The California Collection/TheCaliforniaCollection.cdr/his132/phydeath.lzh/PHYDEATH.TXT

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APO:On the physical death of Jesus Christ

   by William D. Edwards, MD;

   Wesley J Gable, MDiv,

   Floyd E. Hosmer, MS, AMI

   Jesus of Nazareth underwent Jewish and Roman trials, was flogged,
and was sentenced to death by crucifixion. The scourging produced deep
stripelike lacerations and appreciable blood loss, and it probably set
the stage for hypovolemic shock, as evidenced by the fact that Jesus
was too weakened to carry the crossbar (patibulum) to Golgotha. At the
site of crucifixion, his wrists were nailed to the patibulum, and,
after the patibulum was lifted onto the upright post (stipes), his feet
were nailed to the stipes. The major pathophysiologic effect of
crucifixion was an interference with normal respirations. Accordingly,
death resulted primarily from hypovolemic shock and exhaustion
asphyxia. Jesus' death was ensured by the thrust of a soldier's spear
into his side. Modern medical interpretation of the historical evidence
indicates that Jesus was dead when taken down from the cross. (JAMA
1986;225:1455-1463)

   The life and teachings of Jesus of Nazareth have formed the basis
for a major world religion (Christianity), have appreciably influenced
the course of human history, and, by virtue of a compassionate attitude
toward the sick, also have contributed to the development of modern
medicine. The eminence of Jesus as historical figure and the suffering
and controversy associated with his death have stimulated us to
investigate, in an interdisciplinary manner, the circumstances
surrounding his crucifixion. Accordingly, it is our intent to present
not a theological treatise but rather a medically and historically
accurate account of the physical death of the one called Jesus Christ.

   SOURCES

   The source material concerning Christ's death comprises a body of
literature and not a physical body or its skeletal remains.
Accordingly, the credibility of any discussions of Jesus' death will be
determined primarily by the credibility of one's sources. For this
review, the source material includes the writings of ancient Christian
and non-Christian authors, the writings of modern authors, and the
Shroud of Turin. Using the legal- historical method of scientific
investigation, scholars have established the reliability and accuracy
of the ancient manuscripts.

   The most extensive and detailed descriptions of the life and death
of Jesus are to be found in the New Testament gospels of Matthew, Mark,
Luke and John. The other 23 books of the New Testament support but do
not expand on the details recorded in the gospels. Contemporary
Christian, Jewish, and Roman authors provide additional insight
concerning the first-century Jewish and Roman legal systems and the
details of scourging and crucifixion. Seneca, Livy, Plutarch, and
others refer to crucifixion practices in their works. Specifically,
Jesus (or his crucifixion) is mentioned by the Roman historian
Cornelius Tacitus, Pliny the Younger and Suetonius, by non-Roman
historians Thallus and Phlegon by the satirist Lucian of Samosata, by
the Jewish Talmud, and by the Jewish historian Falvius Josephus,
although the authenticity of portions of the latter is problematic.

   The Shroud of Turin is considered by many to represent the actual
burial cloth of Jesus, and several publications concerning the medial
aspects of his death draw conclusions form this assumption. The Shroud
of Turin and recent archaeological findings provide valuable
information concerning Roman crucifixion practices. The interpretations
of modern writers, based on a knowledge of science and medicine not
available in the first century, may offer additional insight concerning
the possible mechanisms of Jesus' death.

   When taken in concert, certain facts--the extensive and early
testimony of both Christian proponents and opponents, and their
universal acceptance of Jesus as a true historical figure; the ethic of
the gospel writers, and the shortness of the time interval between the
events and the extant manuscripts; and the confirmation of the gospel
accounts by historians and archaeological findings--ensure a reliable
testimony from which a modern medical interpretation of Jesus' death
may be made.

