Medical Theories on the Cause of Death in Crucifixion

Medical theories on the cause of death in crucifixion

Matthew W Maslen

Piers D Mitchell

J R Soc Med

2006;

:185–188

INTRODUCTION

Crucifixion may be defined as a method of execution by
which a person is hanged, usually by their arms, from a
cross or similar structure until dead. It has been used in
many parts of the world and in many time periods; but is
perhaps best known today as a cruel method of social
control and punishment in the Roman Empire around 2000
years ago

(pp 22–3). In modern times, the medical

profession has shown considerable interest in crucifixion.
The typical aim of articles by this group has been to
determine how crucified individuals actually died; and they
often focus on the case of Jesus of Nazareth. Since Stroud’s
book of 1847,

at least 10 different theories have been

proposed (Table 1), and many more articles have been
published suggesting various combinations of these theories.
The 10 examples referenced in Table 1 have been chosen
merely as representing the wide difference of opinion in the
published literature: it is not an exhaustive list of all articles
published on the subject. The postulated causes of death
include cardiovascular, respiratory, metabolic, and psycho-
logical pathology. Some authors have even argued that in a
limited proportion of cases the victim only appeared to die,
and recovered consciousness once brought down from the
cross.

When a large number of theories are proposed for a

problem in any scientific discipline, this often demonstrates
that there is no clear evidence indicating the answer. Here
we investigate why there are over 10 completely different
theories described in the medical literature.

METHOD

An extensive search for publications on crucifixion was
undertaken. These were divided into three groups by main
profession of the author, be they physicians, archaeologists
or historians. Over 40 articles and books by physicians that
discussed the medical causes of death in crucifixion were
studied. The publications by historians and archaeologists
were used to provide background information on
crucifixion. Early printed editions of Latin texts dating
from the Roman period, held in the British Library, were

consulted for passages describing crucifixion. The replica
model of the only archaeological case of crucifixion yet
found (from

Giv‘at ha-Mivtar

) was studied during a visit to

Jerusalem. This case was discussed in detail with an
osteoarchaeologist in Israel who examined the original
bones prior to their reburial.

A summary of the available historical, archaeological and

re-enactment evidence was constructed. This was compared
with the evidence discussed in each of the publications by
medical authors, in order to determine the breadth of
information consulted prior to the proposal of their
hypothesis as to how crucifixion victims died.

HISTORICAL EVIDENCE

Written evidence for the details of crucifixion has been
limited to eyewitness accounts and other related written
texts. No Roman period instructions for those performing
crucifixion have been preserved as far as we are aware. The
most detailed accounts of any one particular crucifixion are
the biblical passages covering the death of Jesus of Nazareth;
but we should not assume that this was by any means
representative of all crucifixions. Indeed, the precise details
may well have varied between regions, evolved over time,
or even depending upon the social status of the victim and
the crime he allegedly committed. Flavius Josephus (37–
c.100CE) wrote of the hundreds of Jewish prisoners
crucified at Jerusalem in 70 CE, during an uprising against
the Romans.

‘They were first whipped and then tormented with all
sorts of tortures, before they died, and were crucified
before the wall of the city . . . the soldiers, out of wrath
and hatred they bore the Jews, nailed those they caught
to the crosses in different postures, by way of jest’.

Lucius Anneus Seneca (4BCE–65CE) recorded another
mass crucifixion and noted:

‘I see crosses there, not just of one kind but made in
many different ways: some have their victims with their
head down to the ground, some impale their private
parts, others stretch out their arms’.

In Roman times a common starting point was to be
whipped across the back, buttocks and legs with a

flagrum

REVIEWS

185

J O U R N A L

O F

T H E

R O Y A L

S O C I E T Y

O F

M E D I C I N E

V o l u m e

9 9

A p r i l

2 0 0 6

Faculty of Medicine, Charing Cross Campus, Imperial College London, London

W6 8RP, UK

Correspondence to: Dr Piers Mitchell

E-mail: piers.mitchell@imperial.ac.uk

This was a short whip with sharp objects interweaved into
the thongs. The victim was then often obliged to carry part
of their cross to the place of execution, outside the city
walls. The weight of this would obviously vary depending
upon the region and the type of wood used. Once at the
place of crucifixion, the hands and feet of the prisoner were
fixed to the cross with either nails or cords, and the cross
erected in any one of a range of orientations. If crucified
head up, the victim’s weight may also have been supported
on a small seat. This was believed to prolong the time it
took a man to die. Victims in the head up position could
spend several days on the cross before they died. One
technique used by the Romans to hasten death was to break
the legs below the knee with a blunt instrument

(p. 25).

