sign in sign up
<<
Home , Christ (title), Crucifixion of Jesus, Jesus

Special Communication

On the Physical Death of

William D. Edwards, MD; Wesley J. Gabel, MDiv; Floyd E. Hosmer, MS, AMI

Jesus of underwent Jewish and Roman trials, was flogged, , and by the Jewish historian and· was sentenced to death by . The scourging produced deep Flavius , although the au- stripelike lacerations and appreciable blood loss, and it probably set the thenticity of portions of the latter is stage for hypovolemic shock as evidenced by the fact that Jesus was too problematic.26 weakened to carry the crossbar (patibulum) to Golgotha. At the site of The is considered crucifixion his wrists were nailed to the patibulum, and after the patibulum by many to represent the actual buri- was lifted onto the upright post, (stipes) his feet were nailed to the stipes. al cloth of Jesus,22 and several public- The major pathophysiologic effect of crucifixion was an interference with cations concerning the medical as- normal respirations. Accordingly, death resulted primarily from hypovolemic pects of his death draw conclusions 5,11 shock and exhaustion asphyxia. Jesus’ death was ensured by the thrust of a from this assumption. The Shroud soldier’s into his side. Modern medical interpretation of the historical of Turin and recent archaeological evidence indicates that Jesus was dead when taken down from the . findings provide valuable information (JAMA 1986; 255:1455-1463) concerning Roman crucifixion prac- tices.22-24 The interpretations of mod- ern writers, based on a knowledge of THE LIFE and teachings of Jesus of credibility of any discussion of Jesus’ science and medicine not available in Nazareth have formed the basis for a death will be determined primarily by the first century, may offer addition- major , () the credibility of one’s sources. For al insight concerning the possible have appreciably influenced the this review, the source material mechanisms of Jesus’ death.2-17 course of human history, and, by includes the writings of ancient When taken in concert certain virtue of a compassionate attitude Christian and non-Christian authors, facts—the extensive and early testi- toward the sick, also have contributed the writings of modern authors, and mony of both Christian proponents to the development of modern medi- the Shroud of Turin.1-40 Using the and opponents, and their universal cine. The eminence of Jesus as a legal-historical method of scientific of Jesus as a true histori- and the suffering, investigation,27 scholars have estab- cal figure; the ethic of the and controversy associated with his lished the reliability and accuracy of writers, and the shortness of the time death has stimulated us to investi- the ancient .26,27,29,31 interval between the events and the gate, in an interdisciplinary manner, The most extensive and detailed extant manuscripts; and the confir- the circumstances surrounding his descriptions of the life and death of mation of accounts by crucifixion. Accordingly it is our Jesus are to be found in the New historians and archaeological find- intent to present not a theological Testament of Matthew, Mark, ings26-27—ensure a reliable testimony treatise but rather a medically, and Luke, and John.1 The other 23 books from which a modern medical interpret- historically accurate account of the of the support but do tation of Jesus’ death may be made. physical death of the one called Jesus not expand on the details recorded in Christ. the gospels. Contemporary Christian, Jewish, and Roman authors provide After Jesus and his disciples had SOURCES observed the meal in an additional insight concerning the The source material concerning first-century Jewish and Roman legal upper room in a home in southwest Christ’s death comprises a body of systems and the details of scourging , they traveled to the Mount literature and not a physical body or and crucifixion.5 Seneca, Livy, Plu- of , northeast of the city (Fig 1). its skeletal remains. Accordingly, the tarch, and others refer to crucifixion (Owing to various adjustments in the practices in their works.8,28 Specifical- calendar, the years of Jesus’ birth and 29 From the Departments of Pathology (Dr. Edwards) ly, Jesus (or his crucifixion) is men- death remain controversial. How- and Medical Graphics (Mr. Hosmer), Mayo Clinic, tioned by the Roman historians Cor- ever, it is likely that Jesus was born Rochester, Minn; and the Homestead United Meth- odist , Rochester, Minn, and the West Bethel nelius , Pliny the Younger, in either 4 or 6 BC and died in 30 , Bethel, Minn ( and Suetonius, by non-Roman histori- AD.11,29 During the Passover observ- Gabel). Reprint requests to Department of Pathology, ans and Phlegon, by the satir- ance in 30 AD, the would Mayo Clinic, Rochester, MN 55905 (Dr Edwards). ist Lucian of Samosata, by the Jewish have been observed on Thursday,

JAMA March 21, 1986—Vol 255, No. 11 Death of Christ—Edwards et al 1455

To Sychem N and W E

0 500 1,000 1,500 S Feet Meters Fortress of Possible 0 250 500 Antonia Golgotha Garden of Gethsemane To Joppa 7 4 Traditional 5 Golgotha Suburb () To 6 ’ Temple Palace