   GETHSEMANE

   After Jesus and his disciples had observed the Passover meal in an
upper room in a home in southwest Jerusalem, they traveled to the Mount
of Olives, northeast of the city. (Owing to various adjustments in the
calendar, the years of Jesus' birth and death remain controversial.
However, it is likely that Jesus was born in either 4 or 5 BC and died
in 30 A.D. During the Passover observance in 30 A.D., the Last Supper
would have been observed in Thursday, April 6 [Nisan 13], and Jesus
would have been crucified on Friday, April 7 [Nisan 14.) At nearby
Gethsemane, Jesus, apparently knowing that the time of his death was
near, suffered great mental anguish, and, as described by the physician
Luke, his sweat became like blood.

   Although this is a very rare phenomenon, bloody sweat (hematidrosis
or hemohidrosis)may occur in highly emotional states or in persons with
bleeding disorders. As a result of hemorrhage into the sweat glands,
the skin becomes fragile and tender. Luke's description supports the
diagnosis of hematidrosis rather than eccrine chromidrosis (brown or
yellow-green sweat) or stigmatization (blood oozing from the palms or
elsewhere). Although some authors have suggested that hematidrosis
produced hypovolemia, we agree with Bucklin that Jesus actual blood
loss probably was minimal. However, in the cold night air, it may have
produced chills.

   TRIALS

   Jewish Trials

   Soon after midnight, Jesus was arrested at Gethsemane by the temple
officials and was taken first to Annan and then to Caiaphas, the Jewish
high priest for that year. Between 1 am and daybreak, Jesus was tried
before Caiaphas and the political Sanhedrin and was found guilty of
blasphemy. The guards then blindfolded Jesus, spat on him, and struck
him in the face with their fists. Soon after daybreak, presumably at
the temple, Jesus was tried before the religious Sanhedrin (with the
Pharisees and the Sadducees) and again was found guilty of blasphemy, a
crime punishable by death.

   Roman Trials

   Since permission for an execution had to come from the governing
Romans, Jesus was taken early in the morning by the temple officials to
the Praetorium of the Fortress of Antonia, the residence and
governmental seat of Pontius Pilate, the procurator of Judea. However,
Jesus was presented to Pilate not as a blasphemer but rather as a
self-appointed king who would undermine the Roman authority. Pilate
made no charges against Jesus and sent him to Herod Antipas, the
tetrarch of Judea. Herod likewise made no official charges and then
returned Jesus to Pilate. Again, Pilate could find no basis for a legal
charge against Jesus, but the people persistently demanded crucifixion.
Pilate finally granted their demand and handed over Jesus to be flogged
(scourged) and crucified.

   Health of Jesus

   The rigors of Jesus' ministry (that is, traveling by foot throughout
Palestine) would have precluded any major physical illness or weak
general constitution. Accordingly, it is reasonable to assume that
Jesus was in good physical condition before his walk to Gethsemane.
However, during the 12 hours between 9 pm Thursday and 9 am Friday, he
had suffered great emotional stress (as evidenced by hematidrosis),
abandonment by his closest friends (the disciples), and a physical
beating (after the first Jewish trial). Also, in the setting of a
traumatic and sleepless night, he had been forced to walk more than 2.5
miles (4.0 km) to and from the sites of the various trials. These
physical and emotional factors may have rendered Jesus particularly
vulnerable to the adverse hemodynamic effects of the scourging.

   SCOURGING

   Scourging Practices

   Flogging was a legal preliminary to every Roman execution, and only
women and Roman senators or soldiers (except in cases of desertion)
were exempt. The usual instrument was a short whip (flagrum or
flagellum) with several single or braided leather thongs of variable
lengths, in which small iron balls or sharp pieces of sheep bones were
tied at intervals. For scourging, the man was stripped of his clothing,
and his hands were tied to an upright post. The back, buttocks, and
legs were flogged either by two soldiers (lictors) or by one who
alternated positions. The severity of he scourging depended on the
disposition of the lictors and was intended to weaken the victim to a
state just short of collapse or death. After the scourging, the
soldiers often taunted their victims.

   Medical Aspects of Scourging

   As the Roman soldiers repeatedly struck the victim's back with full
force, the iron balls would cause deep contusions, and the leather
thongs and sheep bones would cut into the skin and subcutaneous
tissues. then, as the flogging continued, the lacerations would tear
into the underlying skeletal muscles and produce quivering ribbons of
bleeding flesh. Pain and blood loss generally set the stage for
circulatory shock. The extent of blood loss may well have determined
how long the victim would survive on the cross.

