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 Dolfi Herscovici, Jr.
Editor

The Surgical
Management of the
Diabetic Foot and Ankle

123
The Surgical Management
of the Diabetic Foot and Ankle
Dolfi Herscovici, Jr.
Editor

The Surgical
Management
of the Diabetic Foot
and Ankle
Editor
Dolfi Herscovici, Jr.
Foot and Ankle/Trauma Service
Tampa General Hospital
Florida Orthopedic Institute
Tampa, FL, USA

ISBN 978-3-319-27621-2 ISBN 978-3-319-27623-6 (eBook)

DOI 10.1007/978-3-319-27623-6

Library of Congress Control Number: 2016935692

© Springer International Publishing Switzerland 2016

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way,
and transmission or information storage and retrieval, electronic adaptation, computer software,
or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, express or implied, with respect to the material
contained herein or for any errors or omissions that may have been made.

Printed on acid-free paper

This Springer imprint is published by Springer Nature

The registered company is Springer International Publishing AG Switzerland
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This book is dedicated to all of the healthcare providers
currently taking care of, or will provide care to, the diabetic
patient who presents with a problem to their foot or ankle.
Hopefully, this information will give you more insight for
managing these patients. It is also dedicated to those patients
who have allowed us, as contributing authors, a chance to
learn how to provide better options for the management of
diabetic pathology and injuries, enabling diabetics to continue
down the successful road to recovery. With the completion of
this book, there are a few people I would like to specifically
thank. First, I would like to thank the people who helped
mentor me in the art and science of foot and ankle surgery:
Randall E. Marcus, M.D.; V. James Sammarco, M.D.; and
especially to G. James Sammarco, M.D. Thank you all for
explaining things to me I did not understand and having the
patience to answer all of my questions. Second, I would like to
thank all of the authors for their hard work and patience with
the edits. Thank you all for your contributions. Third, I would
like to thank my four boys—Derek, Jake, Brad, and Troy—for
putting up with me when I sequestered myself in my office
editing the manuscripts and for understanding the demands
that it took to complete this job. Lastly, I would like to thank my
beautiful wife, Lisa, who through good times and bad has
always been my biggest supporter, has played the task of my
sounding board for ideas and suggestions, and has also played
the role as my de facto editor.

Dolfi Herscovici, Jr., DO

Foreword

Diabetes, a disease of the world, is as old as the pyramids themselves. In fact,

the earliest reference to the condition dates from the Ebers Papyrus, 1552
BCE, in which the patient was observed “… to eliminate urine which is too
plentiful.” This simple observation characterized the most obvious symptom
of the disease. In India, a diabetic was noted to pass “honey urine” since the
urine attracted ants and flies, and in the second century BCE the word diabe-
tes, “to go through,” was introduced. Two centuries later, symptoms leading
to early death were recorded. By the fifth century CE in India, young thin
diabetics were observed to die earlier than older heavier ones, and in China,
patients were noted to be prone to infection. In Bagdad, diabetics were found
to have sweet urine, increased appetite, gangrene, and sexual dysfunction.
During the Renaissance, recorded observations became more detailed.
Paracelsus recognized that a white residue remained when diabetic urine was
allowed to evaporate. In the Age of Enlightenment, Crowley observed that
some patients with severe abdominal and pancreatic trauma developed diabe-
tes. Dobson recorded sweetness in both urine and in blood serum, deducing
that diabetes is a systemic disease.
In the nineteenth century science expanded the understanding of diabetes
with many more investigators contributing findings. Chevreal associated the
sugar in urine with glucose. Rollo added the descriptor “mellitus,” meaning
honey, to differentiate it from diabetes insipidus. Bernard created a model for
diabetes in the laboratory, while Petters found acetone in the urine of patients
in diabetic coma. Noyes described diabetic retinopathy. Allen deduced that
diabetics used food inefficiently, noting that type 1 diabetics died early while
those with type 2 survived longer. Following Langerhans’ discovery of spe-
cial pancreatic cells, Laguesse linked them to a substance he called hormone,
Greek meaning “set in motion,” which, in 1909, de Mayer named “insulin.”
Prior to the twentieth century, natural medicines such as digitalis and
opium, and techniques such as purging, special diets, starvation, physical
therapies, and behavior modification, had failed to control the disease. But
with advances in chemistry, extracts and other compounds began to appear.
In Germany, Zuelzer used acomatol, a pancreatic extract, to treat diabetic
coma. Other attempts followed including the early sulfonylureas.
In 1922, Frederick Banting, a Canadian orthopedist turned researcher, and
his student, Charles Best, isolated the hormone insulin. The purified extract
was administered to a severely diabetic 14-year-old boy resulting in a dra-
matic decrease in his blood sugar. When this was presented at a medical

