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 Jerusalem in Israel. The story of Lazarus’ death and Christ’s rising from the dead is depicted in John 11:1-45.

What are the details of Lazarus’ illness and subsequent reappearance?

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 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’s 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 that 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 the bloodstream), septic shock syndrome, 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 bloodstream adversely affect lung gas exchange, leading to hypoxia or oxygen starvation, i.e., less oxygen in the bloodstream.
2. Blood flow is shunted by toxic factors that stop the regulation of blood vessel tone. This results in shunting more blood to areas not in need and less blood to those 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 breath stimulus, reduced ventilation, and worsened hypoxia.

On the other hand, Lazarus may have suffered from a chronic disease such as cancer, coronary artery disease, heart failure, or other chronic illness responsible for the death. 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 (v 3). This supports the severity and deathly nature of his illness. Jesus waited to come to Bethany for over two days (v 6) and eventually four days (v 39), allowing this deathly state to progress to what was reported to Jesus as Lazarus’ death (v 21). As determined by many at the scene, we know Lazarus is dead. In addition, not only Mary and Martha reported that he was dead, but many others said the same to Christ after he arrived in Bethany (v 37). This included Jewish Pharisees, the most educated of the day (v 46). 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 four days, would have resulted in a “bad odor” when the stone was rolled away from his grave (v 39).

Decomposition occurs only in the dead. A bad odor occurs due to irreversible (except during resurrection) cell death as follows: When respiration and circulation stop, tissue oxygen levels drop, cell metabolism ceases, and energy sources depleted, leading to cell injury and irreversible cell death. Hypoxia (lack of oxygen) causes lactic acidosis and decreased pH, inhibiting enzyme function and protein synthesis.

Cell injury significantly impacts cells due to a lack of energy sources. The effects include:

• Increased membrane permeability, leading to cellular swelling
• Clumping of nuclear chromosomes, which contain DNA, and swelling of the nuclear membrane
• Leakage of digestive enzymes from lysosomes, which store these enzymes, into the cells through leaky membranes. The lysosome eventually swells and ruptures, releasing its contents. This is considered to be a point of no return for cell death.
• Rupture of mitochondria, which produce and store energy, destroying this essential cellular organelle.

The rate of cell death varies depending on the extent of cell damage and the type of organ involved. In general, the point of no return for cell death due to sepsis occurs within 8 hours of its onset.

For specific organs:

• Kidneys: cell death can occur within 15 minutes
• Liver: cell death can occur within 30 to 45 minutes
• Heart: cell death can occur within 24 hours
• Brain: cell death can occur within 4 to 5 minutes

Miscellaneous tissues also undergo decay as normal bacteria invade dead tissue. However, the exact time frame for this process is not specified. A dirty wound can develop after 24 hours.

The appearance of the body

To the witnesses, Lazarus would have appeared as having the following physical characteristics:

• Pallor: pale skin
• Coldness: a low body temperature
• Rigidity: the stiffening of the muscles due to rigor mortis
• Turgidity: bruising of parts of the body that are dependent on gravity, for example, the buttocks if he died on his back
• Cyanosis: a bluish discoloration of areas that are normally pink due to prominent blood flow, such as the lips and nail beds.

The appearance of organs after death:

• Kidneys: enlarged, pale, and yellow in color
• Liver: enlarged, yellow, soft, and greasy to the touch
• Heart: yellow and flabby
• Brain: pale, swollen, and lacking the usual wrinkles or furrows (sulci and gyri)
• Pupils: fixed and dilated (wide open)

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

So Lazarus was dead.

This information is based on the testimony of multiple witnesses who saw Lazarus die. Furthermore, he was placed in a tomb and wrapped in burial cloths, a practice that was never done for those merely thought to be dead. It is also known that his body lay in this state for four days. After such a period of time, there would have been significant cellular decay, decomposition, and a strong, unpleasant odor.

Lazarus was brought back to life from a state of irreversible death, as witnessed by many, including educated and knowledgeable Jewish Pharisees. Some of these witnesses came to believe in Jesus because of this event. The resurrection of Lazarus is also mentioned in a later part of the New Testament.

John 12:1 says, “Six days before the Passover, Jesus came to Bethany, where Lazarus was, who had been dead, whom he raised from the dead.”

Lazarus was a man who died from a progressive illness, such as sepsis. He was confirmed dead by multiple witnesses and was buried for four days. The expected signs of decomposition were present, but Lazarus came back to life. He is mentioned in later chapters of the book of the Apostle John, alive and well.

As a physician, I may sometimes clinically approach the Bible, but the story of Lazarus demonstrates the incredible and documented power of Jesus Christ from Galilee.

William Lynes is a urologist.