   Scourging of Jesus

   At the Praetorium, Jesus was severely whipped. (Although the
severity of the scourging is not discussed in the four gospel accounts,
it is implied in one of the epistles (1 Peter 2:24). A detailed word
study of the ancient Greek text for this verse indicates that the
scourging of Jesus was particularly harsh. It is not known whether the
number of lashes was limited to 39, in accordance with Jewish law. The
Roman soldiers, amused that this weakened man had claimed to be a king,
began to mock him by placing a robe on his shoulders, a crown of thorns
on his head, and a wooden staff as a scepter in his right hand. Next,
they spat on Jesus and struck him on the head with the wooden staff.
Moreover, when the soldiers tore the robe from Jesus' back, they
probably reopened the scourging wounds.

   The severe scourging, with its intense pain and appreciable blood
loss, most probably left Jesus in a preshock state. Moreover,
hematidrosis had rendered his shin particularly tender. The physical
and mental abuse meted out by the Jews and the Romans, as well as the
lack of food, water, and sleep, also contributed to his generally
weakened state. Therefore, even before the actual crucifixion, Jesus'
physical condition was at least serious and possibly critical.

   CRUCIFIXION

   Crucifixion Practices

   Crucifixion probably first began among the Persian. Alexander the
Great and Carthage, and the Romans appear to have learned of it from
the Carthaginians. Although the Romans did not invent crucifixion, they
perfected it as a form of torture and capital punishment that was
designed to produce a slow death with maximum pain and suffering. It
was one of the most disgraceful and cruel methods of execution and
usually was reserved for only slaves, foreigners, revolutionaries, and
the vilest of criminals. Roman law usually protected Roman citizens
from crucifixion, except perhaps in the case of desertion by soldiers.

   It its earliest form in Persia, the victim was either tied to a tree
or was tied to or impaled on an upright post, usually to keep the
guilty victim's feet from touching holy ground. Only later was a true
cross used; it was characterized by an upright post (stipes) and a
horizontal crossbar (patibulum), and it had several variations (Table).

   Variations in Crosses

   Used for Crucifixion

   Latin

   Designation Characteristics

   Infelix lignum Tree

   Crux simples, Upright Post

   crux acuta

   Crus composita Stripes and palbuium

   Crux humillis Low cross

   Crux subimis Tall cross

   Crux commissa T-shaped (Tau) cross)

   Crux immissa T-shaped (Latin)

   cross

   Crux capilata T-shaped (latin

   cross

   Crux desussaia X-shaped cross Although archaeological and historical
evidence strongly indicates that the low Tau cross was preferred by the
Romans in Palestine at the time of Christ crucifixion practices often
varied in a given geographic region and in accordance with the
imagination of the executioners, and the Latin cross and other forms
also may have been used.

   It was customary for the condemned man to carry his own cross from
the flogging post to the site of crucifixion outside the city walls. He
was usually naked, unless this was prohibited by local customers. Since
the weight of the entire cross was probably well over 300 LB (136 kg),
only the crossbar was carried. The patibulum, weighing 75 to 125 lb (34
to 57 kg), was placed across the nope of the victim's neck and balanced
along both shoulders. Usually, the outstretched arms then were tied to
the crossbar. The processional to the site of the crucifixion was led
by a complete Roman military guard, headed by a centurion. One of the
soldiers carried a sign (titulus) on which the condemned man's name and
crime were displayed. Later, the titulus would be attached to the top
of the cross. The Roman guard would not leave the victim until they
were sure of his death.

   Outside the city walls was permanently located the heavy upright
wooden stipes, on which the pitabulum would be secured. In the case of
the Tau cross, this was accomplished by means of a mortise and tenon
joint, with or without reinforcement by ropes. To prolong the
crucifixion process, a horizontal wooden block or plank, serving as a
crude seat (sedile or sudulum), often was attached midway down the
stipes. Only very rarely, and probably later than the time of Christ,
was an additional block (suppedaneum) employed for transfixion of the
feet.

