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BRIEF REPORTS
Saving the Survivors
Ibrahim Saleh Al-Busaidi, BMedSc(Hons)1; Yassar Alamri, MB ChB1,2
University of Otago School of Medicine, Christchurch, New Zealand
2
New Zealand Brain Research Institute, Christchurch, New Zealand
1
ABSTRACT
Crucifixion can be defined as a method of execution in which a person is hanged, usually by their
arms, from a cross or similar structure until
dead.1 It has been used in the past as a means of
social control and punishment in different places
and periods, particularly in the Roman Empire
around 2000 years ago.2 The practice of crucifixion was largely discontinued when it was finally
abolished by Constantine I, the emperor of
Rome, after 320 AD.3,4 Although the medical
field has shown a recent interest in the subject of
crucifixion, relatively little has been published
on the care of crucifixion victims. This article
will discuss the rituals of crucifixion and the injuries associated with it, as well as the initial
assessment and resuscitation of a crucifixion
victim in the emergency department (ED).
INTRODUCTION
Current Prevalence
Corresponding Author: Ibrahim Saleh Al-Busaidi, BMedSc
(Hons), University of Otago School of Medicine, 2 Riccarton
Avenue, Christchurch Central, Christchurch 8011, New Zealand.
Email: [email protected]
The authors claim no conflicts of interest or disclosures.
AMSRJ 2015; 2(1):118-123
http://dx.doi.org/10.15422/amsrj.2015.05.017
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Since its abolition, crucifixion has only been
practiced sporadically. Current prevalence is
unknown as reports of modern-day crucifixion
are often anecdotal, and details are few and far in
between. Media reports of crucifixion from the
Philippines, Ireland, and New Zealand were
largely cases of demonstrating devotion to Jesus
Christ.5-7 The “Auckland man” case, for instance, involved wearing a crown of thorns,
lashing with whips, as well as re-enacting the 14
states of the cross as he and his followers of
around 1000 people marched towards Mangere
Mountain in Auckland, New Zealand.5
More recently, however, an internet Google
search (www.google.com) has revealed a spike
of reported crucifixion cases in the media executed by the so-called Islamic State of Iraq and
the Levant (ISIL) in the Middle East.8 The ISIL
appears to employ crucifixion of already-dead
victims as a means of deterring treason. Victims,
tied to planks of wood with string, are often
blindfolded; banners stating crime(s) that led to
their execution are placed over their heads or
bodies.8
Other practices related to crucifixion, but not
quite as extreme, are also exercised in many
places around the world. For example, self-flagellation (i.e. the act of hitting oneself with a
whip) is commonly practiced for religious purposes, mainly by Shi’a Muslims (e.g. Iran) and,
to a lesser extent, Christians (e.g., the Philip-
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SAVING THE SURVIVORS
pines during Lent). Such practices, however, are
beyond the scope of this article.
Crucifixion was considered to be one of the most
brutal and humiliating forms of execution. It was
probably first used as a mode of execution by
several civilizations, such as the Indians, Persians, Assyrians, Taurians and the Celts.3,4,9 It is
believed that the knowledge of crucifixion was
transferred from these eastern cultures to the
Mediterranean shores by Alexander the Great
before it was brought to Egypt, Syria, Phoenicia,
and Carthage by the subsequent Roman emperors.3,4,10 Although the Romans did not invent the
practice of crucifixion, they favored it as a mode
of torture and social punishment. They modified
it to produce a slow, agonizing death with maximum pain and suffering for slaves, rebels, criminals, and captives of war.3,4,11 A Roman citizen,
on the other hand, was rarely subjected to crucifixion, except in the cases of desertion. In Rome,
crucifixion became a commonplace practice;
during the revolt of Spartacus in 71 BC, more
than 6,000 followers of Spartacus were crucified
as a part of victory celebration.9 The practice of
crucifixion was finally discontinued when it was
outlawed by the Roman emperor Constantine I
early in the fourth century.3,4 Nevertheless, the
practice of crucifixion has been reported periodically throughout subsequent history.3,6
Crucifixion Ritual
To try to understand the injuries and possible
cause(s) of death by crucifixion, one must first
learn about what the process of crucifixion entailed.