Herod’s 2 Palace 3 Upper City

Lower City ’ Residence

Upper 1 Room

Hinnom Valley

To and Hebron To Sea

Fig 1.—Map of Jerusalem at time of Christ. Jesus left Upper Room and walked with disciples to Mount of Olives and Garden of Gethsemane (1), where he was arrested and taken first to and then to Caiaphas (2). After first trial before political at Caiaphas’ residence, Jesus was tried again before religious Sanhedrin, probably at Temple (3) Next, he was taken to (4), who sent him to Herod Antipas (5). Herod returned Jesus to Pilate (6), and Pilate finally handed over Jesus for scourging at Fortress of Antonia and for crucifixion at Golgotha (7). (Modified from Pfeiffer et al.30)

April 6 [ 13], and Jesus would have suggested that hematidrosis ably at the (Fig l), Jesus was have been crucified on , April 7 produced hypovolemia, we agree with tried before the religious Sanhedrin [Nisan 14].29) At nearby Gethsemane, Bucklin5 that Jesus’ actual blood loss (with the and the Saddu- Jesus, apparently knowing that the probably was minimal. However, in cees) and again was found guilty of time of his death was near, suffered the cold night air,1 it may have pro- , a crime punishable by great mental anguish, and, as de- duced chills. death.1,5 scribed by the physician Luke, his 1 TRIALS Roman Trials sweat became like blood. Although this is a very rare phe- Jewish Trials Since permission for an execution nomenon, bloody sweat (hematidrosis Soon after midnight, Jesus was had to come from the governing or hemohidrosis) may occur in highly arrested at Gethsemane by the tem- Romans,1 Jesus was taken early in the emotional states or in persons with ple officials and was taken first to morning by the temple officials to the bleeding disorders.18-20 As a result of Annas and then to Caiaphas, the of the Fortress of Anton- hemorrhage into the sweat glands, Jewish high for that year (Fig ia, the residence and governmental the skin becomes fragile and tender.2,11 1).1 Between 1 AM and daybreak, Jesus seat of Pontius Pilate, the procurator Luke’s description supports the diag- was tried before Caiaphas and the of (Fig 1). However, Jesus was nosis of hematidrosis rather than political Sanhedrin and was found presented to Pilate not as a blas- eccrine chromidrosis (brown or yel- guilty of blasphemy.1 The guards then phemer but rather as a self-appointed low-green sweat) or stigmatization blindfolded Jesus, spat on him, and king who would undermine the Ro- (blood oozing from the palms or else- struck him in the face with their man authority.1 Pilate made no where).18-21 Although some authors fists.1 Soon after daybreak, presum- charges against Jesus and sent him to

1456 JAMA March 21, 1986—Vol 255, No. 11 Death of Christ—Edwards et al

Direction of Whip Against Victim’s Back

Small Bone Leather (Pieces) WoodenThongs Metal Balls Roman Handle

MAYO Legionnaire Flagrum ©1985

Flogging Top View Direction of Whip Marks

Victim

Fig 2.—Scourging. Left, Short whip (flagrum) with lead balls and bones tied into leather thongs. Center left, Naked victim tied to flogging post. Deep stripelike lacerations were usually associated with considerable blood loss. Center right, View from above, showing position of lictors. Right, Inferomedial direction of wounds.

