The following article was published in the March 1989 issue of The Journal of the Mississippi State Medical Association. Some portions have been rewritten, with primary changes being made to conform to web publication. The article contends that Jesus did not die of exhaustion and asphyxiation, which was the intent of crucifixion; but instead died of a rupture of the free wall of the myocardium, which resulted in cardiac tamponade. Pathogenesis of this process is discussed, and postmortem evidence is cited as confirmation.

DAVID A. BALL, M.D.
Batesville, Mississippi

In the March 21, 1986 issue of the Journal of the American Medical Association, there was an article which detailed the physical aspects of the death of Jesus Christ.¹  In general, it was an excellent article with good references and detailed sketches designed to give the reader a better understanding of a now extinct form of execution - the crucifixion.

However, the conclusions drawn by the authors seemed to lack a degree of specificity which I feel should be addressed.  Given the details of the Gospel accounts, we can hypothesize very specific probable cause of the death of Jesus and in turn compile reasonably convincing evidence to validate that probable cause.  The more specific we can be concerning the cause of the death and the more logical we can be in compiling our proof of that cause, then the more certain we can be as to the reality of that death.  So, within the forum of medical literature, I would like to sound my ideas regarding the crucifixion of Jesus and see if you do not agree that, given the facts, my conclusions regarding the cause of the death of Jesus are logical and even likely.

Why are we even addressing this issue at all?  One of the more significant questions raised in regard to the death of Jesus is just that...  Was it the death?  That question seems to be fueled not only by the "natural" reluctance to accept the account of the resurrection without some "natural" explanation (such as Jesus was not really dead), but also by a nagging doubt which is raised when we find that Pilate himself marveled that Jesus was so soon dead (Mark 15:43-45).

No matter what one’s faith might be, I think it would be safe to say that no man’s death has been more questioned, more studied, and more revered than has the death of Jesus Christ.  Through the scrutinizing eyes of history, the resurrection has shaped and continues to shape the destiny of mankind as no other singular event in all of recorded history.  If, however, this man Jesus did not truly die, then a cruel hoax has been perpetrated on mankind, for without the death of Jesus, the resurrection has no meaning.  Therefore, the death of Jesus must be validated, and who is more qualified to evaluate and judge the data relating to the death of Jesus than the modem physician?  It is for that reason we are obligated to carefully re-evaluate the events surrounding the death of Jesus.

Any study of the death of Christ has to begin with the trial because it was inhumane, illegal, and exhausting.  It lasted all night as Jesus was dragged from one "judge" to another.  He was mocked, ridiculed, slapped, spit upon and falsely accused.  When he was finally "convicted," he was beaten unmercifully with a Roman flagrum.

In the JAMA reference article, Edwards et al, comment, 

"The severe scourging, with its intense pain and appreciable blood loss, most probably left Jesus in a preshock state.  Moreover, hematidrosis [bloody sweat in Gethsemane] had rendered his skin 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."²

We sometimes overlook or underestimate the severity of the flogging Jesus received.  The reason might be in part because we tend to think of the whip as a platted leather instrument capable of raising painful blisters and even superficial bleeding if applied repeatedly and with enough force.  The Roman flagrum was something entirely different, however.  It was, indeed, composed of leather strips; but tied to the end of each of these were pieces of metal, glass, and bone.  This whip was designed to cut away at the flesh and render the subject nearly moribund.

C. Truman Davis, M.D., describes the flogging in very graphic terms . . .

Preparations for the scourging were carried out.  The prisoner was stripped of his clothing and his hands tied to a post above his head.  It is doubtful whether the Romans made any attempt to follow the Jewish law in the matter of the scourging.  The Jews had an ancient law prohibiting more than forty lashes.  The Pharisees, always making sure that the law was strictly kept, insisted that only thirty-nine lashes be given.  In the case of a miscount, they were sure of remaining in the law.  The Roman legionnaire stepped forward with the flagrum, or flagellus, in his hand.  This was a short whip consisting of several heavy, leather thongs with two small balls of lead attached near the ends of each.  The heavy whip was brought down with full force again and again across Jesus’ shoulders, back and legs.  At first the heavy thongs cut through the skin only.  Then, as the blows continued, they cut deeper into the subcutaneous tissues producing first an oozing of blood from the capillaries and veins of the skin, and finally spurting arterial bleeding from vessels in the underlying muscles.  The small balls of lead first produced large deep bruises which were broken open by subsequent blows.  Finally, the skin of the back was hanging in long ribbons and the entire area was an unrecognizable mass of torn, bleeding tissue.  When it was determined by the Centurion in charge that the prisoner was near death, the beating was finally stopped. ³

