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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.2015.05.017 118 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- AMSRJ 2015 Volume 2, Number 1 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 AMSRJ 2015 Volume 2, Number 1 119 SAVING THE SURVIVORS 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.13 120 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- AMSRJ 2015 Volume 2, Number 1 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 AMSRJ 2015 Volume 2, Number 1 121 SAVING THE SURVIVORS 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 122 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 1. Maslen MW, Mitchell PD. Medical theories on the cause of death in crucifixion. J R Soc Med. 2006;99(4):185-88. 2. Hengel M. Crucifixion in the ancient world, and the folly of the message of the cross. Philadelphia, PA: Fortress Press;1986. 3. Holoubek JE, Holoubek AB. Execution by crucifixion. History, methods and cause of death. J Med. 1995;26(1-2):1-16. 4. Retief FP, Cilliers L. The history and pathology of crucifixion. S Afr Med J. 2003 ;93(12): 938-41. 5. Auckland man Chris Isaia recovering from welts inflicted to his back following mock crucifixion on Mangere Mountain. NZCity. April 11, 2009. Available at: http://home.nzcity.co.nz/news/article.aspx? id=98772&fm=newsarticle+-+Accident+and+Emergency%2Cnrhl. Accessed December 16, 2012. 6. DeBoer SL, Maddow CL. Emergency care of the crucifixion victim. Accid Emerg Nurs. 2002;10(4): 235-9. 7. Lussiez B. Anatomy of crucifixion. Chir Main. 2005;24(3-4):132-47. 8. Crucifiction from ancient Rome to modern Syria. BBC. May 8, 2014. Available at: http://www.bbc.com/news/magazine-27245852. AMSRJ 2015 Volume 2, Number 1 SAVING THE SURVIVORS Accessed January 27, 2015. medical point of view. Ariz Med. 1965;22:183-7. 10. Edwards WD, Gabel WJ, Hosmer FE. On the physical death of Jesus Christ. JAMA. 1986;255(11):1455-63. 11. DePasquale NP, Burch GE. Death by crucifixion. Am Heart J. 1963;66(3):434-5. 12. Barbet, P. A Doctor at Calvary: The Passion of Our Lord Jesus Christ as Described by a Surgeon. Garden City, NY: Doubleday Image Books; 1953. 13. Tenney SM. On death by crucifixion. Am Heart J. 1964;68(2):286-7. 17. Stroud W. A treatise on the physical cause of the death of Christ. London: Hamiltom & Adams; 1847. BRIEF REPORTS 9. Crucifixion in antiquity, the anthropological evidence. Mercaba. Available at: http://www.joezias.com/CrucifixionAntiquity.html. Accessed December 16, 2012. 18. Brenner B. Did Jesus Christ die of pulmonary embolism? J Thromb Haemost. 2005;3(9): 2130-1. 19. Dicker RA, Mackersie RC. Pitfalls in the management of the trauma patient. In: Wilson WC, Grande CM, Hoyt DB, eds. Trauma: Emergency Resuscitation and Perioperative Management. 1st ed. New York: Informa Healthcare; 2007: 821-34. 20. Harbrecht BG, Billiar TR. Shock. In: Peitzman AB, Rhodes M, Schwab CW, Yealy DM, Fabian TC, eds. The trauma manual: trauma and acute care surgery. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2007: 45-50. 14. Bucklin R. The legal and medical aspects of the trial and death of Christ. Med Sci Law. 1970;10(1):14-26. 15. Zugibe F. The cross and the shroud: a medical inquiry into the crucifixion. New York, NY: Paragon House; 1988. 16. Davis CT. The crucifixion of Jesus: The passion of Christ from a AMSRJ 2015 Volume 2, Number 1 123