1b).
External examination findings
Upon external examination, the corpse presented extensive
evidence of both blunt force trauma and wounds suggestive
of multiple blows to the skull with a sharp and/or semi-sharp
object, causing complex skull fractures, emergence of brain
tissue and considerable blood loss. The time of death of the
victim was estimated to be approximately 2–3 days prior to
the discovery of the corpse. Rigor mortis was beginning to
resolve and the external livores of the body were fixed exclu-
sively on the rear side (Fig. 2).
Postmortem computed tomography findings
Besides skeletal findings related to severe blunt and semi-
sharp forces to the head and a venous air embolism, postmor-
tem computed tomography (PMCT) revealed inner livores
located in the dependent dorsal regions of both lungs, but also
vertical sedimentation levels on the right side of the right lung
were clearly visible (Fig. 3).
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a b
Fig. 1 Scene of discovery. a The corpse was found in supine position,
with the left leg folded over the right leg (solid arrow). The trousers of the
victim showed blood stains on the front, while the soles of the victim’s
socks were clean of blood. b A large pool of dried blood to the right of the
corpse included an area approximately 20 cm to the right of the victim’s
head where only a thin film of dried blood covered the floor and where
brain tissue was found (dotted arrow)
Autopsy findings
At autopsy the traumatic findings could be confirmed. As
incidental finding the right lung presented slightly more
congested than the left one, which was also reflected by the
pulmonary weight of 530 g (right) and 350 g (left).
Discussion
Livor mortis occurs postmortem when active blood flow
throughout the body seizes, and due to gravity, blood passive-
ly sets in the dependent parts of a corpse [1]. External livores
are visible on the body surface and represent blood that has
accumulated in the capillaries of the skin. Livor mortis of the
skin is a thoroughly studied phenomenon, having been ob-
served by forensic experts for decades. The behavior of livores
upon external examination of a corpse can provide crucial
information about the length of the postmortem interval and
therefore plays an important role in the estimation of the time
Fig. 2 Pronounced external livores, fixed exclusively on the rear side
Int J Legal Med (2016) 130:1599–1601
Fig. 3 Postmortem computed tomography revealed inner livores of the
dependent areas of both lungs (solid arrows), corresponding to the final
supine position of the victim upon discovery. In addition, vertical
sedimentation levels appeared solely on the right side of the right lung
(dotted arrows), indicating an initial right-sided position of the corpse
after death
of death [2, 3]. Further, the patterns and distribution of livores
can reveal details about the postmortem position of a body and
possible alterations of the latter.
External livores are the earliest among the certain signs of
death, appearing approximately 20–30 min after the cessa-
tion of the cardiovascular circulation. Within approximately
the first 6 h after death, the plasma and cellular components
of blood sink and sediment within the subcutaneous vessels,
but the blood remains fluid and external livores can rear-
range entirely if the position of a body is altered, setting in
the newly dependent parts of the skin [4, 5]. In the postmor-
tem interval of approximately 6–12 h, due to the cessation of
energy-supplying processes that maintain the vital osmotic
and colloid osmotic pressure within the vascular system,
serum and electrolytes begin to diffuse out of the vascular
lumen, leading to an increase of the hematocrit and of blood
viscosity [6]. This causes a partial fixation and thus an in-
complete rearrangement of external livores upon alteration
of a body’s position. Beyond 12 h after death, the process
has advanced to the point where no passive blood flow can
be induced within the small subcutaneous vessels by moving
the corpse, meaning that external livores remain fixed, not
altering their distribution in the event of a change of the
position of the body [3, 7].
In the presented case, the external livores of the victim were
fixed exclusively on the rear side, corresponding to the supine
position of the corpse upon discovery.
Naturally, sedimentation of blood in the dependent parts of
the body after death does not only occur in the skin but also in
internal organs. In the field of forensic medicine, internal
livores were increasingly documented by the use of postmor-
tem imaging, notably PMCT, a method now applied widely
Int J Legal Med (2016) 130:1599–1601
and routinely as a complement to traditional autopsy in foren-
sic institutions worldwide. Visible sedimentation levels in
PMCT can be observed in the dependent parts of internal
organs, notably the lungs [8], but also other organs such as
the heart [9], the spleen, and the liver [10]. Particularly in the
lungs, the discrimination between natural postmortem chang-
es such as livor mortis and pathological processes, e.g., pneu-
monia, can prove difficult, notably as the formation of inner
livores is a dynamic process and their extent and intensity
most likely change over time. Moreover, late postmortem
changes such as putrefaction can further alter the appearance
of inner organs in PMCT and make a correct interpretation of
radiological findings very challenging [11]. The reliable rec-
ognition and evaluation of inner livores in PMCT, therefore,
requires substantial experience and proficiency on the part of
forensic experts.
In the presented case, PMCT of the corpse revealed both
inner livores in the dependent, rear parts of both lungs, con-
sistent with the external livores and the supine position of the
body upon discovery as well as vertical sedimentation levels
that were located exclusively in the right lung. This combina-
tion suggests an initial position of the body on the right-hand
side, when internal lividity formed in the right lung, and sub-
sequent re-positioning of the body into supine and final posi-
tion, with only a partial displacement of the internal livores to
the newly dependent, rear areas of both lungs.
The assumption that the body of the victim was moved
some time after death is supported by further hints on-site.
The extended position of the lower extremities, with the left
leg folded over the right leg, appears unnatural. It is likely that
it came about through the repositioning of the corpse from the
initial right-hand side position into the final supine position by
a third party, possibly by turning the upper body, with the legs
following the movement passively. The dried pool of blood to
the right-hand side of the corpse shows an area in close prox-
imity to the head where only a thin film of blood covers the
floor and where brain tissue was present. This was presumably
where the head was initially positioned before it was shifted to
the left as part of the turning process of the body.
While the existence of inner livores and their identification
in postmortem CT and MRI are now firmly established, their
time-dependent development and behavior remain poorly un-
derstood. To the authors’ knowledge, the presented case is the
first where a discrepancy between the localization of internal
and external livores was of forensic importance. This discrep-
ancy strongly suggests different patterns of their formation
and/or fixation. Seen as the external livores had rearranged
entirely to the final supine position, the manipulation of the
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corpse most likely happened in the early postmortem interval
(<6 h). An only partial rearrangement of the internal livores
suggests that hemoconcentration and increase of blood viscos-
ity due to diffusion of the serum out of the vascular system
after stagnation of circulation may occur earlier in internal
organs than it does in the skin.
Controlled studies are necessary for a better understanding
of inner livores and can elucidate important characteristics of
their development and evolvement. Such findings can contrib-
ute crucial and novel information in forensic examinations in
the future.
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