This scourging is considered by some to be the reason Jesus died sooner than was expected; but if we are honest, that cannot be true.  The scourging was a routine preamble to the crucifixion.^4,5  Pilate knew this. He must have seen many crucifixions. He was still surprised when he learned of Jesus’ early death.  There was another reason for Jesus’ rapid death, which we shall learn - but first we must understand something of the mechanics of crucifixion.

Today, there is no comparable form of execution, but in Jesus’ day, it was common.  The Romans executed thousands of criminals and malcontents using this form of torture.  It was considered so cruel that Roman citizens were almost never executed in this manner.^6,7

The specific details of the execution process enable us to understand what happened to Jesus and to draw dependable conclusions as to probable cause of death.

Mechanics of Crucifixion
Following the near death scourging, the victim was forced to bear his cross to the place of execution.  There is good evidence that this usually consisted only of the crosspiece or patibulum, which was strapped to the victim’s back and outstretched arms.⁸ (We shall look more at this later.)

On arrival at the site of execution, the victim was placed on the upright; and the slow process of tortured death was begun.  Just how slow and agonizing this process was depended on many details which were controlled by the executioner.

The first option available to the executioner was whether or not to nail the victim to the cross.  The Romans seemed to favor nailing their victims to the cross,^9,10 and the Bible is explicit in this detail of Jesus’ crucifixion (John 20:24-29).  However, we need to understand that death would ensue even if nails were not used and the victims were tied to the cross.  It would simply take longer for death to occur if the victims were tied to the cross.¹¹

The next consideration in the execution process was the positioning of the spikes on the cross and the manner in which the executioners secured the victim to the cross.  Three spikes were necessary to secure the victim - one in each of the upper extremities and one single spike through both lower extremities.

The average layman understands that the spikes securing Jesus’ upper extremities to the cross were nailed through his hands.  This is understandable since most English versions seem to imply such (John 20:24-29).  However, this interpretation is problematic in light of studies done by Pierre Barbet, M.D. Dr. Barbet secured cadaver wrists to a wooden beam using spikes through the palms and found that the weight of a body when suspended from the cross would simply tear the spikes through the hands.  If, however, the spikes were placed in the wrists, a body could be suspended successfully.¹²

This seeming discrepancy can easily be resolved by a brief Greek word study. The Greek word from which our English word hand is translated (John 20:24-29) is cheir. In the Greek language this word may include the hand and the wrist.¹³  This is important in our study here because it confirms the reliability of the Gospel accounts in providing details on which we can base our conclusions.

With both wrists thus fixed to the crosspiece or patibulum, and the victim suspended in this manner, his lungs would remain passively hyperinflated.  In order to exhale so that new air could be inhaled, the victim of crucifixion had to actively lift himself on the cross¹⁴ so that he could force air out of his lungs.

In my own studies of volunteers suspended from a cross - using leather wrist straps and metal hooks instead of nails - I have found the positioning of the arms on the uprights to be very important.  The more outstretched the arms on the crosspiece the more painful to hang suspended.  I rather suspect that the Romans well knew the results of positioning the hands and used this knowledge to achieve their desired results.

But, if the positioning of the hands is important, then I would have to say that my studies suggest the positioning of the feet is critical.  There are two factors here that must be considered.  First is the point of attachment of the feet to the vertical portion of the cross.  If the feet were secured toward the lower reaches of the suspended body, then obviously the victim would not be able to lift himself much in his effort to exhale.  Consequently, he would expend maximum effort and inhale minimum fresh air.  If, however, the feet were fixed further upward on the vertical piece, then the victim would be able to push himself up considerably more.  This would enable him to exhale more completely and to take in more fresh air.  Therefore, all other things being equal, he would live longer on the cross.

