The Hippocratic clubfoot re-visited
New medical readings of De articulis 62 (IV, 264,2-268,1 L.; II, 211-214 Kw.)
p. 461-490
Résumé
The Hippocratic treatise On Joints contains a careful description of the clubfoot, its causes and its rehabilitation. Galen of Pergamum has extensively commented on this passage. More than fifty years ago Markwart Michler devoted a large study on the Hippocratic theory of the clubfoot. It is now time for an innovative, critical reappraisal of this topic in the light of recent research on these ancient medical writings and on their proposed relation to today's medical practice. It will be shown that both the ancient and the modern concept of clubfoot differ in many aspects. That renders comparison nearly impossible, or at least more difficult, bearing also in mind the now experienced historicity of Michler’s work itself.
Entrées d’index
Note de l’auteur
I would like to thank Manfred Horstmanshoff, Lorenzo Perilli (for his and his team’s hospitality in Rome and his professional huge patience with me), Christian Brockmann, Philip van der Eijk, Mathias Witt, and Laurence V. Totelin. Without their help this text could not have found its final form. Thanks also to my wife Nadja Hadem-Graumann for her keen medical eye in the streets of Rome.
Texte intégral
Introduction
1Clubfoot1 today is a very common deformity not only in Europe, nearly 200,000 children are born world-wide every year with clubfoot. It can affect one or both feet. The condition is a birth defect in humans in which the feet are twisted down and inward, and – in case of both feet affected – making them look like golf clubs with the club heads turned to face each other.2 Without orthopedic treatment, the afflicted have an impairment to walk and appear to walk on their ankles or the sides of their feet (picture 1).
2Beside some rare paleopathological evidence since Neolithic time3 the first known text on clubfoot treatment in the Western medical tradition, at least claimed traditionally to be so, is that famous passage in the Hippocratic collection, in the surgical treatise Peri arthrôn (embolês), De articulis (Artic.), On (the reduction of) Joints, chapter 62. It is now over fifty years ago that Markwart Michler (1923-2001), himself both physician (surgeon and orthopedic) and medical historian, has published a thorough study on this short text.4 Time really has come to reassess the content and value of both: the original Hippocratic text and Michler’s study in the light of recent medical experience and developments.5
3Experts in Hippocratic medicine cite this Hippocratic text of On Joints not quite often, but view it more or less linguistically with some reservation relating to the medical view, regularly being content with some hint at Michler’s study results.6 On the other hand, physicians, especially experts in pediatric orthopedics, i.e. the medical experts in treating clubfoot today, all too often only know and cite the name of Hippocrates uncritically like that of a real person and author, or, another extreme, use this ancient text just in bypass or as fixed starting point in order to explain their own medical expert knowledge about clubfoot in terms almost only intelligible to medical experts (intra-medical debate).7 However, many changes and developments in the medical orthopedic treatment of clubfoot happened particularly over the last century, sometimes left unnoticed to the more philological orientated expert community in this topic.8 This on its own justifies a new exploration of the ancient Greek aspects in relation to, at least, some recent medical strategies in diagnosis and treatment of clubfoot. I will try to bridge these two worlds of knowledge again to restore the right place of this fine text which it deserves in my view. Moreover, focusing on this tiny topic inside the extant surgical treatises of the Hippocratic collection can perhaps illuminate the historical potential of these writings in general, and address some medical aspects of this chapter as an ancient piece of technical literature, designed from one medical expert to contemporary and future medical apprentices. Thereby, I would like to encourage scratching more on the big theme of Hippocratic surgery and to realize the unkept value inside these tiny sets of texts.9
Formal contexts and the main text of De articulis 62
4The text of Artic. 62 together with its brief summary in the treatise Mochlikon (Mochl. 32) belongs to a set of some few surgical treatises within the Hippocratic Collection (Corpus Hippocraticum), consisting of De officina (Off., “On Surgery”), De vulneribus capitis (Vuln.cap., “On the Wounds of the Head”), De fracturis (Fract., “On Fractures”) and De articulis (Artic., “On Joints”), Mochlikon10 (Mochl., “Instruments of Reduction” or “Leverage”), De ulceribus (Ulc., “On Wounds”), De fistulis (Fist., “On Fistulas”), De haemorrhoidibus (Haem., “On Haemorrhoids”), and now lost treatises, otherwise only known by its reported titles and some fragments, like De vulneribus et telis (“Wounds and Missiles”).11 Both main surgical and, with regards to the precise content, traumatological treatises of the Hippocratic Collection, Fract. and Artic. originally formed one independent technical therapeutic trauma manual, very probably in the sequence Fract. before Artic.12 These two writings are closely associated with Mochl., the distilled manual of both treatises. Probably due to some early, confuse transmission process, either originally author-intended or not, the text of the separate, but still huge treatise13 Artic. features a complicate, arguably not planned chapter series, e.g. deranged chapters like the very probable introduction now found in chapter 79.14 Likewise, Artic. 62 appears as an enclosed, insular and particular “conservative treatment” chapter between the more general chapter 61 and the series of chapters 63-69 (on complex dislocations).15 By focusing on specific congenital (“ek geneês”) foot dislocations, Artic. 62 further seems to have some associations to the former chapter 53, and to the later chapter 85, maybe also to chapter 87.16 From the formal medical content, Fract./Artic. in the extant shape have a very special structure of human pathological anatomy: centripetally, chiastic with emphasis on parallelizing the upper with the lower extremity.17 The treatise Mochlikon is a short excerpt out of parts of Fract. and Artic. in 43 chapters, leaving the impression of a student’s scrapbook, maybe annotated medical aphorisms easy to learn and to repeat.18 Interestingly and contrary to its main source Fract./Artic., Mochlikon is organized in the traditional order from head to toe (a capite ad calcem).19 The short chapter 32, which elaborates Artic. 62, appears inserted between two series of chapters (26-31, resp. 33-35).20
Some concise thoughts on Hippocratic bone surgery
5Hippocratic surgery, often declared as outstanding bone surgery21, is, at least in its extant written evidence, much more than perhaps expected a very conservative, simple and guarded surgery from point of view of contemporary traumatology. So, today’s surgical approaches (well-established, not any more “heroic” invasive procedures, under the protection of an equivalent anesthesia, strict rules of asepsis and antisepsis) cannot blindly be mirrored into this ancient setting.22 What was undeniable “obvious”, visible, not hidden, disordered in the individual skeletal system in the eyes of the ancient physician was treated by more or less forceful, sometimes brute reduction and refined bandaging. Eventually, one also has to presume and respect an unknown, but significant loss of original surgical texts and, of course, unwritten medical practice of this and later time, without much hope of resurrection of any lost material. So, alas, only the extant material can be reworked today.
Authorship and audience
6The author of Fract./Artic. (obviously a male Greek physician) remains unknown since he does not reveal anywhere his own name. But he appears on many occasions with witty personal, philanthropic expert’s statements and polemical accusations against medical malpractice.23 It is safe enough to speak of him as an Hippocratic physician, and avoiding here any further and, in my opinion, useless debate about genuine Hippocratic authorship.24 One gets the impression of a sophisticated, crafted physician, maybe somebody like a general practitioner with special long-term experience25 in the field of surgical anatomy of bones and joints, and especially of traumatology, working – as it was mostly usual at this ancient time – as itinerant physician in public space.26 The author (or authors?) of Mochl., also unknown, is very probably a later medical reader and epitomizer.27 The target audience of Fract./Artic. are medical practitioners with some basic experience in traumatology, not really beginners, but also literate circles familiar with medical debates of that time.28 It remains safe to conclude that these texts together form some kind of discursive practical manual from one skilled physician to others with practical skills.29
Time and ancient Nachleben of Artic. 62/Mochl.32
7The origin of this very practical text of Artic. should be located in the second half, or towards the end of the fifth century BC.30 The notes of Mochl. could be dated sometimes later into the first half of the fourth century.31 Galen’s commentary of Artic. was probably written in 177 CE.32 Except Galen’s contribution there is no other commentary or reception of Artic. 62/Mochl.32 left from antiquity. There are only just a few traces of specific philological dispute (glossaries).33 Within Galen’s extant commentary of Artic. (4 books) there is in book IV the running commentary of Artic. 62 in 14 chapters.34 The content of this commentary (“Lemmakommentar” corresponding to Mathias Witt) delivers not much more practical information for the expected experienced medical reader than the original text, but shows that even Galen has concerned himself with the rather marginal topic of “clubfoot” treatment.35
The text itself
8The texts of Artic. 62 and Mochl.32 are today available in several modern editions and translations.36 I will give here yet no complete translation, but only repeat Michler’s useful division of Artic. 62 into 11 logical sentences or sequences.37
91. General introducing remark on congenital dislocations [without explicit reference to clubfoot]38
2. The main chapter starts with the statement about the curability of “clubfoot” in young children
3. Quick & early treatment gives good results and prevents bad outcome
4. It is stated that there are variants without more specification, and some pathological specifications are given
5. Then follows the main description of the manual treatment
6. The result should be kept with a linen bandage in valgus position
7. Some statements on shoe sole manufacturing are added, with the advice to sew the end of the bandage in sole position, to stretch it upward, and finally to fix its end by wrapping it above the calf
8. Again, an interesting general comparison of this treatment with wax modelling (“kêroplasteonta”) is made, and the professional tip not to use too much force is given
9. Additional remarks on the correct bandage follow, adapted to the particular type of initial lameness, and the treatment should be supported by a specific shoe sole (like in “Chian boots”)
10. The author praises this simple therapy success without invasive procedures (no cutting, no burning), and with time on its side
11. The text closes with a looking-ahead statement about long-term treatment with specific shoes (“mud shoes”, also “Cretan shoes”)
Mochl.32 similarly can be divided into 5 sentences:
101. General introducing remark: “slight congenital dislocations can be put straight” [again, without explicit reference to clubfoot]
2. best demonstrated in case of “clubfoot”
3. more than one variant of “clubfoot”
4. manual treatment description (in just 5 keywords):
a. molding (like wax, “kêroplasteîn”)
b. apply resined cerate
c. plenty of bandages
d. sandal or
e. sheet of lead bound in with the bandaging, not directly on the skin
5. closing remark on accordance of foot and bandage (5 words)
11Both chapters are textually transmitted relatively conservative.39 The text of Mochlikon gives no really new information, and just shrinks the text of Artic. 62 (453 words) into only 10% of keywords (41 words). However, without the complete background information of the details of manipulation in Artic. 62 itself, especially sentence 5, the text of Mochl. would remain useless for any practitioner of that time.40 I will now abstain here from any deep terminological and stylistic discussions of these texts, and will start instead at once with the medical discussion.