Herod Antipas, the tetrarch of Ju his closest friends (the disciples), and (lictors) or by one who alternated dea.1 Herod likewise made no official a physical beating (after the first positions.5,7,11,28 The severity of the charges and then returned Jesus to Jewish trial). Also, in the setting of a scourging depended on the disposition Pilate (Fig 1).1 Again, Pilate could traumatic and sleepless night, he had of the lictors and was intended to find no basis for a legal been forced to walk more than 2.5 weaken the victim to a state just against Jesus, but the people persist- miles (4.0 km) to and from the sites of short of collapse or death.8 After the ently demanded crucifixion. Pilate the various trials (Fig 1). These phys- scourging, the soldiers often taunted finally granted their demand and ical and emotional factors may have their victim.11 handed over Jesus to be flogged rendered Jesus particularly vulnera- (scourged) and crucified. (McDowell25 ble to the adverse hemodynamic Medical Aspects of Scourging has reviewed the prevailing political, effects of the scourging. As the Roman soldiers repeatedly religious, and economic climates in struck the victim’s back with full Jerusalem at the time of Jesus’ death, SCOURGING force, the iron balls would cause deep 5 and Bucklin has described the vari- Scourging Practices contusions, and the leather thongs ous illegalities of the Jewish and Flogging was a legal preliminary to and sheep bones would cut into the Roman trials.) 7 every Roman execution,28 and only skin and subcutaneous tissues. Then, as the flogging continued, the lacera- Health of Jesus women and Roman senators or sol- diers (except in cases of desertion) tions would tear into the underlying The rigors of Jesus’ ministry (that were exempt.11 The usual instrument skeletal muscles and produce quiver- 2,7,25 is, traveling by foot throughout Pal- was a short whip (flagellum or flagel- ing ribbons of bleeding flesh. Pain estine) would have precluded any lum) with several single or braided and blood loss generally set the stage 12 major physical illness or a weak gen- leather thongs of variable lengths, in for circulatory shock. The extent of eral constitution. Accordingly, it is which small iron balls or sharp pieces blood loss may have determined reasonable to assume that Jesus was of sheep bones were tied at intervals how long the victim would survive on 8 in good physical condition before his (Fig 2).5,7,11 Occasionally, staves also the cross. walk to Gethsemane. However, dur- were used.8,12 For scourging, the man Scourging of Jesus ing the 12 hours between 9 PM Thurs- was stripped of his clothing, and his day and 9 AM Friday, he had suffered hands were tied to an upright post At the Praetorium, Jesus was great emotional stress (as evidenced (Fig 2).11 The back, buttocks, and legs severely whipped. (Although the se- by hematidrosis), abandonment by were flogged either by two soldiers verity of the scourging is not dis- JAMA March 21, 1986—Vol 255, No. 11 Death of Christ—Edwards et al 1457

5 to 6 ft (1.5 to 1.8 m) 75 to 125 lb (34 to 57 kg)

Titulus

Patibulum

6 to 8 ft Stipes Sedile (1.8 to 2.4 m)

MAYO ©1985

Stipes

Fig 3.—Cross and titulus. Left, victim carrying crossbar (patibulum) to site of upright post (stipes). Center Low cross (crux commissa), commonly used by Romans at time of Christ. Upper right, Rendition of Jesus’ titulus with and crime—, King of the —written in Hebrew, , and Greek. Lower right Possible methods for attaching tittles to (left) and Latin cross (right).

10,17 Variations in and struck him on the head with the mum pain and suffering. It was one Used for Crucifixion wooden staff.1 Moreover, when the of the most disgraceful and cruel Latin soldiers tore from Jesus’ methods of execution and usually was Designation Characteristics back, they probably reopened the reserved only for slaves, foreigners, Infelix lignum Tree scourging wounds.7 revolutionaries, and the vilest of , Upright post The severe scourging, with its criminals.3,25,28 Roman law usually pro- Crux acuta intense pain and appreciable blood tected Roman citizens from - Crux composita Stipes and patibulum 5 Crux humilis Low cross loss, most probably left Jesus in a ion, except perhaps in the ease of Crux sublimis Tall cross preshock state. Moreover, hematidro- desertion by soldiers. Crux commissa T-shaped (Tau) cross sis had rendered his skin particularly In its earliest form in Persia, the Crux immissa †-shaped (Latin) tender. The physical and mental victim was either tied to a tree or was cross Crux capitata †-shaped (Latin) abuse meted out by the Jews and the tied to or impaled on an upright post, cross Romans, as well as the lack of food, usually to keep the guilty victim’s feet Crux decussata -shaped cross water, and sleep, also contributed to from touching holy ground.8,11,30,34,38 his generally weakened state. There- Only later was a used; it fore, even before the actual crucifix- was characterized by an upright post cussed in the four gospel accounts, it ion, Jesus’ physical condition was at (stipes) and a horizontal crossbar is implied in one of the [1 least serious and possibly critical. (patibulum), and it had several varia- Peter 2:24]. A detailed word study of tions (Table).11 Although archaeology- the ancient Greek text for this verse CRUCIFIXION cal and historical evidence strongly Crucifixion Practices indicates that the scourging of Jesus indicates that the low Tau cross was was particularly harsh.33) It is not Crucifixion probably first began preferred by the Romans in known whether the number of lashes among the Persians.34 the at the time of Christ (Fig 3),2,7,11 was limited to 39, in accordance with Great introduced the practice to crucifixion practices often varied in a Jewish law.5 The Roman soldiers, and Carthage, and the Romans given geographic region and in ac- amused that this weakened man had appear to have learned of it from the cordance with the imagination of the claimed to be a king, began to mock Carthaginians.11 Although the Ro- executioners, and the Latin cross and him by placing a robe on his shoul- mans did not invent they other forms also may have been ders, a of thorns on his head, perfected it as a form of torture and used.28 and a wooden staff as a scepter in his capital punishment that was designed It was customary for the con- right hand.1 Next, they spat on Jesus to produce a slow death with maxi- demned man to carry his own cross