Modern interpretation in the medical literature as to how
this might work includes blood loss from the fracture site or
respiratory failure from fat embolism. In those positioned
head up then respiratory failure might also ensue as a
consequence of the inability to inflate the chest sufficiently,
since the legs could no longer be used to support the weight
of the body. However, it is unknown which of these three
widely stated hypotheses is correct, since crucifixion is not
employed as a modern legal method of execution.

Analysis of the clinical literature suggests that there has

been suboptimal use of these historical sources in post
publications. Over 40 such articles have been reviewed for
this study, although only a proportion of these have
specifically been quoted in the reference list as they
highlight particular points. The vast majority of articles do
not refer to texts in the original languages that describe the
details of crucifixion, which are mostly in Latin and Greek.
At best there is occasional reference to the few Roman
period texts that have been published in English
translation.

5,6

However, most papers do not even discuss

the translations of these texts, but chose to quote previous
publications by other medical authors for their historical

information.

7,8

In some cases the result is a series of

misquotes that bear limited resemblance to the actual
surviving evidence.

ARCHAEOLOGICAL EVIDENCE

There has been just one archaeological case of crucifixion
published to our knowledge. Cases are rare, as most
crucified people were not formally buried, but left on a
rubbish dump to be eaten by wild dogs and hyenas. The one
case we do have was a young Jewish man buried during the
Roman Period, in a tomb near

Giv‘at ha-Mivtar

in Israel.

The inscription on the ossuary suggests his name was
probably Yehohanan ben Hagkol. The skeletal remains were
only available for study for a few weeks before being given a
Jewish burial, although a model of this calcaneus and nail
have been exhibited in the Israel Museum in Jerusalem. The
excavated remains were fragmentary and incomplete, but
were unmistakably a case of crucifixion. The initial
osteoarchaeological interpretation of the remains

was of

poor quality, and somewhat misleading. A much more
expert analysis of these remains was published in 1985 by
Zias and Sekeles.

They described how an 11.5cm iron nail

had been hammered through the body of the right calcaneus
from lateral to medial, and was still

in situ

(Figure 1). The

tip of the nail was bent, suggesting that during its insertion
it had perhaps met a hard knot of wood or pre-existing nail
left from an earlier crucifixion. The remains of a flat piece
of olive wood were found to be located between the lateral
aspect of the calcaneus and the head of the nail. Its use may
have been to prevent the crucifixion victim freeing his foot
by forcing it laterally over the head of the nail. It seems
that, at least in this case, the heels were nailed to the sides
of the cross. There was no evidence for nail insertion
through the bones of the wrist or forearm, although this is
widely stated in medical articles. The appearance of the

186

J O U R N A L

O F

T H E

R O Y A L

S O C I E T Y

O F

M E D I C I N E

V o l u m e

9 9

A p r i l

2 0 0 6

Table 1

A representative selection of medical hypotheses for the cause of death of Jesus, or crucifixion

in general

Cause of death

Background of author

Reference

Cardiac rupture

Physician

Stroud 1847 (Ref 2)

Heart failure

Physician

Davis 1965 (Ref 15)

Hypovolaemic shock

Forensic pathologist

Zugibe 2005 (Ref 12)

Syncope

Surgeon

LeBec 1925 (Ref 16)

Acidosis

Physician

Wijffels 2000 (Ref 17)

Asphyxia

Surgeon

Barbet 1963 (Ref 18)

Arrhythmia plus asphyxia

Pathologist

Edwards 1986 (Ref 19)

Pulmonary embolism

Haematologist

Brenner 2005 (Ref 20)

Voluntary surrender of life

Physician

Wilkinson 1972 (Ref 21)

Didn’t actually die

Physician

Lloyd-Davies 1991 (Ref 22)

tibial fragments was suggestive of post mortem damage due
to the decomposition process, and not ante mortem
fractures to hasten death. However, several medical articles
incorrectly state that they were ante mortem. We also have
no idea as to whether this particular victim was positioned
head up, head down, or in any other orientation.

Every carving of Jesus’ crucifixion that we have ever

seen in Catholic or Protestant churches have a nail passing
through both feet from front to back. This religious
stereotype has influenced the views of many researchers
over the years. However, there is no evidence that
crucifixion was actually carried out in this way in classical
times.