There was yet a second consideration, though, in this matter of securing the feet.  If the feet were turned sideways and the spike driven through one heel and into the other as it fixed the feet to the vertical piece, then the victim could lock his knees in a fully extended position whenever he pushed up to breathe.  He would then be able to maintain this position for lengthy periods of time and might even die of thirst or starvation.  This would explain how some crucifixion victims have been known to live for days.  On the other hand, if the feet were plantar flexed and one placed flat against the upright with the sole of the other foot on top and both secured by a single through and through spike, then the victim would be unable to fully extend his knees.  Since he would not be able to lock his knees, the energy expenditure for respiration would increase enormously because each respiratory cycle would require the victim to lift his entire weight and then let it down as gently as he could in order to avoid the shearing pain of the spikes in the wrists.

Understanding these factors would make possible the Romans’ "tailoring" of the crucifixion agony to fit the victim.  We know that Jesus had to be dead by sundown because he was crucified on the day of preparation (John 19:31) with the Sabbath / Passover beginning at 6:00 p.m.  We also know that Jesus was crucified at 9:00 AM (Mark 15:25).  Since Jewish law would not allow a victim to remain on the cross past sundown, we can presume that the Romans would have designed Jesus’ crucifixion to be "short-lived."  This would mean, in all likelihood, that Jesus’ feet were plantar flexed with the soles nailed to the uprights.  Even so, we have pointed out that Pilate was still surprised at his early death.  This would suggest other causes for the early death.  Therefore, we need to look closely at some of the mechanics of crucifixion.

As we have seen, each respiratory cycle required that Jesus lift himself on the cross, exhale and gently let himself down as he inhaled.  His back was laid bare from the scourging so that each cycle of breathing necessitated that he rub his back against the upright and agonize as the raw flesh was further macerated.  Each time he took a breath, his leg muscles quivered as his feet pushed against the spike.  Each time he sought relief by resting his legs, the spikes in his wrists would spit fire into the stretched and lacerated median nerve. There was no relief.

The agony helps us appreciate - but the physiology of those terminal hours in the life of Jesus helps us understand.  It is this understanding which allows us to draw conclusions as to the cause of the death of Jesus.  That is here our quest. In terms of those physiologic processes of crucifixion, what actually happens during the terminal hours on a cross?  In rather general terms, I would propose the outline of those events to look something like the following:

1. Respiratory efficiency is decreased because of the following:

• Relative hyperinflation of the lungs produces an increase in residual lung volume

• Lifting the body on the cross during each respiratory cycle produces an enormous increase in energy expenditure

2. Respiratory inefficiency is usually accompanied by an increase in respiratory rate as a means of compensation. This is not possible during crucifixion due to pain and effort of breathing. Therefore, respiratory acidosis develops.
        

3. With diminished oxygen exchange, hypoxemia develops.
         

4. Hypoxemia leads to anaerobic metabolism.  During crucifixion there is continued and significant muscle activity associated with respiration.  Since this occurs in an oxygen deprived state, the energy efficient Krebs Cycle cannot supply the energy to sustain this activity.  Pyruvate is then broken down to lactic acid.  This, of course, is a very inefficient source of energy.  But, perhaps just as important in the crucifixion scenario is that the production of lactic acid causes severe muscle cramps, which further reduces respiratory efficiency
         

5. Hypoxemia, hypovolemia (secondary to blood loss and sweating), and the increased workload previously described, all contribute to produce a compensatory tachycardia.
         

6. As the acidosis (combined respiratory and metabolic) continues and the pH drops, muscle cramps worsen. It then becomes more difficult for the victim to lift himself to breathe.
         

7. In the final stages, blood is shunted from skeletal muscle to vital organs in an effort to salvage the body.
         

8. At this point, skeletal muscle becomes relatively anoxic, therefore respirations are further inhibited and a vicious cycle ensues leading to a quiet death by exhaustion and asphyxiation because there is simply no energy left to resist.

Although I have never seen a crucifixion, I have (as most physicians have also) seen many patients die in the same terminal circumstances described above. Severe COPD and CHF / Pulmonary Edema patients struggling for their last breath are vividly retained in most of our memories.  Although it is an agonizing and frightful way to go (if the patient is conscious), it is, nonetheless, a quiet death.  These patients do not scream and holler because they simply do not have the strength and breath to do so.  Often, they do not even so much as whisper because all of their efforts are directed at saving that precious breath of air.