vii
viii Foreword

conference, there was a standing ovation. An avalanche of research soon fol-

lowed with the rapid manufacturing of many different forms of insulin, thus
saving the lives of millions. This discovery of insulin had propelled research
into virtually all areas of medicine and surgery.
Better control of the disease, however, led to other problems, due to longer
survival and a more active lifestyle of diabetics. Peripheral neuropathy,
peripheral vascular and cardiac disease, and kidney and eye disease became
more common. Neuroarthropathy of the weight-bearing extremities also
increased in incidence. For example, a diabetic woman, while climbing stairs,
would be surprised to see her foot begin to swell without pain, turn red, and
then would be alarmed to watch her foot collapse within a few days. Her doc-
tor would diagnose a “simple fracture” and treat it in “the standard manner.”
The deformity would then progress into “the worst arthritis you have ever
seen.” Closed or open treatment, using the current “acceptable standard of
care,” would result in nonunion or malunion with subsequent foot ulcers and
osteomyelitis leading to possible amputation.
When Jean Martin Charcot described neuropathic deformity, he associated
it with late-stage syphilis, but these patients were not syphilitic. Early case
reports of diabetic Charcot foot and ankle neuroarthropathy now began to
appear in medical literature more frequently. Treatment with nonsurgical
modalities such as rest, limited weight-bearing, bracing, and modified foot-
wear were standard. Surgical treatment generally consisted of soft tissue
debridement and limb amputation.
In the 1950s Paul Brand, at the Carville National Leprosarium, began
using total contact casting to off-weight neuropathic foot ulcers in patients
with Hanson’s disease. This soon became a modality also for treating diabetic
foot ulcers. Total contact casting could help prevent or at least control col-
lapse of an asensory foot or ankle. But it was not a panacea. In the 1980s,
surgical treatment expanded beyond exostectomy, Achilles tenotomy,
arthrodesis, and amputation to include reconstruction, as a means of limb
salvage. Orthopedic researchers along with vascular surgeons became part of
a broad group of diabetic specialists who contributed to reducing the need for
major amputation. The introduction of external fixation as a part of the tech-
nique in controlling deep infection, reducing deformity, and maintaining limb
viability has been remarkable. Likewise staged surgery, intramedullary rods,
and locking screw-plate fixation are now in the orthopedic surgeon’s arma-
mentarium for salvaging severe foot and ankle collapse. Allografts, bone
growth stimulators, bone growth hormone, bone substitutes, and wound suc-
tion devices are also used to fill bony gaps and promote wound healing.
The disease of diabetes has been a focus of physicians and surgeons for
millennia. This book presents current information on diagnosis, treatment,
and prevention of the foot and ankle orthopedic complications related to the
disease. Advances in research will continue to improve our understanding of
this common ailment. The experts offer the special knowledge and skills
developed over recent decades here as a guide to orthopedic surgeons as they
seek to improve care for their patients.

G. James Sammarco
Foreword ix

References
Jacek Z, Shrestha A, et al. Chapter 1: The main events in the history of diabetes. In:
Poretsky L, editors. Principles of diabetes mellitus. 2nd ed. New York: Springer; 2009.
Charcot J-M, Fere C. Affections osseuses et articulaires du pied chez les tabétiques (Pied
tabétique). Archives de Neurologie. 1883;6:305–319 [in French].
Explore https://textbookfull.com now to access a wide range
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Preface

All progress has resulted from people who took unpopular positions.
Adlai Stevenson (1954)