Medical refresher course: Ancient and current diagnosis of clubfoot contested
12The reiterated statement about Artic. 62 is, that it contains the first known and splendid description of congenital clubfoot.41 The truth of this statement has to be rechecked. First, there is a definitely structured, but no coherent, no exhaustive medical description of the main topic in the chapter, namely one specific congenital foot anomaly, as it is now cautiously called by me. There is hidden, implicit knowledge presupposed on the (medical) reader’s side. Today, there is nothing else possible than to reconstruct the whole picture by taking together all relevant passages within the surgical works: Artic. (53, 62, 85, and 87), Mochl.32, and additionally parts of Fract. Besides, contrary to today, there are only words, dry text without any pictures, drawings.42 By that, there are of course some alternative imaginations possible. The general topic of Artic. 62 is the congenital dislocation of the “foot joint”, that is the ankle joint, the joint between the lower leg and the foot.43 This is compared with those at the hand.44 Starting with some diametral reading: the author likes to sum up (“in a word”) this specific congenital foot joint anomaly with its parts being in “unnatural” position both twisted and/or contracted.45 Nevertheless, the self-evident presented “natural” (es phúsin) position of the foot is nowhere consistently displayed, but tacitly presupposed.46 Further, this specific congenital anomaly is classified both slight and reducible into this implicit natural position, and the best reducible type compared to all other minor congenital dislocations he knows, but does not tell.47 Then, the author for the first time is naming this congenital dislocation anomaly “poûs kullôsis”, or much shorter “kullós”.48 He speaks afterwards some cryptically of many different forms or expressions of that “kullós”: there is no single form (“trópos”) of “kullôsis”.49 Again, he qualifies most of these many “kulloí” not completely dislocated, but in a special mode of constant retention (apolêpsis) rendering the foot into this “kullós”-shape (toû podòs kekullôména).50 “Kullós” is moreover defined as the opposite of “blaisós”.51 Each element of a congenital “kullós” in the lower leg and the foot can be concluded indirectly from the subsequent treatment description (sentence 5) by using just the two categories of inward and outward twisting52: 1.) the distal (i.e. lower) end of the lower leg, especially the distal end of the fibular bone is dislocated (or better: positioned) outwards53; 2.) the heel bone is dislocated inwards54; 3.) the forefoot with all toes stays in outward position, i.e. supination55. Moreover, the foot position can be defined by its opposite form, into which the “kullós” should be manipulated: the “poûs blaisós” (Pes valgus). Thus, the “kullós” describes a varus foot.56 Concluding, the complete reconstruction of the congenital “kullós” is: an incomplete, minor dislocation, or contraction at the foot ankle with the ankle rotated outwards, the hindfoot (heel bone, calcaneus) rotated inwards, and finally, all toes (the forefoot) rotated outwards (supination), rendering the whole foot in a constant varus position (Pes varus). Additionally, the author mentions earlier, that all patients with definite “kullós” in the foot are instead of this severe deformity better able to stand and to use their foot for walking than those with a “blaisós”, i.e. valgus deformity of the foot, which is in his opinion the more frequent form of dislocations in the ankle.57 Moreover, the author has observed and developed a theory on bone and tissue atrophy in connection to dislocations of all the leg joints (hip, knee, ankle): the bones and tissues nearest to and below of some injury or dislocation will become deficient in growth dependent of the remaining ability to use the leg.58 In the special case of “kullós”, where the joint at the foot (ankle) is intact, the bones of the foot are less atrophied, because patients are still able to use the foot.59 But, different forms of “kullós” more generally produce different types of lameness, which remain equally implicit like all the types of “kullós” mentioned before.60 Relating to the praised anatomical knowledge61 of the author of Fract./Artic., it is strange enough today to observe that he nowhere mentions explicitly one particular part of the ankle, the talus (or astragalus), but only the heel bone (“pternê”, calcaneus).62 At the ankle (“to sphurón”) he differentiates two still unnamed leg (“knêmê”) bones (the outer or lateral fibula63 and the medial shinbone, the tibia); in the foot he only differentiates bones of the “tarsós” and the toes.64 Coming to the question about differential diagnosis: the author only speaks of the congenital type of “kullós”, and that there are many types of that form. He separates that form definitely from Pes valgus. Modern authors have concluded that the Hippocratic writer indeed must have meant only clubfoot.65 In my view this is a bit simplifying the more complex situation. The practitioner in Antiquity seems to me more probable just unable to differentiate closer. Now, I would advise to use henceforth more cautiously the term “crook foot” or “twisted foot” and not “clubfoot” as translation of “poûs kullôsis” respectively “kullós”.66 This may be further explained by the subsequent discussion of the modern concept and diagnosis of clubfoot.
Panoply of congenital clubfoot today (epidemiology, anatomy, pathophysiology, and shifted paradigms)
13Today, congenital clubfoot is considered medically as a complex three-dimensional foot deformity.67 Clubfoot can be differentiated into the most frequent idiopathic clubfoot, the positional or postural clubfoot (a transient neonatal type), clubfoot with syndrome (e.g., arthrogryposis multiplex), and secondary clubfoot (neurogenic, posttraumatic, rachitic).68 The medical clubfoot “philosophy” today is that of a congenital anomaly of the whole leg (lower limb), not only the foot.69 The epidemiology features a modern prevalence of 1-2/1000 live births (regionally different)70, with a male predominance to female (2-3/1). In 50% of cases both feet are affected (bilateral clubfoot). Though the genetic factors are still unknown (i.e. idiopathic), familial occurrences are well-known (hereditary factor). I would not like to annoy anyone with too much anatomy here, but – in order to understand some of the specifics of clubfoot – one has to reflect a little bit more on the pathological anatomy known so far.71 The foot is divided anatomically into 3 zones: hindfoot (tarsus), midfoot (metatarsus), and forefoot (toes). Clubfoot is to be understood as a combined structural anomaly of bones, joints, sinews, ligaments and muscles. The index bone of the clubfoot deformity is the talus (anklebone, foot part of the ankle joint), which is deformed and rotated laterally, causing a subluxation in the talo-navicular joint (incomplete subtalar dislocation); the calcaneus (heel bone) is positioned in equinus (plantar flexed), inversion and adduction (varus deformity); the navicular and the cuboid bone (tarsal bones, part of the subtalar joint) are medially displaced and inverted; in relation to the leg, the forefoot and midfoot are positioned in adduction and supination (cavus).72 The tibia is rotated internally, the fibula is slightly positioned backwards, giving the impression of an externally rotated leg.73 Posterior and medial ligaments of the affected foot are shortened and thickened resulting in a supination contracture. Leg muscles and sinews are also shortened, especially that of the gastrocnemius muscle (calf atrophy, shortened Achilles’ tendon), and the toe flexors.74 Summing up, this deformity, medically called today Pes or talipes equinovarus (TEV), consists of: equinus of the hindfoot, varus together with supination of the hindfoot, adduction and inversion of the forefoot.75 Every clubfoot is both similar and individually different, even in bilateral forms. Different clinical forms of congenital TEV (mild, moderate, severe) may reflect what is caused by different mechanisms with the same result (“clubfoot syndrome”).76 The clinical diagnosis of clubfoot by subtle inspection and palpation is relatively easy for the medical expert (pediatric orthopedic) without any further equipment (e.g., sonography and radiography), but can be very tricky for the general practitioner and the medical beginner (picture 2). Beside many other, more infrequent congenital foot anomalies like flat foot (rocker bottom foot, vertical talus)77, TEV should be differentiated from cavus foot, forefoot adductus, and the skew foot spectrum (metatarsus adductus).78 Finally, congenital TEV itself may be even associated with other limb anomalies, most frequently precisely this metatarsus adductus and congenital hip dislocation.79 It remains an open question, what the Hippocratic Pes valgus (blaisós, splay foot) as counterpart to his Pes varus could correlate to today.80 Concluding, the ancient diagnosis of some “kullós” with its rudimentary classification into inward/outward rotation and the dis/ability to stand is not the modern diagnosis of a congenital TEV with all its background information (epidemiology, subtle pathological anatomy, supportive radiological information). Modern precise differentiation should not be projected uncritically into the ancient text of Artic. 62.81 Having now reviewed the distinct characteristics between the ancient diagnosis of “poûs kullôsis” and the modern concept of clubfoot (TEV), I’m moving on to the main content of Artic. 62, the treatment method.
Ancient treatment challenged
The manual therapy (”Redressionsbehandlung“) of the clubfoot was already depicted very carefully by Hippocrates (370 BC). He described bandages and retention in shoes.
Fritz Hefti
14Again and again, it has been stated, that the treatment method for congenital “kullós” in Artic. 62 is a Hippocratic masterpiece, which resembles modern contemporary therapy.82 Now, after evaluating the diagnostic difficulties between “kullós” and the modern concept of clubfoot, this “treatment hypothesis” should be equally rechecked, too. First, the author declares generally that his described form of congenital “kullós” is treatable, curable.83 This is best done as early as possible in infancy, before there are structural changes in the bones of the foot and the tissues of the leg.84 In the original text of Artic. 62, sentence 5, one can read:
The things to bear in mind in treatment are the following: (1) push back and adjust the bone of the leg at the ankle from without inwards, (2) making counter-pressure outwards on the bone of the heel where it comes in line with the leg, so (3) as to bring together the bones which project at the middle and side of the foot; at the same time, (4) bend inwards and rotate the toes all together, including the big toe.