   At the site of execution, by law, the victim was given a bitter
drink of wine mixed with myrrh (gall) as a mild analgesic. The criminal
was then thrown to the ground on his back, with his arms outstretched
along the patibulum. The hands could be nailed or tied to the crossbar,
but nailing apparently was preferred by the Romans. The archaeological
remains of a crucified body, found in an ossuary near Jerusalem and
dating from the time of Christ, indicate that the nails were tapered
iron spikes approximately 5 to 7 in (13 to 18 cm) long with a square
shaft 3/8 in (1 cm) long with a square shaft 3/4 (1 cm across).
Furthermore, ossuary findings and the Shroud of Turin have documented
that the nails commonly were driven through the wrists rather than the
palm.

   After both arms were fixed to the crossbar, the patibulum and the
victim, together, were lifted onto the stipes. On the low cross, four
soldiers could accomplish this relatively easily. However, on the tall
cross, the soldiers used either wooden forks or ladders.

   Next, the feet were fixed to the cross, either by nails or ropes.
Ossuary findings and the Shroud of Turin suggest that nailing was the
preferred Roman practice. Although the feet could be fixed to the sides
of the stipes or to a wooden footrest (suppedaneum), they usually were
nailed directly to the front of the stipes". To accomplish this,
flexion of the knees may have been quite prominent, and the best legs
may have been rotated laterally.

   When the nailing was completed, the titulus was attached to the
cross, by nails or cords, just above the victim's head. The soldiers
and the civilian crowd often taunted and jeered the condemned man, and
the soldiers customarily divided up his clothes among themselves. The
length of survival generally ranged from three or four hours to three
or four days and appears to have been inversely related to the severity
of the scourging. However, even if the scourging had been relatively
mild, the Roman soldiers could hasten death by breaking the legs below
the knees (crurifragium or skelopkopia).

   Not uncommonly, insects would light upon or burrow into the open
wounds or the eyes, ears, and nose of the dying and helpless victim,
and birds of pray would tear at these sites. Moreover, it was customary
to leave the corpse on the cross to be devoured by predatory animals.
However, by Roman law, the family of the condemned could take the body
for burial, after obtaining permission from the Roman judge.

   Since no one was intended to survive crucifixion, the body was not
released to the family until the soldiers were sure that the victim was
dead. by custom, one of the Roman guards would pierce the body with a
sword or lance. Traditionally, this had been considered a spear would
to the heart through the right side of the chest - a fatal wound
probably taught to most Roman soldiers. The Shroud of Turin documents
this form of injury. Moreover, the standard infantry spear, which was 5
to 6 ft (1.5 to 1.8 m) long could easily have reached the chest of a
man crucified on the customary low cross.

   Medical Aspects of Crucifixion

   With a knowledge of both anatomy and ancient crucifixion practices,
one may reconstruct the probable medical aspects of this form of slow
execution. Each would apparently was intended to produce intense agony,
and the contributing causes of death were numerous.

   The scourging prior to crucifixion served to weaken the condemned
man and, if blood loss was considerable, to produce orthostatic
hypotension and even hypovolemic shock. When the victim was thrown to
the ground on his back, in preparation for transfixion of the hands,
his scourging would most likely would become torn open again and
contaminated with dirt. Furthermore, with each respiration, the painful
scourging would be scraped against the rough wood of the stipes. As a
result, blood loss from the back probably would continue throughout the
crucifixion ordeal.

   With arms outstretched but not taunt, the wrist were nailed to the
patibulum. It has been shown that the ligaments and bones of the wrist
can support the weight of a body hanging from them, but the palms
cannot. Accordingly, the iron spikes probably were driven between the
radius and the carpals or between the two rows of carpal bones, either
proximal to or through the strong bandlike flexor retinaculum and the
various intercarpal ligaments. Although a nail in either location in
the wrist might pass between the bony elements and thereby produce no
fractures, the likelihood of painful periosteal injury would seem
great. Furthermore, the driven nail would crush or sever the rather
large sensorimotor median nerve. The stimulated nerve would produce
excruciating bolts of fiery pain in both arms. Although the severed
median nerve would result in paralysis of a portion of the hand,
ischemic contracture and impalement of various ligaments by the iron
spike might produce a clawlike grasp.