1458 JAMA March 21, 1986—Vol 255, No. 11 Death of Christ—Edwards et al

? in (1 cm)

Flexor Retinaculum

Ulnar Nerve and Artery Median Nerve

Radial Artery Flexor Pollicus Longus Musculus

MAYO ©1985

5 to 7 in (13 to 18 cm) Radial Artery

Nail in Patibulum

Ulnar Artery

Flexor Retinaculum Median Nerve

Fig 4.—Nailing of wrists. Left, Size of iron . Center, Location of nail in wrist, between carpals and . Right, Cross section of wrist, at level of indicated at left, showing path of nail, with probable transection of median nerve and impalement of flexor pollicis longus, but without injury to major arterial trunks and without fractures of bones.

from the flogging post to the site of by ropes.10,11,30 To prolong the crucifix- After both arms were fixed to the crucifixion outside the city walls.8,11,30 ion process, a horizontal wooden block crossbar, the patibulum and the vic- He was usually naked, unless this was or plank, serving as a crude seat tim, together, were lifted onto the prohibited by local customs.11 Since (sedile or sedulum), often was at- stipes.11 On the low cross, four sol- the weight of the entire cross was tached midway down the stipes.3,11,16 diers could accomplish this relatively probably well over 300 lb (136 kg), Only very rarely, and probably later easily. However, on the tall cross, the only the crossbar was carried (Fig than the time of Christ, was an soldiers used either wooden forks or 3).11 The patibulum, weighing 75 to additional block (suppedaneum) em- ladders.11 125 lb. (34 to 57 kg),11,30 was placed ployed for transfixion of the feet.9,11 Next, the feet were fixed to the across the nape of the victim’s neck At the site of execution, by law, the cross, either by nails or ropes. Ossua- and balanced along both shoulders. victim was given a bitter drink of ry findings and the Shroud of Turin Usually, the outstretched arms then mixed with (gall) as a suggest that nailing was the pre- were tied to the crossbar.7,11 The pro- mild analgesic.7,17 The criminal was ferred Roman practice.23,24,30 Although cessional to the site of crucifixion was then thrown to the ground on his the feet could be fixed to the sides of led by a complete Roman military back, with his arms outstretched the stipes or to a wooden footrest guard, headed by a .3,11 One along the patibulum.11 The hands (suppedaneum), they usually were of the soldiers carried a sign (titulus) could be nailed or tied to the crossbar, nailed directly to the front of the on which the condemned man’s name but nailing apparently was preferred stipes (Fig 5).11 To accomplish this, and crime were displayed (Fig 3).3,11 by the Romans.8,11 The archaeological flexion of the knees may have been Later, the titulus would be attached to remains of a crucified body, found in quite prominent, and the bent legs the top of the cross.11 The Roman an ossuary near Jerusalem and dating may have been rotated laterally (Fig guard would not leave the victim until from the time of Christ, indicate that 6).23-25,30 they were sure of his death.9,11 the nails were tapered iron spikes When the nailing was completed, Outside the city walls was perma- approximately 5 to 7 in (13 to 18 cm) the titulus was attached to the cross, 3 nently located the heavy upright long with a square shaft /8 in (1 cm) by nails or cords, just above the wooden stipes, on which the patibu- across.23,24,30 Furthermore, ossuary victim’s head.11 The soldiers and the lum would be secured. In the case of findings and the Shroud of Turin civilian crowd often taunted and the Tau cross, this was accomplished have documented that the nails com- jeered the condemned man, and the by means of a mortise and tenon monly were driven through the wrists soldiers customarily divided up his joint, with or without reinforcement rather than the palms (Fig 4).22-24,30 clothes among themselves11,25 The

JAMA March 21, 1986—Vol 255, No. 11 Death of Christ—Edwards et al 1459 Medical Aspects of Crucifixion