[…] Bring round the turns of the bandaging in a way corresponding with the manual adjustment of the foot, so (5) that the latter has an inclination somewhat towards “blaisós” (Pes valgus).85
15According to the explanation of Michler86, which he demonstrates by means of some drawings and additionally by the commentary of Galen, the medical interpretation of these few lines is the following: (1) push the extern malleolus (i.e. the lower, distal end of the fibular bone at the ankle) from outward to inward87, (2) push the heel outward in straight direction (direct heel manipulation)88, give (3) attention that the externalized bones should meet each other at the middle of the foot89, simultaneously (4), bow all toes more or less forcefully from inward to outward in slight overcorrection (pronation, direct forefoot manipulation)90, and finally (5) bandage the foot in slight pronation with cured bond (out of resin and linen).91 I have tried to show this technique on a plastic model of clubfoot (see picture 3 and 4). This kind of manual treatment is dynamic, non-invasive, and particularly synchronical. The author stresses to act gently, comparing the manipulation originally with the modelling of wax.92 Retention of the result of this foot manipulation is carried out with a specific bandage in slightly overcorrected valgus position bound up to the calf, the end sewed up on itself and added by stable shoes, fortified by leather or leaden soles.93 Bandages and also shoes are already a big theme in the Hippocratic surgical treatises, and would deserve an extra study.94 One question remains: in what kind of ancient setting could this treatment have happened: at home, in the office, on the street, only in cities?95 Could all the spare, but required equipment (linen bandage, sewing material, resined cerate, footwear, leather, lead) be anywhere, at any time at hand? At least, it is very probable, that no less than two persons performed this procedure together on each child (the physician, his assistant).96
Treatment method today: serial manipulation
16Today treatment’s philosophy of congenital clubfoot has abandoned the ideal of complete curation, treatment is individual, symptomatical with the goal of a sufficient, good up to normal foot function in later life.97 The saying goes “a true clubfoot will never be a normal foot”.98 Treatment today consists of dynamic, subtle, serial foot and long leg manipulation (“redression”) and holding the reached position in weekly-changed plaster casts up to the proximal thigh with the knee flexed to 90°. This is usually performed in an ambulant setting by at least two persons: the physician and a medical assistant (nurse, another physician). Contemporary treatment of choice, the so-called Ponseti method, is based and founded in the experience of functional foot anatomy and biomechanics from the 19th century (especially, that of Louis Hubert Farabeuf, 1841-1910), the development of plaster cast, and of course more than a century of experience in partly extensive foot surgery.99 The conservative, non-operative, manual treatment with weekly new long leg plaster cast starts with a subtalar release by the reduction of the index bone, the talus (i.e., reducing the subluxation in the talo-navicular joint), and with increasing the supination and abduction (to solve the cavus; see picture 5). Afterwards supination is gradually decreased while abduction is further increased. The last step is trying to solve the equinus, what often is impossible only by manipulative means. In that case, tenotomy of the Achilles’ tendon is performed.100 Then, for at least three weeks a molded long leg plaster cast in extreme abduction and dorsiflexion is applied. Immediately afterwards a foot abduction bar is applicated all-day until the age of 1 year, until the moment of first walking on the own feet, which is self-therapy of the affected foot by walking. Finally, this bar is used until the age of 5 years only nightly to prevent the still possible relapse of the clubfoot. Relapsing clubfoot can be treated either with repeating this management, or minor up to major surgical procedures.101 Today known major classical errors in manual treatment of congenital clubfoot are: 1.) synchronous, not serial treatment of all components of clubfoot; 2.) direct heel manipulation (heel bone remains in varus position); 3.) active forefoot pronation (because this increases the cavus position of the foot).102 I.e., from today’s perspective the ancient manual treatment method as it is described in Artic. 62 has to be classified wrong.103
Prognosis of treatment and non-treatment
17The original text of Artic. 62 remains vague and implicit about long-term results, duration of the actual treatment (“till the part has acquired growth in its proper position”), and by that leaves much room for interpretation and friendly projection of own thoughts from each modern medical reader.104 Exemplary, there is no statement, when or how often one has to change the bandage. However, the author maintains the importance to stabilize his manual treatment result apart from his described bandage technique with stiff soles (out of leather or leaden like in “Chian boots”) and later on boots (mud shoes, “Cretan boots”).105 It remains implicit in Artic. 62, too, what will happen to the untreated patient.106 The author boasts, obviously not without proud, that his described manual therapy is straightforward107, and non-invasive (no cutting or burning).108 This could be eventually hint at some earlier more invasive therapeutic approaches, at least gives the probable conclusion, that the author, as innovative as he might have been, should be placed in some earlier tradition of treatment.109 Contrary, the obtainable results today with the Ponseti method of treatment are in 90% successful (good functional outcome, almost painless motion ability), just only in up to 10% of cases with relapse (recurring clubfoot) nowadays some individual planned, at times very extensive foot surgery is required. These more severe cases of congenital clubfoot are associated with long-term complications like scarring, early arthrosis, i.e. bad functional outcome.110
Conclusions
18It is still astonishing for contemporaries to realize which groundbreaking, genuine and medically “true” basic insights111 in the conservative therapy of congenital clubfoot (early begin of treatment, gentle molding manipulation technique, retention of the result in some bandage over a longer period of time) the Hippocratics have done, in quite a different context. However, one has to take cautiously care, not to read too much of one’s own contemporary beliefs into that fine ancient text and by that overstress and misuse it, both unconsciously and consciously. Because of today’s very subtle classification of congenital clubfoot (talipes equinovarus) and its differentiation from other known congenital foot anomalies it is reasonable to assume that the Hippocratic author with his own concept of “kullós”, crook foot, has not solely implied real idiopathic clubfoot. Besides, the author’s limitations – not only technical possibilities – must be respected considering his more or less rudimentary anatomical knowledge of the ankle joint, foot bones, and especially the overall functional anatomy of the foot. This at least renders every attempt of comparison difficult. Coming to the question about treatment outcome it is today only possible to speculate, but to assume from the self-confident presentation of Artic. 62 that there was indeed something like a success in the eyes of the Hippocratic author. From today’s perspective, his described and applied method of manual treatment is medically wrong. Treatment today is a therapy of the whole leg, not only the lower leg and the foot. Today’s treatment goal is not any more curative, but only symptomatically to gain a long-time good function of the affected foot.112 Nevertheless, this text remains an original contribution to the therapy of congenital foot anomalies, the earliest written report known so far.113 But, to speak of some founding Hippocratic treatment method of congenital clubfoot, which furthermore is valid or the source of contemporary therapy even today, as it was still stated in Michler’s time114, is in my view wrong; it should be classified as another wandering myth in medical history and should be therefore abandoned in future. Michler’s study remains a good reference point for text analysis, but his treatment’s description and especially his evaluation is now historical. In future, the ancient text of Artic. 62 and its author should not be glorified too much, and should also not to be read in a too modern manner. On the other hand, the modern reader should not be surprised to find explicit modern medical, pediatric orthopedic principles of conservative treatment of clubfoot which explain themselves epistemologically. The whole treatise Fract./Artic. points at some long, unwritten, and else not any more transmitted medical experience implemented with a certain degree of critical self-reflection115, thus presenting the spirit of some ancient medical fellowship, which itself was somehow aware of its own limitations, but wanted to express the wish for continuous future research. One learning objective of my study here may be also formulated: that there is some biologic constancy in congenital foot anomalies in humans, foremost congenital clubfoot, but this biologic constancy is described differently – neutrally “different”, not “better” or “worse” – in different times and contexts. This more unilateral, medical-orientated discussion may appear superfluously in the eyes of classicists and historians of Antiquity and may be in the same way downgraded to a kind of intra-medical self-entertaining (“Selbstbeschäftigung”). However, this is also untrue, ignoring the repetitive citations of passed medical doctrines by the same historians. Especially, the historian of ancient medicine is likewise obliged to reflect on recent medical opinions, even if the majority of contributions to medical history by contemporary physicians are ignoring current scientific practice in both history and philology. This turns ancient medical history of these fine surgical texts back into the hands of both, the physician and the classicist, to do their job in quite a more fruitful interdisciplinary manner.116
Picture 1 – Beggar child with untreated bilateral clubfoot, atrophied lower leg muscles, at Trevi Fountain, Rome, 26.10.2018 (Photo: N. Hadem-Graumann).
Picture 2 – Clinical example of bilateral clubfoot in a male newborn, University Hospital Gießen 2018 (Photo: L.A. Graumann).
Picture 3 – Plastic model of a moderate type of clubfoot (Photo: L.A. Graumann).
Picture 4 – Hippocratic manual treatment method of congenital “kullós” (Artic. 62) exemplified with the plastic model of picture 3 (Photo: L.A. Graumann).
Picture 5 – Contrary to picture 4, here the modern treatment method by Ponseti with the first step of the manipulation (reduction of the subluxation in the talo-navicular joint, increasing supination via gentle pressure on the first metatarsal bone to solve the cavus foot), exemplified with the same plastic model as in picture 3 (Photo: L.A. Graumann).
Bibliographie
Des DOI sont automatiquement ajoutés aux références bibliographiques par Bilbo, l’outil d’annotation bibliographique d’OpenEdition. Ces références bibliographiques peuvent être téléchargées dans les formats APA, Chicago et MLA.
Format
- APA
- Chicago
- MLA
Primary sources
Adams 1849 = Francis Adams, The genuine works of Hippocrates, Vol. 2, London, Sydenham Society, 1849.
10.1097/00007611-192206000-00025 :Anastassiou-Irmer 1997-2012 = A. Anastassiou, D. Irmer, Testimonien zum Corpus Hippocraticum, 4 vols, Göttingen, Vandenhoeck & Ruprecht, 1997-2012.
Beck 1907 = Th. Beck, Hippokrates’ Erkenntnisse. Im griechischen Text ausgewählt, übersetzt und auf die moderne Heilkunde vielfach bezogen von Th Beck, Jena 1907. Faksimile von 1997: F. Allerberger (rd.), mit einer Einführung von K. Holubar, Innsbruck, Universitätsbuchhandlung Golf Verlag, 1997.
DELG = Pierre Chantraine (ed.), Dictionnaire étymologique de la langue grecque. Histoire des mots. Nouvelle édition mise à jour, avec un Supplément, Paris, Klincksieck, 1999.
Fuchs 1900 = Robert Fuchs, Hippokrates sämmtliche Werke. Ins Deutsche übersetzt und ausführlich commentiert. Vol.III.: München, Dr. H. Lüneburg, 1900.
Garofalo 2005 = Galien, Tome VII. Les os pour les débutants, L’anatomie des muscles. Texte établi, annoté par Ivan Garofalo. Traduit par Ivan Garofalo et Armelle Debru, Paris, CUF, 2005.
Gruner 1780 = Christian Gottfried Gruner (ed.), Bibliothek der alten Aerzte in Uebersetzungen und Auszügen. Erster Theil: Hippokrates. Übersetzt und mit den nöthigsten Anmerkungen versehen von D.C.G. Gruner, Leipzig, Weidmanns Erben und Reich, 1780.
Index Hippocraticus = Josef-Hans Kühn, Ulrich Fleischer (ed.), Index Hippocraticus. Cui elaborando interfuerunt sodales Thesaurus linguae Graecae Hamburgensis, Göttingen, Vandenhoeck & Ruprecht, 1989.
Kapferer 1936 = R. Kapferer, Die Werke des Hippokrates, hrsg. von R.K. unter Mitwirkung von G. Sticker, III, Teil 22: Die Einrenkung der Gelenke, Das Buch vom Hebel, Stuttgart, 1936, Neudruck Anger, 1995.
Kollesch – Kudlien 1965 = J. Kollesch, F. Kudlien (ed.), Apollonii Citiensis In Hippocratis De articulis commentarius – Apollonios von Kition: Kommentar zu Hippokrates Über das Einrenken der Gelenke. Übersetzt von Jutta Kollesch und Diethard Nickel, CMG XI 1,1, Berlin, Akademie, 1965.
Kühlewein II = H. Kühlewein (ed.), Hippocratis Opera quae feruntur omnia, II. Leipzig, B.G. Teubner, 1902.
Kühn = C.G. Kühn (ed.), Galeni opera omnia, Vol. 18a.: Leipzig, Car. Cnoblochii, 1829.
Lara – Torres – Cabellos 1993 = D. Lara, H. Torres, B. Cabellos (ed.), Tratados Hipocráticos. VII: Tratados Quirúrgicos, Madrid, Editorial Gredos, 1993.
Littré = Emile Littré (ed.), Œuvres complètes d’Hippocrate, Paris, J.-B. Baillière, 1841 (vol. III), 1844 (vol. IV).
LSJ = H.G. Liddell, R. Scott (eds.), A Greek-English Lexicon. Revised and augmented throughout by Sir H.S. Jones. With a revised supplement. Oxford, Clarendon Press, 1996.
Michler 1963 = M. Michler, Die Klumpfusslehre der Hippokratiker. Eine Untersuchung von De articulis cap. 62 mit Übersetzung des Textes und des Galenischen Kommentars, in Sudhoffs Archiv für Geschichte der Medizin und der Naturwissenschaften, Beiheft 2, Wiesbaden, Franz Steiner, 1963.
Nachmanson 1918 = Ernst Nachmanson (ed.), Erotiani Vocum Hippocraticarum Collectio cum fragmentis, Gothenburg, Eranos, 1918.
Pétrequin 1878 = J.É. Pétrequin (ed.), Chirurgie d’Hippocrate, Vol. 2, Paris, Imprimerie nationale, 1878.
Upmann 1847 = C.F. Upmann (ed.), Hippokrates Sämmtliche Werke., Uebersetzt von Dr. Upmann, III, Berlin, Albert Nauck, 1847.
Withington 1928 = E.T. Withington (ed.), Hippocrates, III. On Wounds of the Head, In the Surgery, On Fractures, On Joints, Mochlicon, Cambridge, Mass., London, Harvard University Press, 1928.
Secondary sources
Aufderheide-Rodríguez-Martín 2011 = A.C. Aufderheide, C. Rodríguez-Martín, The Cambridge Encyclopedia of human paleopathology, Cambridge, 1998, first paperback edition 2011.