According to the National Center for Health Statistics, in 1900 the life
expectancy in the United States approached 47 years. Of the ten most com-
mon causes leading to death in 1900, six were due to infectious diseases with
strokes, accidents, cancer, and senility contributing to the final four reasons
that someone died. By 1949, the life expectancy had increased to 68 years,
and diabetes mellitus was identified as the tenth most common cause leading
to death. By 2013, the life expectancy increased to almost 79 years with dia-
betes then listed as the seventh most common cause leading to someone’s
death. This indicates that diabetes is certainly a disease of the late twentieth
and early twenty-first centuries. In fact, a report from the World Health
Organization recognizes diabetes as a growing epidemic affecting almost
350 million people worldwide. What does this mean to us, as physicians who
treat and manage diseases of the musculoskeletal system? It means that
because people are living longer, we can expect to see more patients present
with chronic conditions or injuries that are specifically caused or affected by
their diabetes.
Foot and ankle problems produce serious long-term complications, and
any anatomical abnormality can progress to an ulceration, infection, or gan-
grene. These problems are often caused by a combination of such factors as
peripheral neuropathy, vascular disease, immobile joints, an impaired ability
to heal or fight infections, poor management of their diabetes, or outright
denial of their medical problems. That these problems are costly to manage is
implied because these patients often require lengthy and expensive hospital-
izations, which may lead to an amputation.
When a diabetic patient presents with a significant foot or ankle problem,
there are still many physicians who continue to offer only conservative care
or amputation as option. In fact, this approach has not significantly changed
over the last 30–40 years, even though it can ultimately lead to a poor out-
come. There are a few reasons for this. First, the literature is replete with
studies discussing higher rates and more significant complications in diabet-
ics than in the control population. Second, most treating physicians rarely see
these patients and thus have little experience in managing these problems.
Third, there may be a significant hesitancy in offering a surgery, which can

xi
xii Preface

lead to a bad outcome and potential medicolegal issues. Fourth, physicians

often fail to understand that the patients’ associated comorbidities need to be
preoperatively assessed and managed in order to avoid greater problems.
Lastly, for a lot of surgeons their surgical approach that is used to manage a
diabetic patient is similar to techniques used to care for a nondiabetic patient,
often leading to failure of fixation and producing higher rates of morbidity
and mortality. Given these reasons, it is understandable that physicians are
tentative about managing these patients surgically.
This text has been put together to act as a reference guide, with up-to-date
chapter references for the problems associated with the diabetic foot and
ankle. It is also intended to function as a primer with the most current con-
cepts of epidemiology, pathophysiology, workups needed, and treatments
available for the diabetic who presents with abnormalities or injuries to their
foot and ankle. In addition, a glossary has been provided so that the reader
can understand some of the terms used throughout the text. A major strength
of this book is that authors who were solicited are recognized as leading
authorities when it comes to managing problems of the foot and ankle. This
has been demonstrated in some of the treatment chapters with the authors
providing their preferred step-by-step approach for the management of some
of the more commonly encountered foot and ankle problems. By providing a
better understanding of diabetes, and offering improved techniques for man-
aging these patients, we should be able to demonstrate improved outcomes.
This can produce happier patients and families, lower hospital usage, and
decreased overall medical expenses, and it may also allow patients to main-
tain more active lifestyles and potentially return them into the workforce. As
we advance through this century, it is hoped that the information provided in
this text will help all healthcare professionals tasked with caring for the dia-
betic patient who presents with problems to their foot and ankle.

Temple Terrace, FL, USA Dolfi Herscovici, Jr.

Acknowledgments

When I accepted the offer from Springer to put this book together, I knew that
it would be a difficult project. Given the contributions from many authors,
I knew that there were certain technical aspects that I needed to finish this
project. With his input and skills, I would like to acknowledge my son Derek
M. Herscovici for his assistance in helping me prepare and organize this text.
Thanks for all your technical expertise downloading and formatting all of the
incoming information sent to me and making sure that I had everything I
needed to complete this book.