EVIDENCE FROM RE-ENACTMENT

Over the years a number of researchers have tried to test
both the physiology and the symptomatology of crucifixion.
Zugibe has been the most recent, and the most thorough,
with his humane experimental recreation of certain aspects
of crucifixion.

The volunteers were attached to the cross

in a safe and temporary way, were carefully monitored, and
the study terminated at the time of their request. The fact
that none of the re-enactment research has actually crucified
people means that these studies have only limited relevance
to genuine cases. The absence of whipping, carrying a heavy

cross, being nailed to it, the dehydration from water
deprivation and hot sun, and the anxiety of their imminent
death might all have resulted in somewhat different findings
in the modern groups and crucifixion victims 2000 years
ago. Furthermore, re-enacted crucifixions have typically
placed their volunteers in the head up position displayed in
Christian churches, and not in the wide variety of positions
recorded in the written records from Roman times.

Zugibe attached the hands of his volunteers to a cross

with leather gloves. The legs were placed with the knees
and hips flexed and with the plantar surface of the feet flush
with the anterior aspect of the cross upright. They were
attached to the upright using a belt that ran over the dorsum
of the feet. This choice of foot position seems to have been
influenced by images in churches, but is at odds with the
archaeological evidence and, to our knowledge, is not
supported by historical evidence either. Zugibe’s aim was to
establish the cause of death of Jesus of Nazareth, and he
tested many physiological variables in a systematic manner.
He concluded that hypovolaemic shock caused Jesus’ death,
and the asphyxiation theory had been overwhelmingly
disproved

(p. 121). However, the conclusion was not

based on any positive evidence for the shock theory (which
was not tested), but rather upon negative evidence for the
asphyxiation theory. It seems that none of the volunteers
suffered significant difficulty breathing while on the replica
cross. However, the longest time any were left on the cross
seems to have been limited, on account of the physical
discomfort of being on the cross. Since it was extremely
rare for anyone in Roman times to die on a cross within the
first few hours, it could be argued that the time scale of the
study cannot disprove the asphyxiation theory. Further-
more, much of Zugibe’s arguments are based on evidence
from the Turin Shroud. This appears to be a medieval
forgery dating from between 1260 and 1390CE, since fibres
have been radiocarbon dated by three separate labora-
tories.

While some claim that the carbon date merely

reflects the date of a medieval repair to the material,

would argue that there is still no firm evidence to suggest
that the shroud of Turin can be used as part of an impartial
scientific study.

DISCUSSION

We have highlighted 10 theories put forward by medical
practitioners who have investigated the medical cause of
death by crucifixion. They include forensic pathologists,
physicians, and surgeons with outstanding pedigrees from
around the world. At first glance, their medical arguments
appear plausible. However, our principal finding is that on
more detailed examination most of these hypotheses
regarding crucifixion are unsubstantiated by the available
data. The evidence for crucifixion that we have discussed

187

J O U R N A L

O F

T H E

R O Y A L

S O C I E T Y

O F

M E D I C I N E

V o l u m e

9 9

A p r i l

2 0 0 6

Figure 1

Calcaneus transfixed by an iron nail, from a first century

AD Jewish tomb at

Giv‘at ha-Mivtar.

Excavated bone on the right,

model reconstruction on left. [Reproduced with the kind permission

of Dr Joe Zias, Israel.] (In colour online.)

here includes archaeological, historical, and re-enactment.
Very few of the past medical publications in the field show
awareness of this full range of evidence. Many are limited to
those few written sources that have been translated into
English. The arguments of these earlier papers often rely on
the Turin Shroud for evidence, despite the fact that there is
fair evidence to suggest that it is a forgery. Many articles
just quote earlier medical publications, without discussing
original sources themselves. The archaeological evidence,
namely the crucified man from

Giv‘at ha-Mivtar

, is often

ignored. This is a crucial point, as it is arguably the most
important and reliable evidence for crucifixion that exists.
Very few papers show any sign of input from historians or
osteoarchaeologists in order to expand upon the medical
expertise of the authors.

The strengths of this study are that it provides an

impartial assessment of past work in the field. It gives credit
to good published research, but highlights major problems
where they appear. The authors possess the necessary
linguistic, medical and archaeological skills to undertake
such a study. We have not engaged in humane re-enactment
research ourselves, so have no preferred cause of death that
we wish to champion. The weaknesses of the study perhaps
include the fact that, since we have not performed humane
re-enactment research ourselves, it could be argued we
are in a less knowledgeable position from which to
comment on the usefulness of the re-enactment research
that has been undertaken. Neither do we claim to have
first hand experience of the challenges and difficulties
associated with developing a humane and ethical research
protocol.