   Most commonly, the feet were fixed to the front of the stipes by
means of an iron spike driven through the first or second
intermetatarsal space, just distal to the tarsometatarsal joint. It is
likely that the deep peroneal nerve and branches of the medial and
lateral plantar nerves would have been injured by the nails. Although
scourging may have resulted in considerable blood loss, crucifixion per
se was a relatively bloodless procedures, since no major arteries,
other than perhaps the deep plantar arch, pass through the favored
anatomic sites of transfixion.

   The major pathophysiologic effect of crucifixion, beyond the
excruciating pain, was marked interference with normal respiration,
particularly exhalation. The weight of the body, pulling down on the
outstretched arms and shoulders, would tend to fix the intercostal
muscles in an inhalation state and thereby hinder passive exhalation.
Accordingly, exhalation was primarily diaphragmatic, and breathing was
shallow. It is likely that this form of respiration would not suffice
and that hypercarbia would soon result. The onset of muscle cramps or
tetanic contractions, due to fatigue and hypercarbia, would hinder
respiration even further.

   Adequate exhalation required lifting the body by pushing up on the
feet and by flexing the elbows and adducting the shoulders. However,
this maneuver would place the entire weight of the body on the tarsals
and would produce searing pain. Furthermore, flexion of the elbows
would cause rotation of the wrists about the iron nails and cause fiery
pain along the damaged median nerves. Lifting of the body would also
painfully scrape the scourged back against the rough wooden stipes.
Muscle cramps and paresthesias of the outstretched and uplifted arms
would add to the discomfort. As a result, each respiratory effort would
become agonizing and tiring and lead eventually to asphyxia.

   The actual cause of death by crucifixion was multifactorial and
varied somewhat with each case, but the two most prominent causes
probably were hypovolemic shock and exhaustion asphyxia. Other possible
contributing factors included dehydration, stress-induced arrhythmias,
and congestive heart failure with the rapid accumulation of pericardial
and perhaps pleural effusions. Crucifracture (breaking the legs below
the knees), if performed, led to an asphyxic death within minutes.
Death by crucifixion was, in every sense of the word, excruciating
(Latin, excruciatus, or "out of the cross"). Crucifixion of Jesus

   After the scourging and the mocking, at about 9 am, the Roman
soldiers put Jesus' clothes back on him and then led him and two
thieves to be crucified. Jesus apparently was so weakened by the severe
flogging that he could not carry the patibulum from the Praetorium to
the site of crucifixion one third of a mile (600 to 650 m) away. Simon
of Cyrene was summoned to carry Christ's cross, and the processional
then made its way to Golgotha (or Calvary), an established crucifixion
site.

   Here, Jesus' clothes, except for a linen loincloth, again were
removed, thereby probably reopening the scourging wounds. He then was
offered a drink of wine mixed with myrrh (gall) but, after tasting it,
refused the drink. Finally, Jesus and the two thieves were crucified.
Although scriptural references are made to nails in the hands, these
are not at odds with the archaeological evidence of wrist wounds, since
the ancients customarily considered the wrist to be a part of the hand.
The titulus was attached above Jesus' head. It is unclear whether Jesus
was crucified on the Tau cross or the Latin cross; archaeological
findings favor the former and early tradition the latter. The fact that
Jesus later was offered a drink of wine vinegar from a sponge placed on
the stalk of the hyssop plant (approximately 20 in, or 50 cm, long)
strongly supports the belief that Jesus was crucified on the short
cross.

   The soldiers and the civilian crowd taunted Jesus throughout the
crucifixion ordeal, and the soldiers cast lots for his clothing. Christ
spoke seven times from the cross. Since speech occurs during
exhalation, these short, terse utterances must have been particularly
difficult and painful. At about 3 pm that Friday, Jesus cried out in a
loud voice, bowed his head, and died. The Roman soldiers and onlookers
recognized his moment of death.