xiii
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Contents

1 Introduction, Demographics, and Epidemiology

of Diabetes...................................................................................... 1
Erin A. Baker and Paul T. Fortin
2 Pathophysiology of Diabetes and Charcot
Neuroarthropathy ......................................................................... 9
Sandeep P. Soin, Joshua G. Hunter, and Stephen L. Kates
3 Evaluation and Management of Vascular Disease
in the Diabetic Patient .................................................................. 19
Erin Green and Brad Johnson
4 Classification of Diabetic Foot Disease........................................ 29
Ross Taylor
5 Nonoperative Care and Footwear for the Diabetic
Foot and Ankle Patient ................................................................. 51
David E. Karges
6 The Diagnosis and Treatment of Diabetic
Foot Infections ............................................................................... 67
Michael S. Pinzur
7 Management of Acute Hindfoot Fractures
in Diabetics .................................................................................... 85
Stefan Rammelt
8 Management of Acute Diabetic Fractures of the Ankle ............ 103
Dolfi Herscovici, Jr. and Julia M. Scaduto
9 Plate Fixation Techniques for Midfoot
and Forefoot Charcot Arthropathy ............................................. 117
Eric W. Tan and Lew C. Schon
10 Treatment of Charcot Midfoot Deformity
by Arthrodesis Using Long Axial Screws ................................... 133
V. James Sammarco
11 Management of the Charcot Ankle ............................................. 143
John S. Early

xv
Discovering Diverse Content Through
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The text on this page is estimated to be only 29.08%
accurate

SYMBOLISM OF MOTHER AND OF REBIRTH 261 the incest

wish into symbolic acts and symbolic concepts which cheat men, as
it were, so that heaven appears to them as a father and earth as a
mother and the people upon it children and brothers and sisters.
Thus man can remain a child for all time and satisfy his incest wish
all unawares. This state would doubtless be ideal 40 if it were not
infantile and, there fore, merely a one-sided wish, which maintains a
childish attitude. The reverse is anxiety. Much is said of pious people
who remain unshaken in their trust in God and wander unswervingly
safe and blessed through the world. I have never seen this Chidher
yet. It is probably a wish figure. The rule is great uncertainty among
believers, which they drown with fanatical cries among themselves
or among others ; moreover, they have religious doubts, moral
uncertainty, doubts of their own personality, feelings of guilt and,
deepest of all, great fear of the opposite aspect of reality, against
which the most highly intelligent people struggle with all their force.
This other side is the devil, the adversary or, expressed in modern
terms, the corrective of reality, of the infantile world picture, which
has been made acceptable through the predominating pleasure
principle.41 But the world is not a garden of God, of the Father, but
a place of terrors. Not only is heaven no father and earth no mother
and the people not brothers nor sisters, but they represent hostile,
destroying powers, to which we are abandoned the more surely, the
more childishly and thoughtlessly we have entrusted ourselves to the
so-called Fatherly hand of God. One should never forget the harsh
speech of the first Na 
The text on this page is estimated to be only 29.05%
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262 PSYCHOLOGY OF THE UNCONSCIOUS poleon, that the

good God is always on the side of the heaviest artillery. The religious
myth meets us here as one of the greatest and most significant
human institutions which, despite misleading symbols, nevertheless
gives man assurance and strength, so that he may not be
overwhelmed by the monsters of the universe. The symbol,
considered from the standpoint of actual truth, is misleading, indeed,
but it is psychologically true*2 because it was and is the bridge to all
the greatest achievements of humanity. But this does not mean to
say that this unconscious way of transformation of the incest wish
into religious exercises is the only one or the only possible one.
There is also a conscious recognition and understanding with which
we can take possession of this libido which is bound up in incest and
transformed into religious exercises so that we no longer need the
stage of religious symbolism for this end. It is thinkable that instead
of doing good to our fellow-men, for " the love of Christ," we do it
from the knowledge that humanity, even as ourselves, could not
exist if, among the herd, the one could not sacrifice himself for the
other. This would be the course of moral autonomy, of perfect
freedom, when man could without compulsion wish that which he
must do, and this from knowledge, without delusion through belief
in the religious symbols. It is a positive creed which keeps us
infantile and, therefore, ethically inferior. Although of the greatest
significance from the cultural point of view and of imperishable
beauty from the aesthetic standpoint, this
The text on this page is estimated to be only 28.90%
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SYMBOLISM OF MOTHER AND OF REBIRTH 263 delusion

