Lazarus-Forensic Pathology of the Bible

Lazarus is a man of the new testament, living in the time of Jesus Christ in the city of Bethany. He was the brother of two of Christ's followers, sisters Mary and Martha. Bethany sat less than 2 miles south of Jerusalemn in Israel. The story of Lazarus' death and Christ's raising from the dead, is depicted in John 11:1-45.

What are the details of Lazarus' illness and subsequent reapearance.

As only a physician would, when I read this story I ask what disease Lazarus suffered from, did Lazarus truly die or was he just ill, and therefore only healed of his illness. The following discusses this story in a manner that might fit nicely in a Clinical Pathologic Conference such as those reported in the New England Journal of Medicine.

What Caused Lazarus' Illness?

Lazarus did not die suddenly as Jesus was sent word that he was sick, implying some length of illness (v 11:3) . Therefore, he had a progressive illness which led to a mortal condition. This progressive illness could be from an overwhelming infection such as pneumonia or a plague like illness. The infection leads to sepsis (infection in blood stream) and the syndrome of septic shock, systemic collapse, and death.

Septic Shock
is the end result of overwhelming infection. In addition, in death due to chronic illness such as cancer, it is a very common final pathway leading to death. The mechanisms of septic shock or sepsis are very complicated but three major effects of overwhelming infection lead to septic shock and subsequent death.

1. Bacterial products in the blood stream have adverse effects on lung gas exchange, leading to hypoxia or oxygen starvation ie. Less oxygen in blood stream.

2.
Blood flow is shunted by toxic factors which stop regulation of blood vessel tone. This results in shunting more blood to areas not in need, and less blood to areas that are in need. This results in hypoxia of all tissues, of which the kidneys and liver are perhaps the most important in maintaining life.

3. Brain stem hypoxia leads to less stimulus to breath, leading to reduced ventalation and worsening of hypoxia.

Lazarus on the other hand, may have suffered from a chronic disease such as cancer, coronary artery disease and heart failure, or other chronic illness responsible for deaths. Death in these states may occur by wasting and nutritional effects, but in such a chronic illness the last pathway is often infection leading to sepsis.

Was Lazarus dead, or severely ill?

Importantly, Lazarus was deathly ill. His illness was such that the sisters sent word to Jesus, considered "Lord" by Mary and Martha (V3). This supports the severity and deathly nature of his illness. Jesus waited to come to Bethany for over two days (v 6) and eventually 4 days (v 39), allowing this deathly state to progress to what was reported to Jesus as Lazarus' death (v 21). We know that Lazaus was dead, as determined by many at the scene. In addition, not only Mary and Martha reported that he was dead, but many others said the same to Christ after his arrival in Bethany (v 37). This included the most educated of the day, Jewish Pharisees (v46). Evidence includes the fact that he was placed in a tomb, wrapped in grave clothes, and the opening closed off with a stone (v 44); an act only performed on the absolutely dead. Those who witnessed the events worried that the decay process of death, over the now 4 days, would have resulted in a "bad odor" when the stone was rolled away from his grave (v39).

Decomposition occurs only in the dead.

A bad odor occurs due to irreversible (except during resurection) cell death as follows:

Mechanism of cell death

  1. Respiration and circulation stops-tissue oxygen levels drop- cell metabolism ceases and energy sources are depleted. This leads to cell injury and irreversible cell death
  2. Hypoxia leads to lactic acidosis and decrease pH, which results in inhibition of enzyme function and protein synthesis


Cellular effect of cell injury- primarily due to lack of energy sources

  1. Membrane permeability leads to cellular swelling.
  2. Nuclear chromosomes, containing DNA, clump and the nuclear membrane swells.
  3. Lysosomes, which store digestive enzymes, leak these into cells through their leaky membranes. The lysosome eventually swell and eventually rupture. This, dumping of lysosome contents, is thought to signify point of no return
  4. As with the nucleus and lysosome, mitochondria, which produce and store energy, rupture, destroying this necessary cellular organelle.


Cell death depends on the magnitude of cell injury and the type of organ

In general, the point of no return occurs within 8 hours of the onset of sepsis.

1. Kidney 15 minutes
2. Liver 30-45 minutes
3. Heart 24 hours
4.Brain 4-5 mins
5. Miscellaneous tissues decay- normal bacteria invade dead tissue- ? how long? A dirty wound occurs after 24 hours.

Appearance of the body.

Lazarus would have appeared to the witnesses as follows:

- Pallor- pale skin
- Cold
- Rigid- rigor mortis
- Turgidity- bruising of dependent parts of the body ex. Buttocks if died on back
-Cyanosis- blueness of areas normally pink due to prominent blood flow- ex blue lips and nail beds

Appearance of organs when dead

  1. Kidney- enlarged/pale/yellow
    2. Liver- enlarged/yellow/soft/greasy
    3. Heart- yellow/flabby
    4. Brain- pale/swollen/loss of wrinkles (sulcii/ gyrii)
    5. Pupils fixed and dilated

Lazarus was dead, decomposing for four days, and raised from the dead to live another day.

So Lazarus was dead. We know this because many witnessed his death. In addition, he was entombed and placed in grave clothes, something never done in the case of maybe dead. We know as well that he lay in this state for four days. His death at four days would have been accompanied by tremendous cellular death, decomposition, and a horrible stench.