Brockmann 2007 = C. Brockmann, Die hippokratischen Schriften De fracturis und De articulis im kulturellen Kontext des 5. Jahrhunderts, in V. Boudon-Millot, A. Guardasole, C. Magdelaine (ed.), La science médicale antique: Nouveaux regards. Études réunies en l’honneur de Jacques Jouanna, Paris, 2008, p. 119-137.
Codivilla 1906 = A. Codivilla, Sulla cura del piede equino varo congenito. Nuovo metodo di cura cruenta, in Archivio di Ortopedia, 22, 1906, p. 220-229. Reprint in Chir. Org. Mov., 69, 1984, p. 221-226.
Carroll 2012 = N. Carroll, Clubfoot through the ages, in J.G. Raffensperger (ed.), Children’s surgery: A worldwide history, Jefferson, 2012, p. 160-166.
Craik 2015 = E.M. Craik, The ‘Hippocratic’ Corpus. Content and context, London-New York, 2015.
Craik 2018 = E. Craik, The ‘Hippocratic Question’ and the nature of the Hippocratic Corpus, in P.E. Pormann (ed.), The Cambridge Companion to Hippocrates, Cambridge, 2018, p. 25-37.
10.1017/9781107705784 :Debrunner 1936 = H. Debrunner, Zur Geschichte der Klumpfußbehandlung, in Archiv für orthopädische und Unfall-Chirurgie, 36, 1936, p. 101-109.
Di Benedetto 1986 = V. Di Benedetto, Il medico e la malattia: La scienza di Ippocrate, Turin, 1986.
Dobbs 2000 = M.B. Dobbs, J.A. Morcuende, C.A. Gurnett, I.V. Ponseti, Treatment of idiopathic clubfoot: an historical review, in Iowa Orthopedic Journal, 20, 2000, p. 59-64.
Döderlein 1999 = L. Döderlein, W. Wenz, U. Schneider, Der Klumpfuß. Erscheinungsformen und Behandlungsprinzipien jeden Alters. Differentialdiagnose und Differentialtherapie, Unter Mitarbeit von J.A. Fixsen, Berlin, 1999.
Exner 2005 = G.U. Exner, F. Anderhuber F., V. Haldi-Brändle, H.A.C. Jacob, G. Windisch, Klumpfuß: Pathoanatomie. Manuell-funktionelle und operative Behandlung, Darmstadt, 2005.
Flashar 2016 = H. Flashar, Hippokrates: Meister der Heilkunst. Leben und Werk, München 2016.
Hefti 2015 = F. Hefti (ed.), Kinderorthopädie in der Praxis, 3. Auflage, Berlin-Heidelberg, 2015.
Graziati 2009 = G. Graziati, Origini ed evoluzione dell’ortopedia, della traumatologia e delle scienze affini, Mariano del Friuli, 2009.
Golder 2007 = W. Golder, Hippokrates und das Corpus Hippocraticum. Eine Einführung für Philologen und Mediziner, Würzburg, 2007.
Grensemann 1970 = H. Grensemann, Hypothesen zur ursprünglich geplanten Ordnung der hippokratischen Schriften De fracturis und De articulis, in Medizinhistorisches Journal, 5, 1970, p. 217-235.
Gurlt 1898 = E. Gurlt, Geschichte der Chirurgie und ihrer Ausübung. Volkschirurgie – Alterthum – Mittelalter – Renaissance, I, Berlin, 1898.
Hernigou 2017a = P. Hernigou, M. Huys, J. Pariat, S. Jammal, History of clubfoot treatment, Part I: From manipulation in antiquity to splint and plaster in renaissance before tenotomy, in International Orthopaedics (SICOT), 41, 2017, p. 1693-1704.
10.1007/s00264-017-3487-1 :Hernigou 2017b = P. Hernigou, N. Gravina, D. Potage, A. Dubory, History of clubfoot treatment, Part II: Tenotomy in the 19th century, in International Orthopaedics (SICOT), 41, 2017, p. 2205-2212.
Hernigou 2017c = Philippe Hernigou, History of clubfoot treatment, Part III (twentieth century): back to the future, in International Orthopaedics (SICOT), 41, 2017, p. 2407-2414.
Horstmanshoff 2013 = M. Horstmanshoff, Klein gebrek geen bezwaar? Over de klompvoet in de oudheid, in Lampas, 46, 2013, p. 203-221.
Imhäuser 1968 = G. Imhäuser, Sind wir in der Klumpfußbehandlung über Hippokrates hinausgekommen?, in H. Schaldewaldt (ed.), Medicinae et artibus. Festschrift für Wilhelm Katner zu seinem 65. Geburtstag, Düsseldorf, 1968, p. 46-50.
Irmer 1980 = D. Irmer, Die Bezeichnungen der Knochen in Fract. und Art., in M.D. Grmek (ed.), Hippocratica. Actes du Colloque Hippocratique de Paris (4-9 septembre 1978), Paris, 1980, p. 265-284.
Jouanna 1992 = J. Jouanna, Hippocrate, Paris, 1992 (new ed. 2017).
Kollesch 1964 = J. Kollesch, Rez. M. Michler, Die Klumpfußlehre der Hippokratiker, in Deutsche Literaturzeitung 85, 1964, p. 826-829, repr. in Kleine Schriften zur antiken Medizin, CMG Suppl. VI, Berlin, 2019, p. 281-284.
Labiano 2014= M. Labiano, The surgical treatises of the Corpus Hippocraticum: statistical linguistics and authorship, in J. Martínez (ed.), Fakes and forgers of Classical literature: Ergo decipiatur!, Leiden, 2014, p. 109-124.
Le Vay 1990 = D. Le Vay, The history of orthopaedics: an account of the study and the practice of orthopaedics from the earliest times to the modern era, Carnforth-Park Ridge, 1990.
Mach 1987 = J. Mach, Geschichte der Klumpfußbehandlung, in Beitr. Orthop. Traumatol, 34, 1987, p. 493-498.
Martin 2009 = D. Martin, I. Ponseti, Hero to many with clubfoot, dies at 95, in New York Times, October 23, 2009.
Niehaus – Schlösser 2001 = P. Niehaus, A.J.J. Schlösser, Die unblutige Korrektur des angeborenen Klumpfußes – von Hippokrates bis zum Lorenz’schen Osteoclasten, in L. Zichner, M.A. Rauschmann, K.-D. Thomann (ed.), Geschichte operativer Verfahren an den Bewegungsorganen, Darmstadt, 2001, p. 193-201.
Peltier 1993 = L.F. Peltier, Orthopedics. A history and iconography, San Francisco, 1993.
Perilli 2018 = L. Perilli, Epistemologies, in P.E. Pormann (ed.), The Cambridge Companion to Hippocrates, Cambridge, 2018, p. 119-151.
Ponseti 1996 = I.V. Ponseti, Congenital clubfoot. Fundamentals of treatment, Oxford, 1996.
Rauschmann 2000 = M.A. Rauschmann, Zur Geschichte der Tenotomie des Klumpfußes, in L. Zichner, M.A. Rauschmann, K.-D. Thomann (ed.), Geschichte konservativer Verfahren an den Bewegungsorganen, Darmstadt, 2000, 147-152.
10.1007/978-3-642-57709-3 :Roberts-Manchester 2010 = C. Roberts, K. Manchester (ed.), The archaeology of disease, 3rd ed., Ithaca, 2010.
10.1136/adc.62.11.1193 :Roselli 1975 = A. Roselli, Problemi relativi ai trattati chirurgici De Fracturis e De Articulis, in La collection hippocratique et son rôle dans l’histoire de la médecine (Colloque de Strasbourg, 1972), Leiden, 1975, p. 229-234.
Sanzarello 2017 = I. Sanzarello, M. Nanni, F. Cesare, The clubfoot over the centuries, in Journal of Pediatric Orthopaedics B, 26, 2017, p. 143-151.
10.1097/BPB.0000000000000350 :Schlösser 1980 = A.J.J. Schlösser, Ätiologie und Behandlung des angeborenen Klumpfusses: Eine medizin-historische Übersicht, Diss. med., Aachen, 1980.
Schnalke 2000 = Th. Schnalke, Da hilft nur noch das Messer! Eine Sonderausstellung als Brückenschlag zwischen Medizingeschichte und aktueller Medizin, in L. Zichner, M.A. Rauschmann, K.-D. Thomann (ed.), Geschichte operativer Verfahren an den Bewegungsorganen, Darmstadt, 2000, p. 189-196.
Simons 1994 = G.W. Simons (ed.), The clubfoot. The present and a view of the future, New York-Berlin, 1994.
10.1097/01241398-199409000-00026 :Smythe 2017 = T. Smythe et al., Birth prevalence of congenital talipes equinovarus in low- and middle-income countries: a systematic review and meta‐analysis, in TMIH (Tropical Medicine & International Health), 22, 2017, p. 269-285.
10.1111/tmi.12833 :Sponseller 2011 = P.D. Sponseller, Handbook of pediatric orthopedics, New York-Stuttgart 2011, 2nd ed.
10.1055/b-002-80420 :Strach 1986 = E.H. Strach, Club-foot through the centuries, in Progress in Pediatric Surgery 20, 1986, p. 215-237.
Tachdjian 1994 = M.O. Tachdjian, Foreword, in G.W. Simons (ed.), The clubfoot. The present and a view of the future, New York-Berlin, 1994, p. vii-viii.
Valentin 1961 = B. Valentin, Geschichte der Orthopädie, Stuttgart 1961.
Witt 2009 = M. Witt, Weichteil- und Viszeralchirurgie bei Hippokrates. Ein Rekonstruktionsversuch der verlorenen Schrift Peri trômatôn kai belôn (De vulneribus et telis), Berlin, 2009.
Witt 2012 = M. Witt, Galens zweifache Kommentierung zu chirurgischen Schriften des Corpus Hippocraticum (Methodus medendi, Bücher 3-6, und chirurgische Hippokrates-Kommentare), in Les Études Classiques, 80, 2012, p. 73-126.
Witt 2018 = M. Witt, Surgery, in P.E. Pormann (ed.), The Cambridge Companion to Hippocrates, Cambridge, 2018, p. 217-245.
10.1017/9781107705784 :Notes de bas de page
1 There are several possibilities in spelling: club foot, club-foot, or clubfoot; I will use here the latter.
2 Martin 2009. This modern metaphor of golf clubs is commonly used in patient’s information sheets found in randomly selected websites, e.g.: https://mychicagofootexpert.com/club-foot (received on 03.03.2019).
3 Roberts – Manchester 2010, 58; Aufderheide – Rodríguez-Martín 2011, 76.
4 Michler 1963. See also its review by Kollesch 1964.
5 This essay is the outcome of much preliminary interdisciplinary work, partly done together with Manfred Horstmanshoff, who has published the historical results in a separate Dutch article (Horstmanshoff 2013). We have presented and discussed our research together 2012 in Cardiff (School of History, Archaeology and Religion) and 2013 in Berlin (Humboldt Universität, Faculty of Language, Literature and Humanities, Department of Classics). I myself am pediatric surgeon with long-time experience in the treatment of children with clubfoot in collaboration with pediatric orthopedics.
6 E.g., Grensemann 1970, 225, n.10.
7 E.g., Döderlein 1999, 41; Dobbs 2000, 59.
8 Selected historical and current (medical) overviews: Debrunner 1936; Valentin 1961, 67-105; Schlösser 1980; Strach 1986; Mach 1987; Le Vay 1990, 489-508; Peltier 1993, 41-58; Dobbs 2000; Niehaus – Schlösser 2001; Graziati 2009, 152-160; Carroll 2012; Hernigou 2017a-c; Sanzarello 2017.