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

Weight-Bearing The scourging to crucifixion Direction served to weaken the condemned man of Body Placement and, if blood loss was considerable, to 5 4 3 2 of Nail produce orthostatic hypotension and 1 even hypovolemic shock.8,12 When the 1 Metatarsals victim was thrown to the ground on his back, in preparation for transfix- ion of the hands, his scourging wounds most likely would become torn open again and contaminated 2,16 Medial View Frontal View with dirt. Furthermore, with each respiration, the painful scourging wounds would be scraped against the rough wood of the stipes.7 As a result, blood loss from the back probably would continue throughout the cruci- fixion ordeal. With arms outstretched but not Right Foot taut, the wrists were nailed to the patibulum.7,11 It has been shown that Metatarsal 1 the ligaments and bones of the wrist can support the weight of a body hanging from them, but the palms Deep cannot.11 Accordingly, the iron spikes Peroneal Nerve Stipes MAYO probably were driven between the ©1985 Medial radius and the carpals or between the Plantar Nerve two rows of carpal bones,2,10,11,30 either Metatarsal 5 proximal to or through the strong Lateral Plantar Nerve bandlike flexor retinaculum and the various intercarpal ligaments (Fig 4). Fig 5.—Nailing of feet. Left, Position of feet atop one another and against stipes. Upper right, Although a nail in either location in Location of nail in second intermetatarsal space. Lower right, Cross section of foot, at plane the wrist might pass between the indicated at left, showing path of nail. bony elements and thereby produce no fractures, the likelihood of painful length of survival generally ranged for burial, after obtaining permission periosteal injury would seem great. from three or four hours to three or from the Roman judge.11 Furthermore, the driven nail would four days and appears to have been Since no one was intended to sur- crush or sever the rather large senso- inversely related to the severity of vive crucifixion, the body was not rimotor median nerve (Fig 4).2,7,11 The the scourging.8,11 However, even if the released to the family until the sol- stimulated nerve would produce ex- scourging had been relatively mild, diers were sure that the victim was cruciating bolts of fiery pain in both the Roman soldiers could hasten dead. By custom, one of the Roman arms.7,9 Although the severed median death by breaking the legs below the guards would pierce the body with a nerve would result in paralysis of a knees (crurifragium or skelokopia).8,11 sword or lance.8,11 Traditionally, this portion of the hand, ischemic contrac- Not uncommonly, insects would had been considered a spear wound to tures and impalement of various liga- light upon or burrow into the open the through the right side of ments by the iron spike might pro- wounds or the eyes, ears, and nose of the chest—a fatal wound probably duce a clawlike grasp. the dying and helpless victim, and taught to most Roman soldiers.11 The Most commonly, the feet were fixed birds of prey would tear at these Shroud of Turin documents this form to the front of the stipes by means sites.16 Moreover, it was customary to of injury.5,11,22 Moreover, the standard of an iron spike driven through the leave the corpse on the cross to be infantry spear, which was 5 to 6 ft first or second intermetatarsal space, devoured by predatory animals.8,11,12,28 (1.5 to 1.8 m) long,30 could easily have just distal to the tarsometatarsal However, by Roman law, the family reached the chest of a man crucified joint.2,5,8,11,30 It is likely that the deep of the condemned could take the body on the customary low cross.11 peroneal nerve and branches of the

1460 JAMA March 21, 1986—Vol 255, No. 11 Death of Christ—Edwards et al

Sternocleidomastoid Muscle Scalenus Musculi Parasternal Intercartilaginous Pectoralis Muscles Musculus (Major)

External Intercostal Muscles Internal Intercostal Muscles Inhalation Active: Normal Breathing Passive: Crucified Victims External Oblique Muscle

Internal Oblique Rectus Muscle MAYO ©1985 Abdominus Musculus Transverse Abdominus Musculus Exhalation Passive: Normal Breathing Active: Crucified Victims

Fig 6—Respirations during crucifixion. Left, Inhalation. With elbows extended and shoulders abducted, respiratory muscles of inhalation are passively stretched and thorax is expanded. Right, Exhalation. With elbows flexed and shoulders adducted and with weight of body on nailed feet, exhalation is accomplished as active, rather than passive, process. Breaking legs below knees would place burden of exhalation on shoulder and arm muscles alone and soon would result in exhaustion asphyxia.