As we have seen, the usual means of death on the cross was by exhaustion and asphyxiation.  That was its design.  Jesus did not die that way.  We can be sure of it.  The Bible provides the details necessary for us to make this conclusion.

In Luke 23:46 we read: "And when Jesus had cried with a loud voice, he said, Father, into thy hands I commend my spirit, and, having said this, he gave up the spirit."

Matthew 27:50 and Mark 15:37 repeat the part about Jesus’ crying with a loud voice and then suddenly giving up the spirit.  If Jesus had died of exhaustion and asphyxiation, then he would not have had the air in his lungs to have cried out with a loud voice saying, "Father into thy hands I commend my spirit . . . " and then suddenly die.

Instead, the scriptures indicate that something happened suddenly causing Jesus to cry out in pain and then suddenly die.  That is not the picture of death by exhaustion and asphyxiation.  Now, we must honestly ask ourselves, could Jesus have faked it at this point?  Absolutely not!  By its very design the crucifixion would have prevented this.

If Jesus had intentionally tried to pretend death, then he would have had to breathe without anyone in the crowd noticing it, an impossible feat considering that each breath required the victim to lift himself on the cross so he could exhale and then inhale fresh air.  Everyone would have seen this - in particular, the soldiers who were trained executioners.

If Jesus had simply swooned, as some insist, then he would have died anyway because he would not have been able to lift himself to breathe.  That was the design of the crucifixion process.  That was the purpose of breaking the legs of the victims who were not already dead.  Once their legs were broken, they could not lift themselves on the cross to breathe.  Then death would ensue quickly.

The final proof, however, of Jesus’ death was the "coup de grace" of the sword in his side.  This was the soldier’s surety of the victim’s death, a trained maneuver to lay to rest the question of a live victim.  We will look at this maneuver more closely in a moment.

Probable Cause of Death
What then can explain the loud cry and sudden death of Jesus as he hung on the cross?  Once all the evidence is considered, I think you will agree that a true rupture of the myocardium is the most likely probable cause. I think this process can be documented with a high degree of probability.

First, let’s understand that I am referring to a true or external rupture of the myocardium and not a papillary or septal rupture.  In such a situation there would rapidly develop a terminal sequence with cardiac tamponade and rapid fall in arterial pressure.  Under the circumstances of the crucifixion, this would lead to certain and rapid death.

Even though there was no formal postmortem examination, I think we can substantiate this mode of death because the Bible again provides us the critical details.

John 19:34 says, "But one of the soldiers, with a spear, pierced his side and immediately came there out blood and water. "  The significance of this comment is incalculable from a medical point of view.  That makes it all the more interesting when we realize that Dr. Luke doesn’t even mention it.  That’s because he had no way of knowing the significance.  Had Dr. Luke been the one to relate these details, no doubt some antagonist would have insisted that the evidence had been planted.

The truth is, John didn’t even know the significance of what he wrote.  He simply knew something unusual was happening and wanted to be sure it was recorded for posterity.

John 19:35 says, "And he that saw it bore witness, and his witness is true; and he knoweth that he saith true, that ye might believe."

You can almost sense John’s efforts to convince the reader that what he was writing was the truth.  Ordinarily when a dead man is cut, no blood flows.  John and the rest of us know that.  That is probably why he insisted that his witness of the event was true.  But, it is also why this bit of evidence is doubly important.  Since no one present at the crucifixion knew the significance of the blood and water, and indeed, it appeared to be even contrary to the expected norm, we can be assured that this account was not fabricated, but was simply an honest rendering of the crucifixion events.

If indeed a rupture of the free wall of the left ventricular myocardium occurred (as I believe it did), then there would certainly be cause for sudden death with rapid development of cardiac tamponade.  Ordinarily, there is approximately 30 cc of clear fluid in the pericardial cavity.  However, due to the stress of the terminal events of the crucifixion (with congestive heart failure and decreased venous return to the heart resulting from hypovolemia and hyperinflation of the lungs), there could have been 100 cc or more of pericardial fluid present.¹⁵  Rupture of the free wall of the ventricle would have added another 200 or 300 cc of blood before tamponade would have effectively produced cardiac standstill.  This blood would probably be noncoagulating,^16,17 and with the demise of the victim there would be some settling of the cellular components to the bottom of the pericardial cavity.  (There certainly could be some clotting, also^18, which would likewise contribute to the separation of red blood cells and "clear fluid.")