can no longer ethically suffice humanity striving after moral
autonomy. The infantile and moral danger lies in belief in the symbol
because through that we guide the libido to an imaginary reality. The
simple negation of the symbol changes nothing, for the entire
mental disposition remains the same ; we merely remove the
dangerous object. But the object is not dangerous; the danger is our
own infantile mental state, for love of which we have lost something
very beautiful and ingenious through the simple abandonment of the
religious symbol. I think belief should be replaced by understanding;
then we would keep the beauty of the symbol, but still remain free
from the depressing results of submission to belief. This would be
the psychoanalytic cure for belief and disbelief. The vision following
upon that of the city is that of a " strange fir tree with gnarled
branches." This vision does not seem extraordinary to us after all
that we have learned of the tree of life and its associations with the
city and the waters of life. This especial tree seems simply to
continue the category of the mother symbols. The attribute " strange
" probably signifies, as in dreams, a special emphasis, that is, a
special underlying complex material. Unfortunately, the author gives
us no individual material for this. As the tree already suggested in
the symbolism of the city is particularly emphasized through the
further development of Miss Miller's visions
The text on this page is estimated to be only 28.64%
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264 PSYCHOLOGY OF THE UNCONSCIOUS here, I find it

necessary to discuss at some length the history of the symbolism of
the tree. It is well known that trees have played a large part in the
cult myth from the remotest times. The typical myth tree is the tree
of paradise or of life which we discover abundantly used in
Babylonian and also in Jewish lore; and in prechristian times, the
pine tree of Attis, the tree or trees of Mithra; in Germanic mythology,
Ygdrasil and so on. The hanging of the Attis image on the pine tree;
the hanging of Marsyas, which became a celebrated artistic motive ;
the hanging of Odin ; the Germanic hanging sacrifices — indeed, the
whole series of hanged gods — teaches us that the hanging of Christ
on the cross is not a unique occurrence in religious mythology, but
belongs to the same circle of ideas as others. In this world of
imagery the cross of Christ is the tree of life, and equally the wood
of death. This contrast is not astounding. Just as the origin of man
from trees was a legendary idea, so there were also burial customs,
in which people were buried in hollow trees. From that the German
language retains even now the expression " Totenbaum " (tree of
death) for a coffin. Keeping in mind the fact that the tree is
predominantly a mother symbol, then the mystic significance of this
manner of burial can be in no way incomprehensible to us. The dead
are delivered back to the mother for rebirth. We encounter this
symbol in the Osiris myth, handed down by Plutarch,43 which is, in
general, typical in various aspects. Rhea is pregnant with Osiris; at
the same time also with Isis; Osiris and Isis mate even in the
mother's womb (motive of the night
The text on this page is estimated to be only 28.01%
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SYMBOLISM OF MOTHER AND OF REBIRTH 265 journey on

the sea with incest). Their son is Arueris, later called Horus. It is said
of Isis that she was born "in absolute humidity" (rsraprr^ 6s rfjv
"laiv ev navvypoi? yevssdai *). It is said of Osiris that a certain
Pamyles in Thebes heard a voice from the temple of Zeus while
drawing water, which commanded him to proclaim that Osiris was
born }i£yas fiaffiXevz evspysnj? "OGipis.\ In honor of this the
Pamylion were celebrated. They were similar to the phallophorion.
Pamyles is a phallic 'demon, similar to the original Dionysus. The
myth reduced reads: Osiris and Isis were generated by phallus from
the water (mother womb) in the ordinary manner. (Kronos had made
Rhea pregnant, the relation was secret, and Rhea was his sister.
Helios, however, observed it and cursed the relation.) Osiris was
killed in a crafty manner by the god of the underworld, Typhon, who
locked him in a chest. He was thrown into the Nile, and so carried
out to sea. Osiris, however, mated in the underworld with his second
sister, Nephthys (motive of the night journey to the sea with incest).
One sees here how the symbolism is developed. In the mother
womb, before the outward existence, Osiris commits incest; in
death, the second intrauterine existence, Osiris again commits
incest. Both times with a sister who is simply substituted for the
mother as a legal, uncensured symbol, since the marriage with a
sister in early antiquity was not merely tolerated, but was really
commended. Zarathustra also recommended the marriage of
kindred. This * In the fourth place Isis was born in absolute
humidity, t The great beneficent king, Osiris.
The text on this page is estimated to be only 28.70%
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266 PSYCHOLOGY OF THE UNCONSCIOUS form of myth