medial and lateral plantar nerves contractions, due to fatigue and most prominent causes probably were would have been injured by the nails hypercarbia, would hinder respiration hypovolemic shock and exhaustion (Fig 5). Although scourging may have even further.11 asphyxia.2,3,7,10 Other possible contrib- resulted in considerable blood loss, Adequate exhalation required lift- uting factors included dehydration,7,16 crucifixion per se was a relatively ing the body by pushing up on the feet stress-induced arrhythmias,3 and con- bloodless procedure, since no major and by flexing the elbows and adduct- gestive heart failure with the rapid arteries, other than perhaps the ing the shoulders (Fig 6).2 However, accumulation of pericardial and per- deep plantar arch, pass through the this maneuver would place the entire haps pleural effusions.2,7,11 Crucifrac- favored anatomic sites of transfix- weight of the body on the tarsals and ture (breaking the legs below the ion.2,10,11 would produce searing pain.7 Further- knees), if performed, led to an The major pathophysiologic effect more, flexion of the elbows would asphyxic death within minutes.11 of crucifixion, beyond the excruciate- cause rotation of the wrists about the Death by crucifixion was, in ev- ing pain, was a marked interference iron nails and cause fiery pain along ery sense of , excruciating with normal respiration, particularly the damaged median nerves.7 Lifting (Latin, excruciatus, or “out of the exhalation (Fig 6). The weight of the of the body would also painfully cross”). body, pulling down on the out- scrape the scourged back against the 2,7 stretched arms and shoulders, would rough wooden stipes. Muscle cramps tend to fix the intercostal muscles in and paresthesias of the outstretched After the scourging and the mock- an inhalation state and thereby hin- and uplifted arms would add to the ing, at about 9 AM, the Roman soldiers der passive exhalation.2,10,11 According- discomfort.7 As a result, each respire- put Jesus’ clothes back on him and ly, exhalation was primarily dia- tory effort would become agonizing then led him and two thieves to be phragmatic, and breathing was shal- and tiring and lead eventually to crucified.1 Jesus apparently was so low. It is likely that this form of asphyxia.2,3,7,10 weakened by the severe flogging that respiration would not suffice and that The actual cause of death by cruci- he could not carry the patibulum hypercarbia would soon result. The fixion was multifactorial and varied from the Praetorium to the site of onset of muscle cramps or tetanic somewhat with each case, but the two crucifixion one third of a mile (600 to

JAMA March 21, 1986—Vol 255, No. 11 Death of Christ—Edwards et al 1461

Aorta Esophagus

LA

Right Lung RA Left Lung LV

RV

MAYO ©1985 Right Sternum Left Pleural Cavity Ventricular Wall Pericardial Perietal Cavity Pericardium

Fig 7.—Spear wound to chest. Left, Probable path of spear. Right, Cross section of thorax, at level of plane indicated at left, showing structures perforated by spear. LA indicates left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.

650 m) away.1,3,5,7 was taunted Jesus throughout the cruci- namely, the of the wound in his summoned to carry Christ’s cross, fixion ordeal, and the soldiers side4,6 and the cause of his death and the processional then made its cast lots for his clothing.1 Christ spoke after only several hours on the way to Golgotha (or Calvary), an seven times from the cross.1 Since cross.13-17 established crucifixion site. speech occurs during exhalation, The describes the Here, Jesus’ clothes, except for a these short, terse utterances must piercing of Jesus’ side and emphasizes linen loincloth, again were removed, have been particularly difficult and the sudden flow of blood and water.1 thereby probably reopening the painful. At about 3 PM that Friday, Some authors have interpreted the scourging wounds. He then was Jesus cried out in a loud voice, bowed flow of water to be ascites12 or urine, offered a drink of wine mixed with his head, and died.1 The Roman sol- from an abdominal midline perfora- myrrh (gall) but, after tasting it, diers and onlookers recognized his tion of the bladder.15 However, the refused the drink.1 Finally, Jesus and moment of death.1 Greek word (πλευρα, or pleura)32,35,36 the two thieves were crucified. Al- Since the Jews did not want the used by John clearly denoted later- though scriptural references are bodies to remain on the crosses after ality and often implied the ribs.6,32,36 made to nails in the hands,1 these are sunset, the beginning of the , Therefore, it seems probable that the not at odds with the archaeological they asked Pontius Pilate to order wound was in the thorax and well evidence of wrist wounds, since the crucifracture to hasten the deaths of away from the abdominal midline. ancients customarily considered the the three crucified men.1 The soldiers Although the side of the wound was wrist to be a part of the hand.7,11 The broke the legs of the two thieves, but not designated by John, it traditional- titulus (Fig 3) was attached above when they came to Jesus and saw that ly has been depicted on the right Jesus’ head. It is unclear whether he was already dead, they did not side.4 Supporting this tradition is the Jesus was crucified on the Tau cross break his legs.1 Rather, one of the fact that a large flow of blood would or the Latin cross; archaeological soldiers pierced his side, probably be more likely with a perforation of findings favor the former11 and early with an infantry spear, and produced the distended and thin-walled right tradition the latter.38 The fact that a sudden flow of blood and water.1 atrium or ventricle than the thick- Jesus later was offered a drink of Later that day, Jesus’ body was taken walled and contracted left ventricle. wine vinegar from a sponge placed on down from the cross and placed in a Although the side of the wound may the stalk of the hyssop plant1 (approx- .1 never be established with certainty, imately 20 in, or 50 cm, long) strongly the right seems more probable than DEATH OF JESUS supports the that Jesus was the left. crucified on the short cross.6 Two aspects of Jesus’ death have Some of the in accepting The soldiers and the civilian crowd been the source of great controversy, John’s description has arisen from