At this point, the Roman soldiers came to check on the status of the three crucifixion victims and found that Jesus was already dead.  Reacting in true military form, the "coup de grace" thrust of the sword was aimed at the heart.  As soon as it pierced the pericardium, the pressurized contents gushed forth.  The blood, which was on the bottom came first, followed by the clear "water" on the top.  That is exactly the way the Bible says it happened.

Suppose, however, for the sake of argument, that my proposed scenario is not correct.  What then might we have expected from the sword piercing?

If Jesus had been alive at the time, the blood would have flowed as soon as the sword pierced the myocardium and would have stopped as soon as the heart stopped.  There would have been no water to flow.

If Jesus had been dead, but the heart had not ruptured, then not much at all would have happened with the sword piercing.  Perhaps a little blood would have flowed, but not much, because the contents of the heart would not have been under pressure since the heart would have been in asystole.  Therefore, when the sword was removed, the wound would close and simply ooze a little blood. Again, there would have been no flow of water.

The Bible gives us solid evidence of the death of Jesus and of the cause of that death.  What has concerned me in the past has been the lack of an acceptable and rational medical reason for Jesus’ heart to rupture.  Most references dealing with this question simply say that Jesus died of a broken heart and mention John’s account of the blood and water as proof (without even explaining that).  Some have gone one step further and have said that the emotional stress Jesus was under on the cross caused his heart to rupture.  That could be true, I suppose, but there is no evidence in current medical literature that I can find to suggest that emotional stress alone can cause the normal heart to rupture.

If the heart did rupture, and we are to maintain this was the probable cause of death, then we need some evidence suggesting pathogenesis.

To do this, we need to retrace the events prior to the crucifixion because there we find important clues.  We have already shown that Jesus was worn down by a night-long fiasco of trials.  Then he was beaten unmercifully with the Roman flagrum.  Next, we are told in John 19:16-17 that they put the cross on his back and led him away to Golgotha where they crucified him.

Dr. Pierre Barbet states that the crosspiece weighed slightly over 100 pounds and that it was strapped to Jesus’ shoulders and outstretched arms.¹⁹  This weight seems reasonable in view of my personal studies.  The cross, which I use for demonstration and study purposes, is made of kiln-dried pine, 5.5 inches square.  The crosspiece weighs approximately 50 pounds.  Assuming that Jesus’ cross was made of green wood of a more dense nature such as oak, it would be easy to account for a crosspiece weight of approximately 75-100 pounds.  If the wood used were somewhat larger than 5.5 inches square, obviously the weight could be considerably more than 100 pounds.  Now, with this weight strapped to his back, Jesus began his trek to Golgotha.  We have already established the exhausted and debilitated state that Jesus was in following the scourging.  This was enough to overburden even the strongest of men.

Somewhere along the route to Golgotha, Simon of Cyrene was conscripted to carry the cross of Jesus.  This is attested to in Matthew 27:32, Mark 15:21, and Luke 23:26.  There must have been a reason for this conscription, and it could not have been sympathy, for not once do we have a suggestion that the Jews or the Romans were sympathetic to Jesus.  In fact, it was their anger and hatred that literally dominated the scene.  There had to be another reason.

The day of the crucifixion was very busy for the Jews.  It was the preparation for the Passover.  The Jews did not want to leave their bodies on the cross after sundown, for that was against Jewish laws (John 19:31, Deuteronomy 21:23 and Joshua 8:29, 10:26-27).  For this reason, the crucifixion needed to be hastened, and this half-dead Jesus was stumbling along at a snail’s pace.  He was falling as he wearily forced each step of the way.  With his outstretched hands tied to the crosspiece, he was taking a severe battering with each fall, and it was doubtful that he could even make it to Golgotha.  For that reason, Simon of Cyrene was conscripted to carry Jesus’ cross.

Often it is the little details that give us the greatest insight, and they are so often overlooked.  The above paragraph, which explains why Simon of Cyrene was conscripted to carry Jesus’ cross, also explains the pathogenesis of Jesus’ ruptured heart.

