Luke 22:44 And in his anguish he prayed more earnestly, and his sweat was like drops of blood falling to the ground.

The first thing to note is that vv43-44 are text-critically disputed.  Garland, along with others, considers the debate finely balanced.  I shall proceed on the assumption of their authenticity.

1. ‘Bloody sweat’ affirmed

Some old writers, and some modern apologists, eager to squeeze the last drop(!) out of this passage, take it to mean that Jesus actually sweated drops of blood.

Accord to Raymond Brown, Irenaeus understood it to mean that Jesus ‘sweat drops of blood’.

The esteemed Puritan John Flavel:

‘It was a sweat as it had been blood, which, [as] is neither an hyperbole, as some would make it:nor yet a similitude of blood; as others fancy, but a real bloody sweat. For so [as] is sometimes taken for the very thing itself, as John 1:14. And as a worthy divine of our own well notes, that if the Holy Ghost had only intended it for a similitude or resemblance, he would rather have expressed it, as it were drops of water, than as it were drops of blood, for sweat more resembles water than blood.’ (The Fountain of Life, Sermon 22)

Other Puritan writers, including Sibbes and Brooks, seem to assume, without question, that our Lord sweated blood, or ‘water and blood’ (Sibbes) in the garden.

The 19th-century commentator David Brown (in JFB):

‘What was this? It was just the internal struggle, apparently hushed somewhat before, but now swelling up again, convulsing His whole inner man, and this so affecting His animal nature, that the sweat oozed out from every pore in thick drops of blood, falling to the ground. It was just shuddering nature and indomitable will struggling together.’

Alford argues that the the simile works best is what is being described is blood-stained sweat (distinguished from pure blood):

‘The intention of the Evangelist seems clearly to be, to convey the idea that the sweat was (not fell like, but was ) like drops of blood; i.e. coloured with blood , for so I understand the ὡσεί , as just distinguishing the drops highly coloured with blood , from pure blood . Aristotle, speaking of certain morbid states of the blood, says, ἐξυγραινομένου δὲ λίαν νοσοῦσιν · γίνεται γὰρ ἰχωροειδές , καὶ διοῤῥοῦται , οὕτως ὥστε ἤδη τινὲς ἴδισαν αἱματώδη ἱδρῶτα , Hist. Anim. iii. 19. To suppose that it only fell like drops of blood (why not drops of any thing else? and drops of blood from what , and where? ) is to nullify the force of the sentence, and make the insertion of αἵματος not only superfluous but absurd.’ (Alford’s Greek Testament)

J.C. Ryle:

‘It is observed by all the best commentators, that there is good medical evidence that such a mixture of blood and sweat as that here recorded, can take place, and has taken place, in cases of great mental and bodily distress.’

The popular Christian writer Warren Wiersbe:

‘His use of the word like may suggest that the sweat merely fell to the ground like clots of blood. But there is a rare physical phenomenon known as hematidrosis, in which, under great emotional stress, the tiny blood vessels rupture in the sweat glands and produce a mixture of blood and sweat.’

Apologist J. Warner Wallace quotes Dr Joseph Bergeron:

‘Psychogenic (fear induced) hematidrosis has been observed in a handful of reported cases from fear of impending physical harm. Most of these reported cases were in individuals just prior to execution. This appears to have been the case with Jesus, who sensed premonition of his impending crucifixion (Matt 20:18-19).’

William Hendriksen says more or less the same thing.

2. ‘Bloody sweat’ doubted

There is such a (rare) condition.  But such an interpretation may not do justice to the comparative “was like”; we cannot be sure whether Luke intends us to understand the comparison was in terms of the colour, consistency or size of the drops of sweat.  However, if it was red, we might expect it to have been described as blood itself.  It is hard to see how an onlooker could have detected the consistency.  So Luke is probably referring to the size of the drops of sweat.  Some translations (ESV, AV, NKJV, NLT) reflect this, by translating it as ‘great drops of sweat’.

Dionysius the Great (cAD 200 to c265) offered a simple (and to my mind, persuasive) explanation:

‘For in using the expression, “as it were great drops of blood,” he does not declare the drops of sweat to have been actually drops of blood. For he would not then have said that these drops of sweat were like blood. For such is the force of the expression, “as it were great drops.”’ (In Brattston, D. (2020) Bible Problems Solved by Early Christians)

Croteau says that the word Luke uses for ‘like’ is hōsei.  This is ‘a relatively weak marker of a relationship between two things.’  (A more emphatic marker would be the word hōsper, cf. Lk 18:11).  It would be strange if Luke had said that the phenomenon was similar to drops of blood if actual drops of blood were meant.  Another instance of this use of this weaker form of comparison is found in Mt 3:16 – ‘He saw the Spirit of God descending like a dove.’

Raymond Brown:

‘There is no surety…that the passage means that Jesus’ sweat became bloody; it could mean that the sweat became so profuse that it flowed to the ground as freely as if it were drops of blood.’

Luke Timothy Johnson puts the matters as clearly as any:

‘The text does not say that Jesus had a “bloody sweat” as a sort of physiological reaction to stress, but makes a comparison (hōsei) between the profuseness of the sweat (in its huge drops) and globules of blood.’

What we can say is that this verse supports Luke’s portrayal of our Lord’s humanity, and it provides evidence of his deeply emotional state at this time.

Edwards comments:

‘Dripping blood would be expected to describe the crucifixion, but no blood attends that narrative. The most intense description of Jesus’ suffering in the Gospels occurs not at Golgotha but at Gethsemane, in his decision to submit to the Father’s redemptive will. On the Mount of Olives, Jesus’ soul is crucified; on the Mount of Calvary, his body is surrendered.’

Evans (UBCS):

‘The descriptive sentence, his sweat was like drops of blood falling to the ground, should be understood as describing the size and quantity of the drops of perspiration (like drops of blood) and not as a statement that Jesus’ perspiration was actually bloody.’

Bock writes:

‘Readers should not take the text to say that Jesus literally sweated blood. Luke is making a comparison; Jesus’ sweat drops were large like drops of blood flowing from a wound. The scene portrays intense emotion as Jesus faced death. Overall, this fits Luke’s careful portrayal of Jesus’ humanity.’ (Holman Apologetics Commentary)

Garland:

‘It is best not to interpret the phrase “his sweat became like drops of blood” (ἐγένετο ὁ ἱδρὼς αὐτοῦ ὡσεὶ θρόμβοι αἵματος) as bloody sweat, although this phenomenon was not unknown in the ancient world. Luke uses a simile to convey likeness short of identity (compare “tongues of fire that separated,” Acts 2:3).’

Conclusion

I think that the expression is a simile.  Our Lord’s sweat was not tinged with blood, as some think.  Rather, it appeared as drops on his skin, and fell to the ground, as if he were bleeding.