would be impossible to-day, because cohabitation with the sister,
being incestuous, would be repressed. The wicked Typhon entices
Osiris craftily into a box or chest; this distortion of the true state of
affairs is transparent. The u original sin " caused men to wish to go
back into the mother again, that is, the incestuous desire for the
mother, condemned by law, is the ruse supposedly invented by
Typhon. The fact is, the ruse is very significant. Man tries to sneak
into rebirth through subterfuge in order to become a child again. An
early Egyptian hymn 44 even raises an accusation against the
mother Isis because she destroys the sun-god Re by treachery. It
was interpreted as the ill-will of the mother towards her son that she
banished and betrayed him. The hymn describes how Isis fashioned
a snake, put it in the path of Re, and how the snake wounded the
sun-god with a poisonous bite, from which wound he never
recovered, so that finally he had to retire on the back of the
heavenly cow. But this cow is the cowheaded goddess, just as Osiris
is the bull Apis. The mother is accused as if she were the cause of
man flying to the mother in order to be cured of the wound which
she had herself inflicted. This wound is the prohibition of incest.45
Man is thus cut off from the hopeful certainty of childhood and early
youth, from all the unconscious, instinctive happenings which permit
the child to live as an appendage of his parents, unconscious of
himself. There must be contained in this many sensitive memories of
the animal age, where there was not any " thou shalt " and " thou
shalt not," but all was just
The text on this page is estimated to be only 28.41%
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SYMBOLISM OF MOTHER AND OF REBIRTH 267 simple

occurrence. Even yet a deep animosity seems to live in man because
a brutal law has separated him from the instinctive yielding to his
desires and from the great beauty of the harmony of the animal
nature. This separation manifested itself, among other things, in the
incest prohibition and its correlates (laws of marriage, etc.) ;
therefore pain and anger relate to the mother, as if she were
responsible for the domestication of the sons of men. In order not to
become conscious of his incest wish (his backward harking to the
animal nature), the son throws all the burden of the guilt on the
mother, from which arises the idea of the " terrible mother." 46 The
mother becomes for him a spectre of anxiety, a nightmare.47 After
the completed " night journey to the sea,1' the chest of Osiris was
cast ashore by Byblos, and lay in the branches of an Erica, which
grew around the coffin and became a splendid tree. The king of the
land had the tree placed as a column under his roof.48 During this
period of Osiris's absence (the winter solstice) the lament customary
during thousands of years for the dead god and his return occurs,
and its evpecri? is a feast of joy. A passage from the mournful quest
of Isis is especially noteworthy : " She flutters like a swallow
lamenting around the column, which encloses the god sleeping in
death." (This same motive returns in the Kyffhauser saga.) Later on
Typhon dismembers the corpse and scatters the pieces. We come
upon the motive of dismember 
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268 PSYCHOLOGY OF THE UNCONSCIOUS ment in

countless sun myths,49 namely, the inversion of the idea of the
composition of the child in the mother's womb.50 In fact, the
mother Isis collects the pieces of the body with the help of the
jackal-headed Anubis. (She finds the corpse with the help of dogs.)
Here the nocturnal devourers of bodies, the dogs and jackals,
become the assistants of the composition, of the reproduction." The
Egyptian vulture owes its symbolic meaning as mother to this
necrophagic habit. In Persian antiquity the corpses were thrown out
for the dogs to devour, just as to-day in the Indian funeral pyres the
removal of the carcasses is left to the vultures. Persia was familiar
with the custom of leading a dog to the bed of one dying,
whereupon the latter had to present the dog with a morsel.52 The
custom, on its surface, evidently signifies that the morsel is to
belong to the dog, so that he will spare the body of the dead,
precisely as Cerberus was soothed by the honey-cakes which
Hercules gave to him in the journey to hell. But when we bear in
mind the jackalheaded Anubis who rendered his good services in the
gathering together of the dismembered Osiris, and the mother
significance of the vulture, then the question arises whether
something deeper was not meant by this ceremony. Creuzer has also
concerned himself with this idea, and has come to the conclusion
that the astral form of the dog ceremony, that is, the appearance of
Sirius, the dog star, at the period of the sun's highest position, is
related to this in that the introduction of the dog has a
compensatory significance, death being thereby made, re 
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FRUCTIFICATION FOLLOWING UPON THE MITHRAIC