As we explained, Jesus’ outstretched arms were tied to the crosspiece.  When he fell, he had no way to break the fall, so he fell straightforward into the street.  With the weight of the crosspiece on his back, this was sufficient to inflict significant injury to the chest wall, which would have borne the brunt of the force.  The resultant injury would have been similar to blunt chest trauma sustained in an automobile accident when the chest collides with the steering wheel of a car.

The following quote from Friedberg’s Diseases of the Heart helps us to understand this type of injury better.

A frequent cause of nonpenetrating cardiac injury is the well-publicized steering-wheel accident.  The driver’s chest is pinned against the steering wheel when the forward momentum of the car is suddenly arrested.  Severe cardiac injury or rupture of the heart often follows crushing chest accidents when an auto, train or other vehicle runs over the prostrate body... Direct blows to the anterior chest wall by a baseball, golf or tennis ball traveling at high speed, by heavy falling or swinging objects which strike at great velocity, fist blows and kicks by a horse or other powerful animal and compression of the chest between two moving objects are among the causes of nonpenetrating cardiac trauma. . .

Serious contusions and even rupture of the heart often occurs without significant visible external injury of the chest wall and without fracture of the chest wall and without fracture of the ribs. In fact, in a series of 250 nonpenetrating chest injuries by Arenberg, the greater cardiac damage occurred among the cases without rib fracture.²⁰

That is particularly important since we know that Jesus had no broken bones (John 19:36).

There seems to be no reasonable doubt that the fall could cause significant myocardial injury and even rupture. It also seems to be reasonably certain that should there have been such an injury, which predisposed to myocardial rupture, that the tremendous workload of the crucifixion process would have increased the likelihood of such a catastrophic event taking place. The remaining question seems to be, would it have occurred so soon? So, the question of Pilate (Mark 15:43-45) as to why Jesus was so soon dead demonstrates the reliability of the Bible, not only as an important source of facts, but also an important source of probing questions which lead us to the truth.

In an article by Becker and van Mantgen appearing in the European Journal of Cardiology, a study is made of 50 episodes of death by cardiac tamponade.²¹ Three types of rupture are defined in this study.  Type I is characterized by an abrupt slitlike tear which correlates clinically with an infarct usually of less than 24 hours.  Type II shows an erosion of the infarcted myocardium, indicative of a slowly progressing tear.  This type correlated with a somewhat longer time interval between onset of symptoms and tamponade.  Type III is characterized by early aneurysm formation, which correlated clinically with older infarcts.

These three types of rupture are then correlated with the location of the myocardial injury - either anterior, lateral, or posterior. Twenty-nine ruptures occurred anteriorly which the authors point out is consistent with the incidence of anterior infarcts in the general population. What is interesting to me is that a rupture occurring in this anterior group was very likely (72%) to be a Type 1, which would result in sudden rupture and rapid demise.

It would seem likely that blunt trauma to the anterior chest wall, such as Jesus received, would result in anterior myocardial injury. Therefore, if a rupture were to occur in such a situation, we would expect it to occur within 24 hours - even if the subject were at rest. Certainly, it would seem reasonable that under the stress of crucifixion such a rupture could be likely to occur within 6-7 hours. This time span for Jesus’ death would be likely considering the walk to Golgotha, crucifixion beginning at the third hour (Mark 15:25) and ending sometime after the ninth hour (Mark 15:33-37).

Summary
In summary, I would suggest that Jesus was unable to carry his cross because of his cruel treatment and scourging. He then fell with the 100 pound crosspiece on his back and was unable to break the fall because his outstretched hands were tied to the crosspiece. This resulted in blunt chest trauma and a contused heart. On the cross the workload of the heart was greatly increased due to multiple factors, but primarily the increased effort necessary to breathe. This resulted in a rupture of the free wall of the heart, which caused Jesus to cry out in a loud voice and suddenly die. This cause of death is confirmed for us by the sword pierce to the side, which resulted in the flow of blood and water. In effect, that was a brief and legitimate postmortem exam. JESUS WAS DEAD! THAT WAS FRIDAY! SUNDAY WAS COMING!

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Reprinted from the JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION March 1989, Vol. XXX, No. 3, pages 77-83 Copyright, 1989, Mississippi State Medical Association