9 As is now well hinted at by Witt 2018.
10 The Latin title Vectuarius is not used regularly; only Littré has used in his edition the title “Mochlikos”, which is not attested in the extant manuscripts; Craik 2015, 167.
11 For a recent overview see Witt 2018, who includes now convincingly the gynecological (surgical) treatises of the Hippocratic Collection, too. This list of surgical treatises goes back to the ancient summary of the grammarian Erotian; see Golder 2007, 39-45, and Witt 2018, 221. For a study of the handful fragments of the otherwise lost treatise De vulneribus et telis, itself already an epitome, see Witt 2009.
12 Grensemann 1970, 225 and 228; Roselli 1975, 229; Di Benedetto 1986, 248; Jouanna 1992, 539; Labiano 2014, 123 (linguistic arguments); Craik 2015, 107. The dissociation of both treatises must have happened very early, perhaps already before their arrival in the library of Alexandria; Withington 1928, xxiii.
13 Consisting of 87 different chapters, making up 125 pages of Greek text in the reference edition of Littré (Littré IV, 78-327; 134 pages in Kühlewein II, 111-244). Flashar 2016, 163, calls Artic. “eine der bedeutendsten und auch umfangreichsten Schriften des Corpus Hippocraticum”. Following the commentaries of Apollonius of Citium and Galen chapter 78 should be regarded as original end chapter of the treatise (being the last chapter in their respective commentaries); the remaining chapters 79 to 87 could be interpreted as “dislocated”, partly unedited or “rediscovered” material (e.g., chapter 79 as original introduction), some part maybe only falsely recopied from Mochl.; Withington 1928, 387, n.2.
14 General overview in Grensemann 1970; contra this transmission hypothesis: Di Benedetto 1986, 256 (“l’ordine voluto dall’autore”).
15 Grensemann 1970, 224 (“das der assoziativen Aneinanderreihung in der Besprechung benachbarter Knochen und Gelenke“), and 229; Witt 2018, 221, n.15. Artic. 61 concludes the series 51-61 on dislocations of the hip; Withington 1928, 88. See also Golder 2007, 43-44, who presents twelve possible subdivisions of Artic.; his tenth subdivision contains ch. 62.
16 Michler 1963, 3, and 18, n.1; Grensemann 1970, 229. Artic. 53 (Littré IV,232-233; Kühlewein II,193-197) describes at two instances “clubfoot”: first (Littré IV,234,3; Kühlewein II,194,10), if an outward dislocation is at the ankle, then it becomes a “kullós”, but these patients can stand, contrary to those with inward dislocation which become “splay-footed” (“blaisós”); second (Littré IV, 234,16; Kühlewein II, 195,3), after a dislocation at the knee joint, bones of the foot will atrophy, but not to the same extent when the joint at the foot (ankle) is not intact, so that injured persons can still use their feet, as is the case even in “clubfoot” (“hôs[per] kai tô kullô”), the bones of the foot in their case would be still less atrophied. Artic. 85 (Littré IV,324,1-2; Kühlewein II,242,20-243,2) reports very briefly of dislocated ankle joints (“the bones connecting the foot with the leg”) either congenitally (“ek geneês”) or during adolescence (“en auksêsei”), and compares their similar (natural) course with the dislocations (“eksarthrêsanta”) in the hand (i.e., of the wrist joint). Artic. 87 (Littré IV,326,9-15; Kühlewein II,244,7-14; Withington 1928, 395/397) describes the course of untreated foot dislocations, usually displaced inwards (“es tó esô”), compares the treatment with that of the wrist joint (stronger extension required), and closes with the remark that congenital and adolescent cases (“tó dé ek geneês ê en auksêsei”) “follow the rule given before”.
17 Probably due to its disordered transmission; see Withington 1928, 85; Grensemann 1970, 224-225. Incorrect: Flashar 2016, 159: “Der Autor ist ein erfahrener Arzt, der einen stupenden Überblick über alle Arten von Einrenkungen verletzter Gelenke gibt, angeordnet in der Reihenfolge vom Kopf bis zum Fuß“.
18 Most part of Mochl. represents a summary of Artic., some material of Fract. and possible associations with other writings of the Hippocratic Collection; Craik 2015, 167-168.
19 Withington 1928, 85; Grensemann 1970, 233; Craik 2015, 167.
20 Surrounded first by Mochl.31 concerning traumatological dislocations of the foot, ending with a hint at similar treatment in cases at birth and adolescence (summary of Fract.13 and Artic. 87), and second by Mochl.33 (summary of Fract.36 and Artic. 63); Pétrequin 1878, 597, 599; Withington 1928, 86.
21 E.g., the cheering remark in Adams 1849, 499: “Hippocrates, the great ancient authority on fractures and dislocations”.
22 See Witt 2018, 227 and 244.
23 Di Benedetto 1986, 248 and 255; Jouanna 1992, 539 calls him therefore “un grand patron”. Some examples: Fract.1 (Littré III,412,4-414,2; Kühlewein II, 46,6-10; transl. Withington 1928, 95): “those who have no preconceived idea make no mistake as a rule […] The theorizing practitioners are just the ones who go wrong“; Fract.2 (Littré III,422,10-11; Kühlewein II,49,6-7; Withington 1928, 99): “perhaps our theorizer would not have committed this error”; Fract.16 (Littré III,474,17; Kühlewein II,73,7-8; Withington 1928, 137): “I am at a loss what to advise as regards their use”; Artic. 11 (Littré IV,104,20-21; Kühlewein II,127,17-18; Withington 1928, 223): “I know of no one who uses the correct treatment”; Artic. 11 (Littré IV,106,16-17; Kühlewein II,128,19-20; Withington 1928, 225): “This indeed is no great evil, but looks rather bad and shows want of skill”; Artic. 13 (Littré IV,116,10-11; Kühlewein II,133,10-11; Withington 1928, 233): “I know many otherwise excellent practitioners who have done much damage”; Artic. 37 (Littré IV,166,9-10; Kühlewein II,158,17-18; Withington 1928, 271): “I never saw a nose fractured in this way”; Artic. 42 (Littré IV,184,2-4; Kühlewein II,168,3-5; Withington 1928, 285): “For myself, however, I felt ashamed to treat all such cases in this way, and that because such methods appertain rather to charlatans”; Artic. 44 (Littré IV,188,14-16; Kühlewein II,171,7-10; Withington 1928, 289): “but it is disgraceful in any art, and especially in medicine, to make parade of much trouble, display, and talk, and then do no good”; Artic. 46 (Littré IV,198,4-5; Kühlewein II,175,2-3; Withington 1928, 293): “One might do this with a corpse, but hardly with a living patient. Why then am I writing this?”; Artic. 46 (Littré IV,198,9-10; Kühlewein II,175,8-10; Withington 1928, 293): “There are many ignorant practitioners; and they profit by their ignorance, for they get credit with their neighbours”; Artic. 48 (Littré IV,212,17; Kühlewein II,182,19-20; Withington 1928, 305): “For my part, I know of no method for reducing such an injury”; Artic. 55 (Littré IV,242,12-14; Kühlewein II,200,4-5; Withington 1928, 331): “The greatest care is required in cases where this lesion occurs when they are very young”; Artic. 58 (Littré IV,252,8-10; Kühlewein II,205,12-14; Withington 1928, 339): “Why, forsooth, trouble one’s mind further about cases which have become incurable? This is far from the right attitude”; Artic. 77 (Littré IV,308,8-9; Kühlewein II,235,1-3; Withington 1928, 381): “I have seen some who, through incompetence, kept trying to reduce”; general motto of the treatise in Artic. 78 (Littré IV,312,1-3; Kühlewein II,236,16-18; Withington 1928, 383): “What you should put first in all the practice of our art is how to make the patient well; and if he can be made well in many ways, one should choose the least troublesome”.
24 It is speculated that the author belongs to the Coan spirit. Despite these, in my view, overcome, unfruitful debates on genuine Hippocratic authorship see contemporary pretenders like Flashar 2016, 163, and Craik 2018, 36 (but see also her critical appraisal, xx-xxiv). To speak even of “Hippocrates, the Father of Medicine and of Clubfoot Treatment” (e.g., Niehaus – Schlösser 2001, 193) naturally is ridiculous, and just another romantic, anachronistical and finally ahistorical projection.
25 Fract.25 (Littré III,500,13-15; Kühlewein II,83,16-18; Withington 1928, 153): “it is an evidence of the truth of what was written before on the question whether the greatest or the least pressure should come at the fracture”.
26 Fract.13 (Littré III,466,3-4; Kühlewein II,68,19-20; Withington 1928, 131): “The best thing for anyone who practices in a large city”; Artic. 1 (Littré IV,78,9-11, Kühlewein II,111,12-112,1; Withington 1928, 201): “In such a case I myself once got into disrepute both with practitioners and the public”; see Flashar 2016, 164. On the Hippocratics’ self-awareness of their medical craft as a science, see Perilli 2018, esp.144.
27 Withington 1928, xxv; Craik 2015, 168.
28 Brockmann 2007, 139. Contrary position in Flashar 2016, 165: “Eindeutig steht die Praxis über der Theorie. In diesem Sinn ist die Schrift an junge Ärzte gerichtet, nicht an eine breite Öffentlichkeit”.
29 Di Benedetto 1986, 248.
30 Golder 2007, 43; Craik 2015, 111. Brockmann 2007, 140, discusses a similar, but still debatable spirit like that in the historian Herodotus, and therefore dates Artic. around 420 BC.
31 Grensemann 1970, 234; Golder 2007, 42; Craik 2015, 168, speculates about an even much later date.
32 This commentary was perhaps first formed in 170 and then revised by Galen in 177; see Witt 2012, 115.
33 Discussion about the meaning of “Chîai”, Chian boots, in Artic. 62 (Littré IV,268,1; Kühlewein II,214,2) is attested in Erotian (1st century), who names as commentators Epikles, Eratosthenes, and Kallistratos (fl. 3rd century BC in Alexandria); see Nachmanson 1918, 94,11-13, and Withington 1928, 351, n.1. Further, Galen attests some discussion about the meaning of “ek geneês” by “some” (“enioi”); Galen, Hipp.Artic. Comm. IV, 1 (Kühn XVIIIA, 667,4-5); Michler 1963, 9. Interestingly, in the (extant) medical commentary of Apollonius of Citium from 1st century BC Artic. 62 and Mochl. 32 are left out from discussion (this commentary cites around a quarter of the text of Artic.): see Kollesch – Kudlien 1965, esp. 131-133. On the reception of Artic. see in general Anastassiou-Irmer 1997-2012.
34 Galen, Hipp.Artic. Comm. IV, 1-14 (Kühn XVIIIA, 667-683), Michler 1963, 9-16 (German translation). A recent CMG translation is on the way by Christian Brockmann, see preview: http://cmg.bbaw.de/online-publikationen/probeedition-online (received 05.05.2019). Not available for me was: M. Abballe (ed.), I quattro commentari al trattato delle articolazioni di Ippocrate [di] Galeno, Roma 1972.