SACRIFICE
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SYMBOLISM OF MOTHER AND OF REBIRTH 269 versedly,

equal to the sun's highest position. This is quite in conformity with
psychologic thought, which results from the very general fact that
death is interpreted as entrance into the mother's womb (rebirth).
This interpretation would seem to be supported by the otherwise
enigmatic function of the dog in the Sacrificium Mithriacum. In the
monuments a dog always leaps up upon the bull killed by Mithra.
However, this sacrifice is probably to be interpreted through the
Persian legend, as well as through the monument, as the moment of
the highest fecundity. The most beautiful expression of this is seen
upon the magnificent Mithra relief of Heddernheim. Upon one side of
a large stone slab (formerly probably rotating) is seen the
stereotyped overthrowing and sacrifice of the bull, but upon the
other side stands Sol, with a bunch of grapes in his hand, Mithra
with the cornucopia, the Dadophores with fruits, corresponding to
the legend that all fecundity proceeds from the dead bull of the
world, fruits from the horns, wine from its blood, grain from the tail,
cattle from its sperma, leek from its nose, and so on. Silvanus stands
above this scene with the animals of the forest arising from him. The
significance suspected by Creuzer might very easily belong to the
dog in this connection.53 Let us now turn back to the myth of Osiris.
In spite of the restoration of the corpse accomplished by Isis, the
resuscitation succeeds only incompletely in so far as the phallus of
Osiris cannot again be produced, because it was eaten by the fishes;
the power of life was wanting.54 Osiris as a phantom once more
impregnated Isis, but the fruit is Harpocrates,
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270 PSYCHOLOGY OF THE UNCONSCIOUS who was feeble

in TOIZ Haroodsv yviois (in the lower limbs), that is, corresponding
to the significance of yvlov (at the feet). (Here, as is plainly evident,
foot is used in the phallic meaning.) This incurability of the setting -
sun corresponds to the incurability of Re in the above-mentioned
older Egyptian sun hymn. Osiris, although only a phantom, now
prepares the young sun, his son Horus, for a battle with Typhon, the
evil spirit of darkness. Osiris and Horus correspond to the fatherson
symbolism mentioned in the beginning, which symbolic figure,
corresponding again to the above formulation,55 is flanked by the
well-formed and ugly figures of Horus and Harpocrates, the latter
appearing mostly as a cripple, often represented distorted to a mere
caricature.58 He is confused in the tradition very much with Horus,
with whom he also has the name in common. Hor-pichrud, as his
real name 57 reads, is composed from chrud, " child," and Hor, from
the adjective hri — up, on top, and signifies the up-coming child, as
the rising sun, and opposed to Osiris, who personifies the setting
sun — the sun of the west. Thus Osiris and Horpichrud or Horus are
one being, both husband and son of .the same mother, Hathor-Isis.
The Chnum-Ra, the sun god of lower Egypt, represented as a ram,
has at his side, as the female divinity of the land, Hatmehit, who
wears the fish on her head. She is the mother and wife of Bi-neb-did
(Ram, local name of Chnum-Ra). In the hymn of Hibis,58 Amon-ra
was invoked: "Thy (Chum-Ram) dwells in Mendes, united as the
quadruple god Thmuis. He is the phallus, the lord of the gods. The
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SYMBOLISM OF MOTHER AND OF REBIRTH 271 bull of his

mother rejoices in the cow (ahet, the mother) and man fructifies
through his semen." In further inscriptions Hatmehit was directly
referred to as the " mother of Mendes." (Mendes is the Greek form
of Bi-neb-did: ram.) She is also invoked as the " Good," with the
additional significance of ta-nofert, or " young woman." The cow as
symbol of the mother is found in all possible forms and variations of
HathorIsis, and also in the female Nun (parallel to this is the
primitive goddess Nit or Neith), the protoplasm which, related to the
Hindoo Atman,59 is equally of masculine and feminine nature. Nun
is, therefore, invoked as Amon,60 the original water,61 which is in
the beginning. He is also designated as the father of fathers, the
mother of mothers. To this corresponds the invocation to the female
side of Nun-Amon, of Nit or Neith. " Nit, the ancient, the mother of
god, the mistress of Esne, the father of fathers, the mother of
mothers, who is the beetle and the vulture, the being in its
beginning. " Nit, the ancient, the mother who bore the light god, Ra,
who bore first of all, when there was nothing which brought forth. "
The cow, the ancient, which bore the sun, and then laid the germ of
gods and men." The word " nun " has the significance of young,
fresh, new, also the on-coming waters of the Nile flood. In a
transferred sense " nun " was also used for the chaotic primitive
waters; in general for the primitive generating matter 62 which was
personified by the goddess Nunet. From her Nut sprang, the
goddess of heaven, who was
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272 PSYCHOLOGY OF THE UNCONSCIOUS represented

