William D. Edwards, MD; Wesley J. Gabel, MDiv; Floyd E Hosmer, MS, AMI
Reprinted from MISC/JAMA - The Journal of the American Medical Association
March 21, 1986, Volume 256
Copyright 1986, American Medical Association
Medical Aspects of Crucifixion
With a knowledge of both anatomy and ancient crucifixion practices, one may reconstruct the probably medical aspects of this form of slow execution. Each wound apparently was intended to produce intense agony, and the contributing causes of death were numerous.
The scourging prior to crucifixion served to weaken the condemned man and, if blood loss was considerable, to produce orthostatic hypotension and even hypovolemic shock. (8, 12) When the victim was thrown to the ground on his back, in preparation for transfixion of his hands, his scourging wounds most likely would become torn open again and contaminated with dirt. (2,14) Furthermore, with each respiration, the painful scourging wounds would be scraped against the rough wood of the stipes. (7) As a result, blood loss from the back probably would continue throughout the crucifixion ordeal.
With arms outstretched but not taut, the wrists were nailed to the patibulum. (7,11) It has been shown that the ligaments and bones of the wrist can support the weight of a body hanging from them , but the palms cannot. (11) Accordingly, the iron spikes probably were driven between the radius and the carpals or between the two rows of carpal bones, (2,10,11,30) either proximal to or through the strong bandlike flexor retinaculum and the various intercarpal ligaments. Although a nail in either location in the wrist might pass between the bony elements and thereby produce no fractures, the likelihood of painful periosteal injury would seem great. Furthermore, the driven nail would crush or sever the rather large sensorimotor median nerve. (2,7,11) The stimulated nerve would produce excruciating bolts of fiery pain in both arms. (7,9) Although the severed median nerve would result in paralysis of a portion of the hand, ischemic contractures and impalement of various ligaments by the iron spike might produce a clawlike grasp.
Most commonly, the feet were fixed to the front of the stipes by means of an iron spike driven through the first or second intermetatarsal space, just distal to the tarsometatarssal joint. (2,5,8,11,30) It is likely that the deep peroneal nerve and branches of the medial and lateral plantar nerves would have been injured by the nails. Although scourging may have resulted in considerable blood loss, crucifixion per se was a relatively bloodless procedure, since no major arteries, other than perhaps the deep plantar arch, pass through the favored anatomic sites of transfixion. (2,10,11)
The major pathophysiologic effect of crucifixion, beyond the excruciating pain, was a marked interference with normal respiration, particularly exhalation. The weight of the body, pulling down on the outstretched arms and shoulders, would tend to fix the intercostal muscles in an inhalation state and thereby hinder passive exhalation. (2,10,11) Accordingly, exhalation was primarily diaphragmatic, and breathing was shallow. It is likely that this form of respiration would not suffice and that hypercarbia would soon result. The onset of muscle cramps or tetanic contractions, due to fatigue and hypercarbia, would hinder respiration even further. (11)
Adequate exhalation required lifting the body by pushing up on the feet and by flexing the elbows and adducting the shoulders. (2) However, this maneuver would place the entire weight of the body on the tarsals and would produce searing pain. (7) Furthermore, flexion of the elbows would cause rotation of the wrists about the iron nails and cause fiery pain along the damaged median nerves. (7) Lifting of the body would also painfully scrape the scourged back against the rough wooden stipes. (2,7) Muscle cramps and paresthesias of the outstretched and uplifted arms would add to the discomfort. (7) As a result, each respiratory effort would become agonizing and tiring and lead eventually to asphyxia. (2,3,7,10)
The actual cause of death by crucifixion was multifactorial and varied somewhat with each case, but the two most prominent causes probably were hypovolemic shock and exhaustion asphyxia. (2,3,7,10) Other possible contributing factors included dehydration, (7,16) stress-induced arrhythmias, (3) and congestive heart failure with the rapid accumulation of pericardial and perhaps pleural effusions. (2,7,11) Crucifracture (breaking the legs below the knees), if performed, led to an asphyxic death within minutes. (11) Death by crucifixion was, in every sense of the word, excruciating (Latin, excruciatus, or "out of the cross").