The cross
In the earliest forms of crucifixion, the subject
was merely tied to a tree (L. infelix lignum) or a
simple upright post (crux simplex). Only later in
Roman times had the famous Latin cross ( ,
BRIEF REPORTS
Background And History Of Crucifixion
crux immissa) or Tau cross (T, crux commissa)
been used.4,10 The usual execution cross was
made up of two pieces, a vertical post (known as
stipes) which remained implanted outside the
city walls in the place of crucifixion and a horizontal cross-beam (known as patibulum) which
was carried by the condemned from the place of
scourging to the designated site of crucifixion.4,6,10
Preliminary procedure
It was reported that the condemned victim sentenced to execution by crucifixion was subjected
to compulsory scourging or flogging as a legal
prerequisite to all crucifixion.3,6 Only women
and Roman senators or soldiers were not subjected to flogging, except in cases of desertion.4,10 Although scourging had been used in ancient times as a mode of execution itself, Romans employed it before crucifixion to significantly weaken the victim.3,6,10 Therefore, it was
prohibited in the Roman law for the soldiers (lictors) to execute the condemned at the scourging
process.12
Two scourging instruments were often utilised:
a three-chained whip (known as a flagrum or
flagellum) consisting of a wooden handle with
metal balls and small, sharp fragments of sheep
bones attached into leather straps, and wooden
staves, both of which produced deep bruising.4,6,10,13 The condemned victim was then
stripped off their clothing with their hands tied to
a flogging post.10,12-14 One or two soldiers then
flogged the naked back, buttocks, and legs in an
arc-like fashion. This forceful scourging resulted in deep lacerations of the skin, extensive subcutaneous damage, blood loss, and intense
pain.4,10,15 By the time of the actual crucifixion,
the victim’s physical state would have almost
been critical. The extent of blood loss would
principally be determined by the degree of lacerations.10,12 Moreover, some condemned victims
had been subjected to maiming, such as excision
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BRIEF REPORTS
of body parts.4 From time to time, the victims
were reported to have fainted during the scourging event and sudden death was not uncommon.10
Such prerequisites of crucifixion as flogging and
maiming caused the condemned victim to reach
the cross with severe trauma. Scourging caused
substantial blood loss from deep wounds on the
back, legs, and buttocks.4,10 Furthermore, the
nailing of the victim’s arms and feet aggravated
bleeding and caused severe pain perhaps
through damaging the median, peroneal, and
plantar nerves. The pain due to crucifixion was
truly excruciating and constant.4,6
March to the crucifixion site
After surviving the scourging procedure, the
soldiers usually mocked the victims then required them to carry their own cross-beam (patibulum), weighing 34 to 57 kg, to the place of
crucifixion.6,10,12 One of the soldiers walked
ahead carrying a sign called the titulus on which
the victim’s name and crime were displayed.
This sign would eventually be nailed to the
stipes above the head of the victim.4,10,12
The crucifixion process
Upon eventually reaching the designated location of execution, it was customary for the condemned victim to be given a mixture of bitter
wine and myrrh as a mild analgesic to eliminate
some of the pain.4,16 The victim was then thrown
to the ground on his back with his arms stretched
over the crossbar.3,12 Subsequently, the arms
were nailed or tied to the patibulum, but the Romans preferred nailing over ropes as a means of
fixing the arms to the cross.12,13 Some archaeological evidence suggested that nails were driven through the wrists or the upper forearms instead of the hands. Although some blood is lost
from nailing, the amount is not extensive compared to that of scourging.10,12 Rarely, the condemned victim was crucified upside down.13
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As the arms were fixed to the cross-beam, the
subject was lifted onto the stipes and the feet,
separately or together, were tied or nailed to the
vertical post. After the nailing was completed,
the titulus was affixed to the stipes by ropes or
nails.10,12 The guards then divide the subject’s
cloths amongst themselves while awaiting the
death of the crucified. Normally, the length of
survival on the cross varied from three or four
hours to three or four days. In the presence of any
reason to hasten the death of the victim, one
technique used by the Romans was to break the
legs below the knees (crurifragium or
skelokopia) with a blunt instrument.4,10 It was habitual to leave the victim’s corpse on the cross to
be devoured by predators and wild beasts. Only
after obtaining permission from the Roman
judge was the family of the deceased permitted
to remove the body for burial.12,13
DISCUSSION
Major Theories On The Cause(s) Of Death
The pathogenesis of the death of a crucified victim is complicated and still widely debated. Several proposed mechanisms of death include cardiovascular, respiratory, metabolic, and psychological pathologies. More than ten different theories have been postulated since the publication
of Stroud’s book titled “A treatise on the physical cause of the death of Christ,” and several
articles have proposed more than one mechanism of death.1,17 Among these hypotheses are
hypovolemic shock, cardiac rupture, asphyxia,
heart failure, and pulmonary embolism. More
likely, however, is that the exact mechanism of
death of a crucified victim is multifactorial.12,16
Table 1 shows a representative selection of medical hypotheses for the mechanism of death by
crucifixion.