35 Witt 2012, 118.
36 The texts of Artic. 62 and Mochl.32 are transmitted within the medieval (original Byzantine) manuscripts B (Laurentianus Pluteus graecus 74.7, codex of Nicetas; which however does not contain Mochl.), M (Marcianus Venetus graecus 269) and V (Vaticanus graecus 276), reference editions are that of Littré 1844 (Littré IV, 262,10-268,11, resp. 374,11-15) and Kühlewein 1902 (Kühlewein II, 211,19-214,13, resp. 263,2-7). Selected translations into modern languages are: English in Adams 1849 (632-634, resp. 674), and Withington 1928 (346-351, resp. 428-431); French in Pétrequin 1878 (466-472, resp. 598-599), and Littré 1844 (see above); German in Gruner 1780 (only Artic. 62, split into two paragraphs: §352,541,21-§353,544,2), Upmann 1847 (Artic. 62: vol.3, 223-224, abbreviated cited in Schlösser 1980, 22 and 24; Mochl.32: 248), Gurlt 1898 (only Artic. 62, 266-267), Fuchs 1900 (152-154, resp. 247), Beck 1907 (only Artic. 62, 108-115), Kapferer 1936 (XXII/81-83, resp. XII/130), and Michler 1963 (only Artic. 62, 5-8); Spanish in Lara – Torres – Cabellos 1993 (Artic. 62: 201-202, transl. by Beatriz Cabellos; Mochl.32: 248, transl. by M. Dolores Lara); modern Greek: Cactus Editions: Ippokrates, Apanta, Tomos 8, Athens, 1992 (496-501, resp. 594-597; here Artic. and Mochl. are separated from other surgical treatises, especially from Fract.). Strikingly, both, Artic. 62 and Mochl. 32, are missing in several modern editions of the Hippocratic surgical treatises, e.g. in: Amneris Roselli (ed.), La chirurgia ippocratica. Saggio introduttivo e traduzioni, Firenze 1975; also missing in: Mario Vegetti (ed.), Opere di Ippocrate. Seconda edizione ampliata, Torino 1976; in John Chadwick, W.N. Mann (ed.), Hippocratic Writings, with an introduction by G.E.R. Lloyd, Harmondsworth 1978/1983; and in Armelle Debru, Hippocrate: La Consultation, Paris 1986. Aldo Benedetti, La traumatologia al tempo di Ippocrate, Roma 1969, was unfortunately not available to me.
37 Michler 1963, 5-8.
38 There were and are some doubts – which I share – about the connection of this more general, asyndetic sentence with the original composition of the chapter; maybe there also is some “internal feedback” with the beginning of Mochl.32 (sentence 1, see below); e.g., see Pétrequin 1878, 598, n.1, and Grensemann 1970, 229.
39 There are only slight differences in the edited texts of Littré 1844, Pétrequin 1878 and Kühlewein 1902 (used by Withington 1928). Michler 1963, 21-26, discusses extensively the reading of egklínein/ekklínein in sentence 5 of Artic.62.
40 Holding in mind that crucial medical practice is and was learned by practice from one physician to another, not (only) texts!
41 Withington 1928, 88: “the excellent description of club foot”; Michler 1963, 57: “es ist uns keine […] Behandlungsmethode überliefert, die ihm [=dem hippokratischen Heilverfahren] vorangegangen sein könnte”; Dobbs 2000, 59: “The first description of clubfoot was given to us by Hippocrates (circa 400 B.C.)”.
42 Which could of course have been integrated in the original manuscripts, comparable to the thirty illustrations accompanying the commentary of Artic. by Apollonius; see Kollesch – Kudlien 1965, 135-166.
43 Artic. 62, sentence 1 (Littré IV,262,10-264,2; Kühlewein II,211,19-212,1; Withington 1928, 347): “There are certain congenital displacements (tôn ek geneês olistêmátôn) which, when they are slight (mikròn olísthê), can be reduced to their natural position (es tên phúsin ágesthai), especially those at the foot-joints (málista tà parà toû podòs árthra)”. Compare Artic. 53 (Littré IV,234,15; Kühlewein II,195,2; Withington 1928, 323,10): “because the joint at the foot (tò arthron tò parà tòn póda) is intact (sôón esti)”.
44 Artic. 85 (Littré IV,324,1-2; Kühlewein II,242,20-243,2; Withington 1928, 393): “The bones connecting the foot with the leg (tà dè tês knêmês sugkoinôméonta), whether dislocated from birth (ekpesónta ek geneês) or put out during adolescence (en auksêsei eksarthrêsanta), follow the same course as those in the hand”. See also Artic. 87 (Littré IV,326,9-15; Kühlewein II,244,7-14), where the dislocations of the foot joint (ankle), either acquired or congenital, are compared to those at the wrist (“hôsper karpoû”).
45 Artic. 62, sentence 8 (Littre IV,266,13-15; Kühlewein II,213,15-17; Withington 1928, 349/351): “In a word (haplô dè lógô), as in wax modelling, one should bring the parts into their true natural position (es tên phúsin tên dikaíên ágein), both those that are twisted (tà ekkekliména) and | those that are abnormally contracted (tà suntetaména parà tên phúsin)”.
46 Most likely, it is the middle position in the normal, relaxed foot in standing position.
47 Artic. 62, sentence 1: “which, when they are slight (mikròn olísthê), can be reduced to their natural position (es tên phúsin ágesthai)”. Equals Mochl.32, sentence 1 (Littré IV,374,11-12; Kühlewein II,263,2-3; Withington 1928, 429): “Among slight congenital dislocations (tà smikròn ôlisthêkóta ek geneês), some can be put straight (énia hoîá te diorthoûsthai)”. “Diorthoûsthai” (itself just meaning not very precise “straight”) is here obviously synonymous with “es tên phúsin ágesthai”.
48 Artic. 62, sentence 2 (Littré IV,264,2; Kühlewein II,212,1-2; Withington 1928, 347): Cases of congenital “club-foot” (hopósoi ek geneês kulloì gínontai); Mochl.32, sentence 2 (Littré IV,374,12; Kühlewein II,263,3-4; Withington 1928, 429). I won’t attempt here any complete terminological discussion, but will only focus on some lexicographic remarks (by use of the Index Hippocraticus 461, LSJ 1008-1009 with Suppl.189, and DELG 598-599, 1412): first, the term “kullós” appears earlier on in Artic. 53. The term is definitely no new, ad-hoc invention of the author of Artic. 62, it is already used (and by that collectively known) in its original meaning of “crook” (DELG 1412: “recourbé”) in Homer as epithet of the limping god Hephaestus “kullopodíôn” (“club-footed”, limping, halting): Il.18.371; 20.270; 21.331. Moreover, it is used in “kullopoûs”, “club-footed” in Aristophanes, Aves 1379 (póda kullón). Only Galen (2nd century CE) has the term “kullôma” (LSJ 1009), in Hipp.Artic. Comm.IV,4 (Kühn XVIIIA,670,15).
49 Artic. 62, sentence 4 (Littré IV,264,7-8; Kühlewein II,212,8-9; Withington 1928, 349,1-2): “Now the mode of club-foot (trópos mèn oûn kullôsios) is not one, but manifold (ouch heîs, allà pleíones)” = reduced to Mochl.32, sentence 3 (Littré IV,374,12-13; Kühlewein II,263,4; Withington 1928,431,1): “Now there is more than one kind of club-foot (kullôsios gàr ouch heîs estì trópos)”.
50 Artic. 62, sentence 4 (Littré IV,264,8-10; Kühlewein II,212,9-11; Withington 1928, 349,3-5): “most cases are not the result of complete dislocation (tà pleîsta mên ouk eksêrthrêkóta pantápasin), but are deformities due to the constant retention of the foot in a contracted position (allà di’éthos schêmatos én tini apolêpsei toû podòs kekullôména)”.
51 See below, note 55 and 56.
52 Artic. 53 (Littré IV,232,13-15; Kühlewein II,194,3-4; Withington 1928, 321,19-21; example of hip dislocation): “a marked difference (diáphoron) between inward and outward dislocation (es tò ésô ê es tò éksô eksarthrêsai)”.
53 Artic. 62, sentence 5 (Littré IV,264,11-12; Kühlewein II,212,12-14; Withington 1928, 349,6-7): Pressure on fibula inwards. This corresponds to the statement in Artic. 53 (Littré IV,234,3-4; Kühlewein II,194,9-10; Withington 1928, 321,26-28): “when the [traumatic joint] dislocation is at the ankle (parà tò sphuròn eksarthrêsê), if it is outwards (es tò èksô méros), they become club-footed (kulloì mèn gínontai)”. Moreover, it fits to Artic. 87 on cases with ankle dislocation relating to the resulting foot position (Littré IV,326,9-15; Kühlewein II,244,7-14; Withington 1928, 395/397): “In cases where the foot is dislocated, either by itself or with the epiphysis, it is usually displaced inwards (mâllon es tò ésô) […] | Congenital (tò dè ek geneês) and adolescent cases follow the rule given before”.
54 Artic. 62, sentence 5 (Littré IV,264,12-13; Kühlewein II,212,14-15; Withington 1928, 349,8-10): Counter-pressure outwards on the heel (“antôtheîn dè es tò éksô méros tò tês ptérnês tò katà tên íksin”).
55 Artic. 62, sentence 5 (Littré IV,264,15-266,1; Kühlewein II,212,17-19; Withington 1928, 349,11-13): Bending and rotating inwards (es tò ésô méros egklínein kaì perianagkázein) of all toes (pronation). This reading and interpretation is hotly discussed by Michler 1963, 21-26, who argues “orthopedically” that the correct reading should be that “the toes together with the big toe are positioned inwards, so that they has to be bend and rotated outwards” (“Die Zehen aber hinwiederum, welche mitsamt dem Großzeh nach innen (neigen), muß man nach außen biegen und so herumzwängen”; Michler 1963, 7,1-3). I think, changing the text with modern orthopedic arguments is maybe somewhat dubious (as Michler himself is showing by the discussion of the former medical interpretation of this text by Guérin and Pétrequin, see Michler, 24-25, n.3), especially, when the result, active pronation of the forefoot, is the same.
56 Artic. 62, end of sentence 6 (Littré IV,266,4-5; Kühlewein II,213,4-5; Withington 1928, 349,17-19): “the manual adjustment of the foot (katórthôsis ên toû podós), so that the latter has an inclination somewhat towards splay-footedness (hópôs ho poùs olígô mâllon es tò blaisòn rhépôn phaínêtai) [i.e. valgus]”. See also Artic. 53 (Littré IV,234,4-5; Kühlewein II,194,10-11; Withington 1928, 321,28-29): “if the ankle dislocation is inwards, they become blaisoí”. In Kühn’s edition of Galen’s commentary on Artic., e.g. Kühn XVIIIA, 670, 23, “kullós” is translated into Latin “pes varus”.
57 Artic. 53 (Littré IV,234,2-4/16, Kühlewein II,194,8-12/195,3; Withington 1928, 321/323): “Similarly, when the dislocation is at the ankle (parà tò sphuròn eksarthrêsê), if it is outwards (es tò éksô), they become club-footed (kulloì mèn gínontai), but are able to stand; while if it is inwards (es tò ésô méros), they become splay-footed (blaisoì mèn gínontai), and are less able to stand.” and further “they should be able to use the part, as is the case even in club-foot (hôsper kaì tô kullô)”. See also Artic. 87 (Littré IV,326,9-10; Kühlewein II,244,7-8; Withington 1928, 395) on acquired and congenital ankle dislocations: “it is usually displaced inwards (ekpíptei mèn mâllon es tò ésô)”.
