Crucifixion probably first began among the Persians. Alexander the Great introduced the practice to Egypt and Carthage, and the Romans appear to have learned of it from the Carthaginians. Although the Romans did not invent crucifixions they perfected it as a form of torture and capital punishment that was designed to produce a slow death with maximum pain and suffering. It was one of the most disgraceful and cruel methods of execution and usually was reserved only for slaves, foreigners, revolutionaries, and the vilest of criminals. Roman law usually protected Roman citizens from crucifixion, except perhaps in the ease of desertion by soldiers. In its earliest form in Persia, the victim was either tied to a tree or was tied to or impaled on an upright post, usually to keep the guilty victim's feet from touching holy ground. Only later was a true cross used; it was characterized by an upright post (stipes) and a horizontal crossbar (patibulum), and it had several variations (Table). Although archaeological and historical evidence strongly indicates that the low Tau cross was preferred by the Romans in Palestine at the time of Christ (Fig 3), crucifixion practices often varied in a given geographic region and in accordance with the imagination of the executioners, and the Latin cross and other forms also may have been used.

Fig 4.  Nailing of wrists.  Left, Size of iron nail.  Center, location of nail in wrist, between carpals and radius.  Right, cross section of wrist, at level of plane indicated at left, showing path of nail, with probable transection of median nerve and impalement of flexor pollicis longus, but without injury to major arterial trunks and with fractures of bones.

At the site of execution, by law, the victim was given a bitter drink of wine mixed with myrrh (gall) as a mild analgesic. The criminal was then thrown to the ground on his back, with his arms outstretched along the patibulum. The hands could be nailed or tied to the crossbar, but nailing apparently was preferred by the Romans.  The archaeological remains of a crucified body, found in an ossuary near Jerusalem and dating from the time of Christ, indicate that the nails were tapered iron spikes approximately 5 to 7 in (13 to 18 cm) long with a square shaft 3/8 in (1 cm) across.  Furthermore, ossuary findings and the Shroud of Turin have documented that the nails commonly were driven through the wrists rather than the palms (Fig 4). After both arms were fixed to the crossbar, the patibulum and the victim, together, were lifted onto the stipes. On the low cross, four soldiers could accomplish this relatively easily. However, on the tall cross, the soldiers used either wooden forks or ladders. Next, the feet were fixed to the cross, either by nails or ropes. Ossuary findings and the Shroud of Turin suggest that nailing was the preferred Roman practice. Although the feet could be fixed to the sides of the stipes or to a wooden footrest (suppedaneum), they usually were nailed directly to the front of the stipes (Fig 5). To accomplish this, flexion of the knees may have been quite prominent, and the bent legs may have been rotated laterally. (Fig 6)

 Fig. 5.  Nailing of feet.  Left, position of feet atop one another and against stipes.  Upper right, location of nail in second intermetatarsal space.  Lower right, cross section of foot, at plane indicated at left, showing path of nail.

When the nailing was completed, the titulus was attached to the cross, by nails or cords, just above the victim's head. The soldiers and the civilian crowd often taunted and jeered the condemned man, and the soldiers customarily divided up his clothes among themselves. The length of survival generally ranged from three or four hours to three or four days and appears to have been inversely related to the severity of the scourging. However, even if the scourging had been relatively mild, the Roman soldiers could hasten death by breaking the legs below the knees (erurifragium or skelokopia). 

  Not uncommonly, insects would light upon or burrow into the open wounds or the eyes, ears, and nose of the dying and helpless victim, and birds of prey would tear at these sites. Moreover, it was customary to leave the corpse on the cross to be devoured by predatory animals. However, by Roman law, the family of the condemned could take the body for burial, after obtaining permission from the Roman judge. 

Since no one was intended to survive crucifixions the body was not released to the family until the soldiers were sure that the victim was dead. By custom, one of the Roman guards would pierce the body with a sword or lance. Traditionally, this had been considered a spear wound to the heart through the right side of the chest -- a fatal wound probably taught to most Roman soldiers. The Shroud of Turin documents this form of injury. Moreover, the standard infantry spear, which was 5 to 6 ft (1.5 to 1.8 m) long, could easily have reached the chest of a man crucified on the customary low cross."   With knowledge of both anatomy and ancient crucifixion practices, one may reconstruct the probable 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 orthostatie hypotension and even hypovolemie shock. When the victim was thrown to the ground on his back, in preparation for transfixion of the hands, his scourging wounds most likely would become torn open again and contaminated with dirt. Furthermore, with each respiration, the painful scourging wounds would be scraped against the rough wood of the stipes.    As a result, blood loss from the back probably would continue throughout the crucifixion ordeal.

 Fig 6.  Respirations During Crucifixion.  Inhalation--With elbows extended and shoulders abducted, respiratory muscles of inhalation are passively stretched and thorax is expanded.  Right, Exhalation--With elbows flexed and shoulders adducted and with weight of body on nailed feet, exhalation is accomplished as active, rather than passive, process.  Breaking legs below knees would place burden of exhalation on shoulder and arm muscles alone and soon would result in exhaustion asphyxia.

  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 tarsometatarsal joint.  It is likely that the deep peroneal nerve and branches of the medial and lateral plantar nerves would have been injured by the nails (Fig 5). 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.

  The major pathophysiologic effect of crucifixion, beyond the excruciating pain, was a marked interference with normal respiration, particularly exhalation (Fig 6). 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. 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.

Adequate exhalation required lifting the body by pushing up on the feet and by flexing the elbows and adducting the shoulders (Fig 6) However, this maneuver would place the entire weight of the body on the tarsals and would produce searing pain. Furthermore, flexion of the elbows would cause rotation of the wrists about the iron nails and cause fiery pain along the damaged median nerves. Lifting of the body would also painfully scrape the scourged back against the rough wooden stipes.  Muscle cramps and paresthesias of the outstretched and uplifted arms would add to the discomfort.  As a result, each respiratory effort would become agonizing and tiring and lead eventually to asphyxia.

  The actual cause of death by crucifixion was multifactorial and varied somewhat with each ease, but the two most prominent causes probably were hypovolemie shock and exhaustion asphyxia. Other possible contributing factors included dehydration, stress-induced arrhythmias, and congestive heart failure with the rapid accumulation of pericardial and perhaps pleural effusions.  Crucifracture (breaking the legs below the knees), if performed, led to an asphyxia death within minutes. Death by crucifixion was, in every sense of the word, excruciating (Latin, excruciatus, or "out of the cross").