Lazarus was raised then from irreversible death. There were many witnesses to this including Jewish Pharisees, educated knowledgeable men; some believed in Jesus because of this event. In addition, Lazarus appears at a later time in the New Testament.

Then Jesus six days before the passover came to Bethany, where Lazarus was which had been dead, whom he raised from the dead. John 12:1

Lazarus then is a man who died of a progressive illness such as sepsis. He was dead as witnessed by many and entombed for four days. Decomposition changes were expected by all including educated me, but Lazarus lived. Lazarus was alive in later chapters of the book of the Apostle John.

Being a Physician, I may sometimes look at the bible in a clinical manner. However, the story of Lazarus shows documented awesome power of the man from Gallilea, Jesus Christ.

Posted 22nd February 2007 by SPages

Suicidal Ideation

Suicidal ideation is a clinical term used to describe thoughts of suicide or wanting to take one's life. These thoughts do not occur suddenly, but rather evolve over time in individuals who eventually attempt suicide. Generally, this evolution follows four distinctive stages.

Acknowledge:

People are born with a sense of self preservation. Upon hearing for the first time, about an individual who has committed or attempted suicide, the natural sense is one of repulsion. The first stage in the evolution of suicidal ideation requires a loss of this repulsion. The person somehow acknowledges that suicide in some individuals is understandable and tragic.

Accept:

Accepting that under overwhelming circumstances, suicide would be acceptable for himself marks the second stage in the evolution of suicidal ideation. In many suicidal individuals, accepting suicide as a possible action in their own life, never resolves. Even when this individual decides to never commit suicide, he still has the memory of feeling that this would be an acceptable action. It is my experience, these memories continue to haunt the individual even when clinically doing well.

Anticipate:

The third stage in the evolution of suicidal ideation involves the anticipation that at sometime in the future, suicide is inevitable. As this individual decompensates, plans to commit suicide begin.

Action:

The last stage in the evolution of suicidal ideation involves action, which takes two forms.

In the first form, action involves a sudden decision and suicidal activity. This action occurs at the spur of the moment and shows little organization. The result is a poorly planned overdose or other possibly lethal action.

In the second manner, action takes the form of a plan. In this plan the individual decides on a day and the action necessary to end his life.

We are born with mental reflexes designed for self preservation, which makes the concept of suicide repulsive. The evolution of these complex ideas to those in which an individual carries out a suicide attempt, do not occur in one step, but rather by a series of, in many instances, irrepressible changes in thinking.

The suicidal individual first acknowledges that certain individuals are justified in attempting suicide. Secondly, this person accepts that if the situation becomes intolerable, suicide would be an acceptable response. Next, suicidal ideation anticipates that sometime in the future the act of suicide will be carried out. The last stage in suicidal ideation involves action, either actively with a plan or as a sudden poorly organized action.

In no way does the description of the stages in the evolution of suicidal ideation defend the act of suicide. The act of suicide is an irrational reaction to what is perceived as an unrelenting overwhelming sense of pain. This is a complex set of thought processes which do not occur quickly, but rather evolve over some period of time. Recognizing the early stages in the development of suicidal ideation could benefit the individual, by directing effective intervention, early in the course of this evolution.

WMD 2007

Posted 23rd February 2007 by SPages

The Invisibility of Mental Illness

While the mental illness patient is afflicted by very real and painful feelings, these feelings are not visible to others. The indications of the condition then, whether those of depression, anxiety, or even schizophrenia, can be said to be invisible to observers; family, doctor, etc., in fact to everyone other than individual sufferer of mental illness.

A constellation of signs and symptoms are often used to describe a clinical condition such as mental illness. These terms, while often used interchangeable are very different.

  • A sign is something that is measurable, something that an observer can see or measure. Signs differ from symptoms in that they are seen and confirmed by the clinician. Signs would include fever, pallor, heart rate, blood pressure, and others.
  • A symptom is something that is described by the patient and included among others, anxiety, depression, pain, and others. Symptoms can not be seen or measured by the observer, but rather must be relate to others.

The sufferer of mental illness is aware that everyone around him cannot see his suffering. This invisibility often leads to a feeling that others do not believe they are suffering. Their feeling about the beliefs of others is a distortion of fact. A malinger falsifies their symptoms to gain some benefit. Most people do not believe that the sufferer of mental illness is actually a phony, but rather do not understand the nature of their symptoms.

Sufferers of mental illness often believe that others feel they have control of their symptoms, only having to decide to not be, for example, depressed. While they themselves suffer the symptoms of mental illness, they often have the feeling that they should be able to control them. Depending upon their experience, the observer of the mental illness sufferer believes that the patient can decide to some extent to not feel the symptoms. Others feel that the mental illness sufferer is somehow to blame for their suffering.

When observing someone with mental illness, the examiner does not see signs referable to the condition. Information concerning the patient’s clinical condition consists entirely of symptoms, and must be related to the clinician. There are no true signs of mental illness, but rather feelings; conditions which are inside, and hence invisible to everyone else. This invisibility leads often leads to feelings of isolation and the destructive feeling that their suffering is by the fault of themselves.

Posted 1st March 2007 by SPages