58 Artic. 53 (Littré IV,234,5-9; Kühlewein II,194,12-16; Withington 1928, 321/323): “As regards growth of the bones, the following is what happens: when the bones of the | leg at the ankle is dislocated, the bones of the foot show least growth, for they are nearest to the injury”. Somewhat strangely, in Artic. 87, the authors states generally on the development of the opposite lower extremity in cases of untreated ankle dislocations (Littré IV,326,10-12; Kühlewein II,244,2-4; Withington 1928, 395/397): “if not reduced, the hip, | thigh and leg become in time attenuated (leptúnetai anà chrónon) on the side opposed to the dislocation (tò antíon toû olisthêmatos)”.
59 As regards to the bones, not the tissues (muscles) of the leg. Artic. 53 (Littré IV,234,14-17; Kühlewein II,194,22-195,4; Withington 1928, 323): “The bones of the foot are atrophied, but not to the same extent as was noticed a little above, because the joint at the foot (tò árthron tò parà tòn póda) is intact (sôón ésti); and should they be able to use the part, as is the case even in club-foot (hôsper kaì tô kullô), the bones of the foot (tà toû podòs ostéa) in their case would be still less atrophied”. Interestingly, here the author is obviously using “kullós” in the sense of “ek geneês poûs kullôsis”.
60 Artic. 62, sentence 9 (Littré IV,266,18-19; Kühlewein II,213,21; Withington 1928, 351,5-7), referring back to sentence 4: “for different forms of lameness (állês tôn chôlômátôn) require different kinds of support (analêpsios)”.
61 It is believed that the knowledge of the anatomy of the human musculoskeletal system and of the head represented in the surgical treatises of the Hippocratic collection is very good, even surpasses that of later Aristotle; Witt 2018, 223. May this be true, anatomical basics in Fract./Artic. are rather called still rudimentary from modern view, e.g. the classification of articulations in Art.79,1 (Littré IV,316,9-12; Kühlewein II,239,7-10; Withington 1928, 387); see Irmer 1980.
62 Irmer 1980, 283. Compare Mochl.1 (Littré IV,340,3; Kühlewein II,245,3-4; Withington 1928, 399): “The heel has a single bone”. Withington 1928, 90 and more specifically 425-429 profoundly asks and discusses the question “Why is there no mention of the astragalus in ankle dislocations?” and offers as solution, that the so-called “epiphysis” at the ankle (e.g., Fract.12, and Artic. 87) is what today is called “talus bone”, but which the Hippocratic writer of Fract./Artic. refers to be part of lower end of the leg, not of the (hind)foot. Another solution could be, according to Beck 1907, 110 and Michler 1963, 6, n.14, that “pternê” just means both bones, calcaneus and talus, which the author of Fract./Artic. considers as only one singular bone complex. Though the “astrágalos” (literally “little bone”) is mentioned in earlier non-medical literature (e.g., Persian king Darius’ injured “ankle” in Herodotus 3.129.2; but in the meaning of a cervical vertebra in Homer, Il. 14.466, Od. 11.65), there isn’t any constant definition of it in the other writings of the Hippocratic Corpus (e.g., “sheep’s vertebra” in Hipp., Int.20, Littré VII, 216,20; but uniquely as part of the heel “the so-called astragalos” in the case-story in Hipp., Epid.5.48, Littré V, 236,4): see DELG 129, LSJ 262, and Index Hippocraticus 96. Galen (Oss. 24.1; Kühn II, 775,16 = Garofalo 2005, 81,18-19) mentions and defines the “astrágalos” anatomically correct as “talus bone”.
63 Which, in his opinion, but anatomically wrong, is slightly longer than the inner tibia: Fract.12, and 37; Withington 1928, 90 (hypothesis of an exaggerated analogy with the outer bone of the lower arm, the ulna), 127, and 183.
64 Leg: Fract.12 (Littré III,460,1-7; Kühlewein II,66,13-21; Withington 1928, 127); see Irmer 1980, 283. “Tarsós”: Fract.9 (Littré III,448,17-450,1; Kühlewein II,61,16-19; Withington 1928, 119): “But if any of the bones be displaced, whether a joint of the toes or some bone of what is called the tarsus (ê állo ti tôn ostéôn toû tarsoû kalouménou), you should press each back into its proper place just in the way described as regards the bones of the hand”. Bones of the foot are always compared to those of the hand: Fract.9 (Littré III,448,13-14; Kühlewein II,61,11-12; Withington 1928,119): “The human foot, like the hand, is composed of many small bones (poùs dè anthrôpou ek pollôn kaì smikrôn ostéôn sungkeîtai, hôsper kaì cheìr ákrê)”.
65 Dobbs 2000, 59: “When clubfoot is analyzed from an historical perspective, it is difficult to ascertain if other types of foot deformity, for example equinovarus or metatarsus adductus, were included in the definition. However, we believe most experienced authors were able to differentiate it from other foot deformities when they referred to a clubfoot, given the natural history of no improvement without treatment.”.
66 Taken German translations as impressive historical example: the older translations of the physicians Gruner 1780, 541, Upmann 1847, 223, and still Kapferer 1936, XXII/81, all have “Krummfuß” (crook foot). Starting with Gurlt 1898, 266 (“Klumpfuß”), Fuchs 1900, 152, translates yet “Krummfuß”, but puts “Klumpfuß“ in brackets; Beck 1907, 108, already has only “clubfoot” throughout (“Klumpfuß und dessen Behandlung”). In this observable medical historical process, the retrospective diagnosis of “clubfoot” has somehow penetrated all translations.
67 Dobbs 2000, 59. Indeed, it takes several years of experience to understand this complex anomaly nearly fully.
68 Döderlein 1999, 2-4; Hefti 2015, 441.
69 Exner 2005, 29.
70 Smythe et al. 2017 present a recent birth prevalence of clubfoot between 0.51 and 2.03/1,000 live births (from China with 0.51, the Africa region with 1.11, the Eastern Mediterranean region with 1.19, and European Turkey with 2.03). Still, this makes clubfoot the most frequent congenital anomaly of limbs in humans.
71 Ponseti 1996, 8-20; Döderlein 1999, 10-19; Exner 2005, 29-35; Hefti 2015, 439-440.
72 The forefoot position in relation only to the foot itself, especially the hindfoot is eversion, or pronation; Hefti 2015, 441. In the midfoot, the first metatarsal bone is in more flexion than the other lateral metatarsals, what accounts additionally for the cavus; Ponseti 1996, 20.
73 Hefti 2015, 439.
74 Ponseti 1996, 21-36. Moreover, there are further structural muscle anomalies; Simons 1994, 42-48.
75 Exner 2005, 3.
76 Tachdjian 1994, vii. Today, scientific comparability of clubfeet has been improved by clinical classification scores; Exner 2005, 37-45; Hefti 2015, 437-438.
77 According to Hefti 2015, 452, the diagnosis of congenital flat foot was only possible by radiography since at least 1914.
78 Hefti 2015, 442.
79 Ponseti 1996, 1; Hefti 2015, 441.
80 Beside flat (valgus) foot, it could be the congenital calcaneovalgus foot, a positional foot deformity in newborns with the foot dorsiflexed at the ankle and valgus, which does not need any treatment (spontaneous resolution). Another possibility could be congenital (posteromedial) bowing of the tibia giving the clinical impression of a valgus foot; see Sponseller 2011, 92-93/98-99.
81 E.g., like Imhäuser 1968, 47: “Ganz offensichtlich hatten die HIPPOKRATIKER unterschieden zwischen dem angeborenen Klumpfuß (verschiedener Stärkegrad), den Klumphaltungen und den erworbenen Klumpfüßen (die wir heute in Klumpfüße durch Lähmungen, Traumen, Entzündungen etc. unterteilen würden). Diese Trennung ist gerechtfertigt und hat nicht an Aktualität verloren. Was dagegen HIPPOKRATES nicht bekannt war, ist der Mißbildungscharakter einiger Klumpfüße (z. B. bei der Arthrogryposis multiplex), die jedoch gegenüber dem sog. muskulären Klumpfüßen an Zahl ganz zurücktreten”.
82 Adams 1849, 556: “In § 62, congenital displacement of the bones of the ankle-joint, that is to say, congenital club-foot, is treated with great precision”, 557: “Several sections of the work are perfect masterpieces”; Gurlt 1898, 266: “wenden wir uns zu dem folgenden [Abschnitt] über Klumpfüsse (62) und deren Behandlung, der so vortrefflich ist, dass wir ihn ganz im Folgenden wiedergeben“, 267: “Wen erinnert die vorstehende Beschreibung der Behandlung von Klumpfüssen junger Kinder nicht an die ganz moderne Behandlung solcher mittelst erhärtender Verbände?”; Debrunner 1936, 102: “Über das Wesentliche dieser mechanischen Behandlungsmethoden sind wir heute nicht hinausgekommen”; Michler 1963, 40: “wie weitgehend sich altes und modernes konservatives Verfahren zur Deckung bringen lassen”; Kollesch 1964, 826: “Es gibt sicher nur wenige Behandlungsmethoden der alten griechischen Medizin, die sich wie die hippokratische Klumpfußbehandlung rühmen können, in ihrer ursprünglichen Form auch in der heutigen Medizin noch angewandt zu werden”; Imhäuser 1968, 48: “Die beschriebene Technik der manuellen Reposition ist nach wie vor als wirksam anzusehen”; Mach 1987, 498: “Wie vor 2000 Jahren gilt auch heute noch bei der Behandlung des kongenitalen Klumpfußes das frühzeitige unblutige schrittweise Verfahren mit manueller Redression und umformenden Verbänden unter bewußter Ausnutzung der funktionellen Anpassungsfähigkeit als Methode der Wahl”; Golder 2007, 158: “Der angeborene Klumpfuß wurde frühzeitig redressiert [...] und in einem geeigneten orthopädischen Schuh fixiert”; Graziati 2009, 153; Hefti 2015, 436 (introducing citation).
83 Artic. 62, sentence 2 (Littré IV,264,2-3; Kühlewein II,212,2-3; Withington 1928, 347): “most cases of club-foot are curable (tà pleîsta toútôn iêsimá estin)”. Mochl.32, sentence 4 (Littré IV,374,13; Kühlewein II,263,4; Withington 1928, ), has only “iêsis”.
84 Artic. 62, sentence 2/3 (Littré IV,264,3-7; Kühlewein II,212,3-8; Withington 1928, 347-348): “[Clubfoot is curable], if deviation is not very great or the children advanced in growth. It is therefore best to treat such cases as soon as possible, before there is any very great deficiency (megálê endeia) in the bones of the foot (tôn ostéôn tôn en tô pódi), and | before the like occurs in the tissues of the leg (tôn sarkôn tôn kata tên knêmên)”.
85 Modified translation of Withington 1928, 349; the numeration is mine.
86 Michler 1963, 20-27 (“Die Redressionsmethode”).
87 Michler 1963, 6,12-13 (Artic. 62, sentence 5), and 11,21-22, transl. Galen (Hipp.Art.Comm.) IV,5: “Dieses (Wadenbein) also befiehlt er, nach innen zu stoßen“; exemplified in picture 1 and 3 as 1a; Michler 1963, 22-23. Michler’s translation is slightly corrected by Irmer 1980, 283.
88 Michler 1963, 6,13-7,1, and 11,23-26, transl. Galen IV,5: “und, während man dies vornimmt, die Ferse nach außen gegenzustoßen [...] ungefähr in Richtung auf das Schienbein zu, weil es in naturgemäßer Stellung der Ferse anliegt“. Exemplified in picture 1 and 3 as 1b; Michler 1963, 22-23.