1462 JAMA March 21, 1986—Vol 255, No. 11 Death of Christ—Edwards et al the difficulty in explaining, with med- cried out in a loud voice and then supports this interpretation. The ac- ical accuracy, the flow of both blood bowed his head and died suggests the tual cause of Jesus’ death, like that of and water. Part of this difficulty has possibility of a catastrophic terminal other crucified victims, may have been based on the assumption that event. One popular explanation has been multifactorial and related pri- the blood appeared first, then the been that Jesus died of cardiac rup- marily to hypovolemic shock, exhaus- water. However, in the ancient Greek, ture. In the setting of the scourging tion asphyxia, and perhaps acute the order of words generally denoted and crucifixions with associated hypo- heart failure.2,3,5-7,10,11 A fatal cardiac prominence and not necessarily a volemia, hypoxemia, and perhaps an arrhythmia may have accounted for time sequence.37 Therefore, it seems altered coagulable state, friable non- the apparent catastrophic terminal likely that John was emphasizing the infective thrombotic vegetations event. prominence of blood rather than its could have formed on the aortic or Thus, it remains unsettled whether appearance preceding the water. mitral valve. These then could have Jesus died of cardiac rupture or of Therefore, the water probably dislodged and embolized into the cor- cardiorespiratory failure. However, represented serous pleural and pericardi- onary circulation and thereby pro- the important feature may be not al fluid,5-7,11 and would have preceded duced an acute transmural myocar- how he died but rather whether he the flow of blood and been smaller in dial infarction. Thrombotic valvular died. Clearly, the weight of historical volume than the blood. Perhaps in the vegetations have been reported to and medical evidence indicates that setting of hypovolemia and impend- develop under analogous acute trau- Jesus was dead before the wound to ing acute heart failure, pleural and matic conditions.39 Rupture of the left his side was inflicted and supports pericardial effusions may have devel- ventricular free wall may occur, the traditional view that the spear, oped and would have added to the though uncommonly, in the first few thrust between his right ribs, proba- volume of apparent water.5,11 The hours following infarction.40 bly perforated not only the right lung blood, in contrast, may have origin- However, another explanation may but also the pericardium and heart and nated from the right atrium or the be more likely. Jesus’ death may have thereby ensured his death (Fig 7). right ventricle (Fig 7) or perhaps been hastened simply by his state of Accordingly, interpretations based on from a hemopericardium.5,7,11 exhaustion and by the severity of the the assumption that Jesus did not die Jesus’ death after only three to six scourging, with its resultant blood on the cross appear to be at odds with hours on the cross surprised even loss and preshock state.7 The fact that modern medical knowledge. Pontius Pilate.1 The fact that Jesus he could not carry his patibulum