Our conclusion is that, at present, there is insufficient

evidence to safely state exactly how people did die from
crucifixion in Roman times. It is quite likely that different
individuals died from different physiological causes, and we
would expect that the orientation in which they were
crucified would be crucial in this respect. Until new
archaeological or textual evidence comes to light then it is
only through more realistic humane re-enactment research
that we may move closer to an answer. However, the
difficulty in creating a research method that is more
realistic, while ensuring that it remains humane, ethical and
painless may be quite a challenge. Most importantly, future
publication of articles in the medical literature should be
restricted to those that consider the full range of historical
and archaeological evidence. This may well require a
collaborative team approach including historians and
archaeologists as well as physicians.

Acknowledgments

We are most grateful to Dr Joe Zias

(formerly Curator for Physical Anthropology, Israel
Antiquities Authority) for discussing the archaeological
evidence with us, and for allowing us to reproduce his
images of the calcaneus and crucifixion nail.

Funding

None.

REFERENCES

Hengel M.

Crucifixion in the Ancient World, and the Folly of the Message of

the Cross,

transl Bowden J. London: SCM Press, 1986

Stroud W.

A Treatise on the Physical Cause of the Death of Christ

. London:

Hamilton & Adams, 1847

Josephus F. In: Rufinus T, ed.

De Bello Iudaico

. Lugduni: Sebastian

Germa, 1528:323–4

Seneca LA. In: Michaelis HC, ed.

De Consolatione ad Marciam

. Harlem:

Vincent Loosjes, 1840

Retief FP, Cilliers L. The history and pathology of crucifixion.

S Afr

Med J

2003;

:938–41

Holoubek JE, Holoubek AB. Execution by crucifixion: history,
methods and cause of death.

J Med

1995;

:1–16

DeBoer SL, Maddow CL. Emergency care of the crucifixion victim.

Accid Emerg Nurs

2002;

:235–9

Ball DA. The crucifixion and death of a man called Jesus.

J Miss State

Med Assoc

1989;

:77–83

Tzaferis V. Jewish tombs at and near Giv‘at ha-Mivtar, Jerusalem.

Israel Explor J

1970;

:18–32

Haas N. Anthropological observations on the skeletal remains from
Giv‘at ha-Mivtar.

Israel Explor J

1970;

:38–59

Zias J, Sekeles E. The crucified man from Giv‘at ha-Mivtar: a
reappraisal.

Israel Explor J

1985;

:22–7

Zugibe FT.

The Crucifixion of Jesus: a Forensic Enquiry.

New York: M

Evans, 2005

Damon PE, Donahue DJ, Gore BH,

et al.

Radiocarbon dating of the

Shroud of Turin.

Nature

1989;

337

:611–15

Bollone PB.

The Shroud Under the Microscope: Forensic Examination

, transl

Neame A. High Wycombe: St Pauls, 1998

Davis CT. The crucifixion of Jesus: the passion of Christ from a
medical point of view.

Ariz Med

1965;

:183–7

LeBec A. The death of the cross: a physiological study of the passion of
Our Lord Jesus Christ.

Catholic Med Guardian

1925;

:126–32

Wijffels F. Death on the cross: did the Turin Shroud once envelop a
crucified body?

Br Soc Turin Shroud Newsl

2000;

(3)

Barbet P.

A Doctor at Calvary: the Passion of Our Lord Jesus Christ as

Described by a Surgeon

, transl The Earl of Wicklow. New York: Image

Books, 1963:87

Edwards WD, Gabel WJ, Hosmer FE. On the physical cause of death
of Jesus Christ.

JAMA

1986;

255

:1455–63

Brenner B. Did Jesus Christ die of pulmonary embolism?

J Thromb

Haemost

2005;

:1–2

Wilkinson J. The physical cause of the death of Christ.

Expository Times

1972;

:104–7

Lloyd-Davies M, Lloyd-Davies TA. Resurrection or resuscitation?

Roy Coll Phys Lond

1991;

:167–70

188

J O U R N A L

O F

T H E

R O Y A L

S O C I E T Y

O F

M E D I C I N E

V o l u m e

9 9

A p r i l

2 0 0 6