89 Michler 1963, 12,28-13,3, transl. Galen IV,7: “Vielmehr empfiehlt er, ein wenig mehr darüber hinauszugehen, damit wir infolgedessen ihre hart- | näckige Neigung zur Ausrenkung dadurch, daß wir auf die andere Seite ziehen, (tatsächlich) in der Mittelstellung zur Fixation bringen, was genau im Sinne der natürlichen Stellung war”.
90 Michler 1963, 7,1-3, and 13,12-16, transl. Galen IV,7: “Und da nun also als Leiden die Einwärtskrümmung (des Fußes) entgegengesetzt ist der Auswärtskrümmung, empfiehlt Hippokrates bei der Einrenkung sinngemäß, das Glied solle in die Auswärtskrümmung über die genaue, natürliche Mittelstellung hinausneigen” (Michler’s emphasis). Exemplified in picture 1 (“traditional” interpretation: inward bending of the forefoot) as 2a/b; Michler 1963, 22. After some lengthy philological discussion of egklínein/ekklínein, Michler offers his own final explanation of the method in picture 3 (outward bending) as new 2a/b; Michler 1963, 21-26. In my view, Michler’s subtle “orthopedic” emendation does not change so much the overall meaning, i.e. that the forefoot (positioned in adduction and supination in relation to the hindfoot) is treated by active pronation; see above, note 55.
91 Michler 1963, 7,4-10 (Artic. 62, sentence 6), and 13,23-26, transl. Galen IV,9: “(Hippokrates) nimmt den Korrekturzug vom Kleinzehenrand aus vor, das bedeutet: vom Außenrand des Fußes her, in Richtung auf die Wade, und zwar deshalb, weil er ja einen nach einwärts gekrümmten Fuß behandelt” (Michler’s emphasis).
92 Artic. 62, sentence 8 (Littré IV,266,13-14/16-17; Kühlewein II,213,15/18-19; Withington 1928, 349,28-29/351,3-4): “kêroplastéonta”/“proságein dè ou biaíôs, allà parêgorikôs“); Mochl.32, sentence 4 (Littré IV,374,13; Kühlewein II,263,5; Withington 1928, 431,2: “kêroplasteîn”. See Dobbs 2000, 59; Flashar 2016, 161.
93 Artic. 62, sentence 6-9. Discussed extensively in Michler 1963, 27-41, and illustrated by his pictures 4 and 9. Curiously, all his drawings show always the left leg, with pictures 4 and 9 obviously an adult leg.
94 I only hint here at the major passages in: Off. 7-12, 21-24, Fract. 48, and De medico (Medic.) 3-4, 12.
95 Michler 1963, 59, speculates about a “medical center”, where the necessary number of patients with congenital clubfoot could be treated to get such an experience as it is expressed in Artic. 62.
96 Compare Fract.13 (Littré III,462,5; Kühlewein II, 67,8; Withington 1928, 127): “as a rule two men suffice”.
97 This goes definitely contrary to the medical opinion still valid in the 1960s, e.g., in Michler 1963, 41, and Imhäuser 1968, 50.
98 Döderlein 1999, 40. The only exception is the positional clubfoot, which does not need any treatment, because it will pass away by itself anyway.
99 Ponseti 1996, 37-48; Dobbs 2000; Exner 2005, 7-15. One major early and innovative contribution to clubfoot surgery goes back to Alessandro Codivilla (1861-1912), director of the famous Istituto Ortopedico Rizzoli (1899-1912); Codivilla 1906; Schlösser 1980, 71.
100 On the history of the development of Achillotenotomy, see Hernigou 2017b, Rauschmann 2000.
101 Ponseti 1996, 61-81; Sanzarello 2017, 150-151; Sponseller 2011, 95. I’m practicing this treatment method myself, and have met its promotor and eponym, Ignacio Ponseti (1914-2009), personally during a clubfoot symposium in Zurich in 2005.
102 Ponseti 1996, 62-64, Döderlein 1999, 43-44; Dobbs 2000, 62.
103 Like most of the manual therapies practiced before, especially during the 1950s and 1960s, to which both Michler 1963, 40-41, and Kollesch 1964, 827, are relating; Niehaus – Schlösser 2001, 200. The Ponseti method, developed already in the 1940s in Iowa by Ponseti and his team, was only established as standard therapy of congenital clubfoot since the 2000s.
104 Artic. 62, sentence 11 (Littré IV,268,5-7; Kühlewein II,214,7-9; Withington 1928, 351): “for such cases yield to treatment more rapidly than one would think. Still, time is required for complete success, till the part has acquired growth in its proper position”. E.g., Adams 1849, 560, has stated: “Though there be certain obscurities in some of the expressions which occur in it, its general meaning is sufficiently obvious; and I can attest from ample experience recently acquired in the treatment of this surgical case, that rules of treatment here laid down by our author are very judicious”; see his further remarks at 633, n.3, and 634, n.2.
105 Artic. 62, sentence 9 and 11.
106 Only indirectly one can get notions from Artic. 53 (statements on kullós; see above, note 57), and Artic. 58 (last sentence, Littré IV,254,14-17; Kühlewein II,207,3-7; Withington 1928, 341), on patients with unilateral hip dislocation: “Such patients, then, when they become adults (andrôthôsi), keep the leg raised and contracted, and walk on the other, supported themselves, some with one and some with two crutches (tô ksúlô)”.
107 Artic. 62, sentence 10 (Littré IV,268,3-5; Kühlewein II,214,5-6; Withington 1928, 351): “no need for complicated methods (out‘ allês poikiliês)”. This refers to Artic. 78 (Littré IV,312,2-3; Kühlewein II,236,16-18; Withington 1928, 383): “if he [=the patient] can be made well in many ways, one should choose the least troublesome (tón aochlótaton chrê haireîsthai)”.
108 Artic. 62, sentence 10: “There is no need for incision, cautery (oúte tomês oúte kaúsios)”.
109 Michler 1963, 58; Peltier 1993, 42. The general conclusion that all invasive methods were abandoned at this time in the case of congenital clubfoot (such as in Döderlein 1999, 41, and Exner 2005, 47) is in my view wrong.
110 Döderlein 1999, 63-88; Hefti 2015, 442-450.
111 Craik 2018, 37.
112 Contrary to historical opinions, like that of Imhäuser 1968, 49: “Wir können heute nachweisen, daß der frühbehandelte Klumpfuß in Form und Funktion geheilt werden kann; auch das Wachstum des Fußes wird regelrecht. HIPPOKRATES hat also auch in dieser Frage recht behalten, wenn auch zur Verwirklichung dieses Zieles sehr viel (zuviel) Zeit der Erfahrung und Forschung notwendig war”.
113 Leaving here aside the at times more anachronistic discussion about priority in history, especially history of medicine, as performed so easily by medical practitioners themselves who like to present medical history as some sequence of medical celebrities.
114 Valentin 1961, 5 (still cited by Schlösser 1980, 24): “viele der einschlägigen Arbeiten, welche zwischen 370 v.Chr. [...] und heute liegen, überflüssig sind, weil sie nichts anderes enthalten als das, was schon der Vater der Medizin empfohlen hat”; Michler 1963, 59: “Kos als Geburtsstätte der Klumpfußbehandlung”; Kollesch 1964, 827: “Sehr zu begrüßen ist, daß M.[ichler] diese Beschreibung durch Skizzen und Abbildungen veranschaulicht, weil sie dadurch nicht nur auch dem Laien verständlich wird, sondern auch die Übereinstimmung zwischen der alten und der zum Vergleich herangezogenen modernen Behandlungsmethode besonders deutlich wird”; Imhäuser 1968, 48: ”die Behandlungsvorschriften aus dem Corpus Hippocraticum [haben] bis in die Jetztzeit ihre Bedeutung behalten”.
115 E.g., Artic. 47 (Littré IV, 212,4-5; Kühlewein II, 182,3-5; Withington 1928, 303): “I relate this on purpose; for those things also give good instruction which after trial show themselves failures, and show why they failed”; see Perilli 2018, 142.
116 Schnalke 2000, 195: “Der Brückenschlag zwischen Medizingeschichte und aktueller Medizin war in diesem Ausstellungsprojekt Programm. [...] Der Medizinhistoriker kann gerade die Entwicklungen der letzten 200 Jahre nur dann richtig verstehen, einordnen und interpretieren, wenn er den gegenwärtigen Stand der medizinischen Dinge kennt. Der ärztliche Forscher oder Kliniker hingegen wird in seiner Heilkunst nur dann wirklich weiterkommen, wenn er die historischen Voraussetzungen, Bedingungen und Entwicklungen auf seinem Gebiet wahrnimmt”.
Auteur
Justus-Liebig-Universität Gießen - l_graumann@yahoo.com
Le texte seul est utilisable sous licence Licence OpenEdition Books. Les autres éléments (illustrations, fichiers annexes importés) sont « Tous droits réservés », sauf mention contraire.
Le Thermalisme en Toscane à la fin du Moyen Âge
Les bains siennois de la fin du XIIIe siècle au début du XVIe siècle
Didier Boisseuil
2002
Rome et la Révolution française
La théologie politique et la politique du Saint-Siège devant la Révolution française (1789-1799)
Gérard Pelletier
2004
Sainte-Marie-Majeure
Une basilique de Rome dans l’histoire de la ville et de son église (Ve-XIIIe siècle)
Victor Saxer
2001
Offices et papauté (XIVe-XVIIe siècle)
Charges, hommes, destins
Armand Jamme et Olivier Poncet (dir.)
2005
La politique au naturel
Comportement des hommes politiques et représentations publiques en France et en Italie du XIXe au XXIe siècle
Fabrice D’Almeida
2007
La Réforme en France et en Italie
Contacts, comparaisons et contrastes
Philip Benedict, Silvana Seidel Menchi et Alain Tallon (dir.)
2007
Pratiques sociales et politiques judiciaires dans les villes de l’Occident à la fin du Moyen Âge
Jacques Chiffoleau, Claude Gauvard et Andrea Zorzi (dir.)
2007
Souverain et pontife
Recherches prosopographiques sur la Curie Romaine à l’âge de la Restauration (1814-1846)
Philippe Bountry
2002
Le Thermalisme en Toscane à la fin du Moyen Âge
Les bains siennois de la fin du XIIIe siècle au début du XVIe siècle
Didier Boisseuil
2002
Rome et la Révolution française
La théologie politique et la politique du Saint-Siège devant la Révolution française (1789-1799)
Gérard Pelletier
2004
Sainte-Marie-Majeure
Une basilique de Rome dans l’histoire de la ville et de son église (Ve-XIIIe siècle)
Victor Saxer
2001
Offices et papauté (XIVe-XVIIe siècle)
Charges, hommes, destins
Armand Jamme et Olivier Poncet (dir.)
2005
La politique au naturel
Comportement des hommes politiques et représentations publiques en France et en Italie du XIXe au XXIe siècle
Fabrice D’Almeida
2007
La Réforme en France et en Italie
Contacts, comparaisons et contrastes
Philip Benedict, Silvana Seidel Menchi et Alain Tallon (dir.)
2007
Pratiques sociales et politiques judiciaires dans les villes de l’Occident à la fin du Moyen Âge
Jacques Chiffoleau, Claude Gauvard et Andrea Zorzi (dir.)
2007
Souverain et pontife
Recherches prosopographiques sur la Curie Romaine à l’âge de la Restauration (1814-1846)
Philippe Bountry
2002