   Since the Jews did not want the bodies to remain on the crosses
after sunset, the beginning of Sabbath, they asked Pontius Pilate to
order crucifracture to hasten the deaths of the three crucified men.
The soldiers broke the legs of the two thieves, but when they came to
Jesus and saw that he was already dead, they did not break his legs.
Rather, one of the soldiers pierced his side, probably with an infantry
spear, and produced a sudden flow of blood and water. Later that day,
Jesus' body was taken down from the cross and placed in a tomb.

   Death of Jesus

   Two aspects of Jesus' death have been the source of great
controversy, namely, the nature of the wound in his side and the cause
of his death after only several hours on the cross.

   The gospel of John describes the piercing of Jesus' side and
emphasizes the sudden flow of blood and water. Some authors have
interpreted the flow of water to be ascites or urine, from an abdominal
midline perforation of the bladder. However, the Greek word (pleura)
used by John clearly denoted laterality and often implied the ribs.
Therefore, it seems probable that the wound was in the thorax and well
away from the abdominal midline.

   Although the side of the wound was not designated by John, it
traditionally has been depicted on the right side. Supporting this
tradition is the fact that a large flow of blood would be more likely
with a perforation of the distended and thin-walled right atrium or
ventricle than the thick-walled and contracted left ventricle. Although
the side of the would may never be established with certainty, the
right seems more probable than the left.

   Some of the skepticism in accepting John's description has arisen
from the difficulty in explaining, with medical accuracy, the flow of
both blood and water. Part of this difficulty has been based on the
assumption that the blood appeared first, then the water. However, in
the ancient Greek, the order of words generally denoted prominence and
not necessarily a time sequence. Therefore, it seems likely that John
was emphasizing the prominence of blood rather than its appearance
preceding the water.

   Therefore, the water probably represented serous pleural and
pericardial fluid, and would have preceded the flow of blood and been
smaller in volume than the blood. Perhaps in the setting of hypovolemia
and impending acute heart failure, pleural and pericardial effusions
may have developed and would have added to the volume of apparent
water. The blood, in contrast, may have originated from the right
atrium or the right ventricle or perhaps from a hemopericardium.

   Jesus' death after only three to six hours on the cross surprised
even Pontius Pilate. The fact that Jesus cried out in a loud voice and
then bowed his head and died suggests the possibility of a catastrophic
terminal event. One popular explanation has been that Jesus died or
cardiac rupture. In the setting of the scourging and crucifixion, with
associated hypovolemia, hypoxemia, and perhaps an altered coagulable
state, friable non-infective thrombotic vegetation could have formed on
the aortic or mitral valve. These then could have dislodged and
embolized into the coronary circulation and thereby produced an acute
transmural myocardial infarction. Thrombotic valvular vegetations have
been reported to develop under analogous acute traumatic conditions.
Rupture of the left ventricular free wall may occur, though uncommonly,
in the first few hours following infarction.

   However, another explanation may be more likely. Jesus' death may
have been hastened simply by his state of exhaustion and by the
severity of the scourging, with its resultant blood loss and preshock
state. The fact that he could not carry his patibulum supports this
interpretation. The actual cause of Jesus' death, like that of other
crucified victims, may have been multifactorial and related primarily
to hypovolemic shock, exhaustion asphyxia, and perhaps acute heart
failure. A fatal cardiac arrhythmia may have accounted for the apparent
catastrophic terminal event.

   Thus, it remains unsettled whether Jesus died of cardia rupture or
of cardiorespiratory failure. However, the important feature may be not
how he died but rather whether he died. Clearly, the weight of
historical and medical evidence indicates that Jesus was dead before
the wound to his side was inflicted and supports the traditional view
that the spear, thrust between his right ribs, probably perforated not
only the right lung but also the pericardium and heart and thereby
ensured his death. Accordingly, interpretations based on the assumption
that Jesus did not die on the cross appear to be at odds with modern
medical knowledge.

   This file was copied from the JAMA, March 21, 1986 - Vol 255, No. 11
Journal and was written by Dr. William D. Edwards, MD, Wesley J. Gable,
MDiv; Floyd E. Hosmer, MS, AMI.