Perhaps the most plausible medical hypotheses
on the causes of death in crucifixion include res-
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SAVING THE SURVIVORS
Author
Year
Cardiac rupture
Stroud
1847
Asphyxia
LeBec
1925
Did not actually die*
Primrose
1949
Heart failure
Smith
1950
Voluntary surrender of life
Wilkinson
1972
Arrhythmia and asphyxia
Edwards
1986
Acidosis
Wijffels
2000
Wide menu of proximal causes of death
DeBoer and Maddow
2003
Pulmonary embolism
Brenner
2005
Hypovolemic shock
Zugbie
2005
BRIEF REPORTS
Cause(s) of death
*Some authors argued that since “somatic activities having been maintained at a very low level” in victims of crucifixion, they only appear to
die but regain consciousness once taken down from the cross.1,6
Table 1. Published Selection of Medical Hypotheses for the Mechanism of Death by Crucifixion
piratory failure and hypovolemic shock. Death
by crucifixion through exhaustion asphyxia
(respiratory failure) is believed to be caused by
interference with normal respiration, particularly exhalation. With the body’s weight tiring the
intercostal muscles, the breathing is shallow,
and the diaphragm becomes the sole muscle of
exhalation. This pattern of breathing would result in impaired exhalation with progressive hypercarbia.10 Furthermore, pulmonary contusions, painful rib fractures or flail chest as well
as hemopneumothorax from scourging further
impair respiratory mechanics and oxygenation.6,10 Hypovolemic shock would have resulted from dehydration and continuing traumatic
blood/fluid loss.6 Other causes of death could
have included pulmonary thromboembolism
due to dehydration, multiple traumatic injuries,
immobilization,18 myocardial infarction and
cardiac rupture secondary to valvular aseptic
emboli, and heart failure precipitated by anoxiainduced pericardial effusions.10
Resuscitation Of A Crucified Victim
Resuscitating a crucified patient is complicated
and daunting due to the multitude of injuries.19
Adding to this difficulty is the plethora of literature describing various mechanisms of death,
which can serve as a distraction if one tries to
focus on a single mechanism. Furthermore, a review of the medical literature identified no cases
of crucifixion victims being managed in the ED.
Therefore, we tried to describe a simple protocol, divided into three stages, with the ultimate
aim of rescuing the patient before expiration in
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the ED.
BRIEF REPORTS
The first stage is the DRS stage: identifying dangers, checking for response, and sending for
help. This will have most likely been carried out
before the patient’s arrival in the ED. The second
stage starts as soon as the patient arrives in the
ED (or even before) and is the CAB (or ABC)
stage: circulation, airway, and breathing. Firstly, at least two peripheral large-bore intravenous
lines should be established. This is to administer
fluids and blood products to replace what the
patient has lost through flayed tissues, edema,
and environmental exposure.20 With loss of skin
barrier, an infection is likely to be present, and
broad-spectrum antibiotics are often warranted.
Crucified patients will, most likely, require endotracheal intubation and mechanical ventilation. This is usually due to cardiac arrest, depressed mental state (Glasgow coma score ≤ 8),
absence of gag or ineffective ventilation. Rib
fracture may have resulted in hemopneumothorax. Therefore, needle decompression, followed
by bilateral chest tube placement, is a reasonable
option to consider.20
The third stage is the if-all-fails stage. Depending upon the hospital setting and local protocols,
such care escalation may require transfer to the
operating room rather than continuing care in
the ED. If venous access has failed, fluids can be
placed directly into the right atrium or the aorta.
If a lance spear wound is apparent, it must be
assumed that the heart/great vessels have been
hit. The clinician has the option of cross-clamping the descending aorta if it was assumed injured. If this fails to stabilize the patient, the clinician may decide to perform a left-sided thoracotomy to identify the heart and mediastinum.19
Penetrating heart injuries can cause cardiac tamponade, which should be evacuated. Following
heart closure, resuscitation can be performed
through defibrillation or manually. If the resuscitation is still unsuccessful, a right-sided thoracotomy is the last resort. This is done to check for
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any injury to the pulmonary vasculature, and if
any is identified, cross-clamping is required. If
this fails, however, resuscitation attempts are
said to have failed and the clinician should terminate intervention and announce time of
death.19,20
CONCLUSION
Encountering such gruesome trauma in ED is
unlikely in this day and age in most parts of the
world. This is not only due to the low prevalence
of crucifixion, but also the fact that patients may
not survive to reach ED care. However, it may be
useful for healthcare providers to consider the
immediate dangers crucified patients face, and
how to manage them in an effective and systematic manner. Following the described threestage protocol may give the patients a maximal
chance of survival.
REFERENCES
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Accessed January 27, 2015.
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BRIEF REPORTS
9. Crucifixion in antiquity, the anthropological evidence. Mercaba.
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