References

1. :17-27:61, :12-15:47, of the Death of Christ and Its Relation to the 31. Greenleaf S: An Examination of the Testi- :7-23:56, :1-19:42, in The Holy Principles and Practice of Christianity, ed 2. mony of the by the Rules of (New International Version). Grand Rap- London, Hamilton & , 1871, pp 28-156, Evidence Administered in the Courts of . ids, Mich, Zondervan Bible Publishers, 1978. 489-494. Grand Rapids, Mich, Baker Book House, 1965, 2. Lumpkin R: The physical suffering of 18. Allen AC: The Skin: A Clinicopathological p 29. Christ. J Med Assoc Ala 1978;47:8-10,47. Treatise, ed 2. New York, Grune & Stratton Inc, 32. Hatch E, Redpath HA: A Concordance to 3. Johnson CD: Medical and cardiological 1967, pp 745-747. the and the Other Greek Versions of aspects of and crucifixion of Jesus, 19. Sutton RL Jr: Diseases of the Skin, ed 11. the (Including the Apocryphal the Christ. Bol Assoc Med PR 1978;70:97-102. St Louis, CV Mosby Co, 1956, pp 1393-1394. Books). Graz, Austria, Akademische Druce U 4. Barb AA: The wound in Christ’s side. J 20. Scott CT: A case of haematidrosis. Br Med Verlagsanstalt, 1975, p 1142. Warburg Courtauld Inst 1971;34:320-321. J 1918;1:532-533. 33. Wuest KS: Wuest Word Studies From the 5. Bucklin R: The legal and medical aspects of 21. Klauder JV: Stigmatization. Arch Derma- Greek New Testament for the English Reader. the trial and death of Christ. Sci Law 1970; tol Syphilol 1938;37:650-659. Grand Rapids, Mich, WB Eerdmans Publisher, 10:14-26. 22. Weaver KF: The mystery of the shroud. 1973, vol 1, p 280. 6. Mikulicz-Radecki FV: The chest wound in Natl Geogr 1980:157:730-753. 34. Friedrich G: Theological Dictionary of the the crucified Christ. Med News 1966;14:30-40. 23. Tzaferis V: Jewish at and near New Testament, Bremiley G (ed-trans). Grand 7. Davis CT: The crucifixion of Jesus: The Giv’at ha-Mivtar, Jerusalem. Israel Explor J Rapids, Mich, WB Eerdmans Publisher, 1971, vol passion of Christ from a medical point of view. 1970;20:18-32. 7, pp 572, 573, 632. Ariz Med 1965;22:183-187. 24. Haas N: Anthropological observations on 35. Arndt WF, Gingrich FW: A Greek-English 8. Tenney SM: On death by crucifixion. Am the skeletal remains from Giv’at ha-Mivtar. Lexicon of the New Testament and Other Early Heart J 1964;68:286-287. Israel Explor J 1970;20:38-59. . University of Chicago 9. Bloomquist ER: A doctor looks at crucifix- 25. McDowell J: The Factor. San Press, 1957, p 673. ion. Christian Herald, March 1964, pp 35, 46-48. Bernardino, Calif, Here’s Life Publishers, 1981, 36. Brown F, Driver SR, Briggs CA: A Hebrew 10. DePasquale NP, Burch GE: Death by cru- pp 20-53, 75-103. and English Lexicon of the Old Testament With cifixion. Am Heart J 1963;66:434-435. 26. McDowell J: Evidence That Demands a an Appendix Containing the Biblical . 11. Barbet P: A Doctor at Calvary: The Pas- Verdict: Historical Evidences for the Christian Oxford, England, Clarendon Press, 1953, pp 841, sion of Our Jesus Christ as Described by a . San Bernardino, Calif, Here’s Life Pub- 854. Surgeon, Earl of Wicklow (trans). Garden City, lishers, 1979, pp 39-87, 141-263. 37. Robertson AT: A Grammar of the Greek NY, Doubleday Image Books, 1953, pp 12-18, 27. McDowell J: More Than a Carpenter. New Testament in Light of Historical Research. 37-147, 159-175, 187-208. Wheaton, Ill, Tyndale House Publishers, 1977, Nashville, Tenn, Broadman Press, 1931, pp 417- 12. Primrose WB: A surgeon looks at the pp 36-71, 89-100. 427. crucifixion. Hibbert J, 1949, pp 382-388. 28. Hengel M: Crucifixion in the Ancient 38. Jackson SM (ed): The New Schaff-Herzog 13. Bergsma S: Did Jesus die of a broken World and the Folly of the Message of the Cross, Encyclopedia of Religious Knowledge. New York, heart? Calvin 1948;14:163-167. Bowden J (trans). Philadelphia, Fortress Press, Funk & Wagnalls, 1909, pp 312-314. 14. Whitaker JR: The physical cause of the 1977, pp 22-45, 86-90. 39. Kim H-S, Suzuki M, Lie JT, et al: Nonbac- death of our Lord. Cath Manchester Guard 29. Ricciotti G: The Life of Christ, Zizzamia terial thrombotic endocarditis (NBTE) and dis- 1937;15:83-91. AI (trans). Milwaukee, Bruce Publishing Co, seminated intravascular coagulation (DIC): Au- 15. Clark CCP: What was the physical cause of 1947, pp 29-57, 78-153, 161-167, 586-647. topsy study of 36 patients. Arch Pathol Lab Med the death of Jesus Christ? Med Rec 1890;38:543. 16. 30. Pfeiffer CF, Vos HF, Rea J (eds): Wycliffe 1977;101:65-68. 16. Cooper HC: The agony of death by cruci- Bible Encyclopedia. Chicago, Moody Press, 1975, 40. Becker AE, van Mantgem J-P: Cardiac fixion. NY Med J 1883;38:150-153. pp 149-152, 404-405, 713-723, 1173-1174, 1520- tamponade: A study of 50 . Eur J Cardiol 17. Stroud W: Treatise on the Physical Cause 1523. 1975;3:349-358.

JAMA March 21, 1986—Vol 255, No. 11 Death of Christ—Edwards et al 1463