with a starry body, and also as the heavenly cow with a starry body.
When the sun-god, little by little, retires on the back of the heavenly
cow, just as poor Lazarus returns into Abraham's bosom, each has
the same significance; they return into the mother, in order to rise as
Horus. Thus it can be said that in the morning the goddess is the
mother, at noon the sister-wife and in the evening again the mother,
who receives the dying in her lap, reminding us of the Fieri of
Michelangelo. As shown by the illustration (from Dideron's "
Iconographie Chretienne "), this thought has been transferred as a
whole into Christianity. Thus the fate of Osiris is explained: he
passes into the mother's womb, the chest, the sea, the tree, the
column of Astartes; he is dismembered, re-formed, and reappears
again in his son, Hor-pi-chrud. Before entering upon the further
mysteries which the beautiful myth reveals to us, there is still much
to be said about the symbol of the tree. Osiris lies in the branches of
the tree, surrounded by them, as in the mother's womb. The motive
of embracing and entwining is often found in the sun myths,
meaning that it is the myth of rebirth. A good example is the
Sleeping Beauty, also the legend of the girl who is enclosed between
the bark and the trunk, but who is freed by a youth with his horn.63
The horn is of gold and silver, which hints at the sunbeam in the
phallic meaning. (Compare the previous legend of the horn.) An
exotic legend tells of the sun-hero, how he must be freed from the
plant entwining around him.64
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SYMBOLISM OF MOTHER AND OF REBIRTH 273 A girl

dreams of her lover who has fallen into the water; she tries to save
him, but first has to pull seaweed and sea-grass from the water;
then she catches him. In an African myth the hero, after his act,
must first be disentangled from the seaweed. In a Polynesian myth
the hero's ship was encoiled by the tentacles of a gigantic polyp.
Re's ship is encoiled by a night serpent on its night journey on the
sea. In the poetic rendering of the history of Buddha's birth by Sir
Edwin Arnold ("The Light of Asia," p. 5) the motive of an embrace is
also found : " Queen Maya stood at noon, her days fulfilled, Under a
Palso in the palace grounds, A stately trunk, straight as a temple
shaft, With crown of glossy leaves and fragrant blooms; And
knowing the time come — for all things knew — The conscious tree
bent down its boughs to make A bower about Queen Maya's
majesty: And earth put forth a thousand sudden flowers To spread a
couch: while ready for the bath The rock hard by gave out a limpid
stream Of crystal flow. So brought she forth the child." 65 We come
across a very similar motive in the cult legend of the Samian Hera.
Yearly it was claimed that the image disappeared from the temple,
was fastened somewhere on the seashore on a trunk of a Lygos tree
and wound about with its branches. There it was u found," and was
treated with wedding-cake. This feast is undoubtedly a iepo? ydfjios
(ritual marriage), because in Samos there was a legend that Zeus
had first had a longcontinued secret love relation with Hera. In
Plataea
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274 PSYCHOLOGY OF THE UNCONSCIOUS and Argos, the

marriage procession was represented with bridesmaids, marriage
feast, and so on. The festival took place in the wedding month "
raprfhiGov" (beginning of February). But in Plataea the image was
previously carried into a lonely place in the wood; approximately
corresponding to the legend of Plutarch that Zeus had kidnapped
Hera and then had hidden her in a cave of Cithaeron. According to
our deductions, previously made, we must conclude from this that
there is still another train of thought, namely, the magic charm of
rejuvenation, which is condensed in the Hierosgamos. The
disappearance and hiding in the wood, in the cave, on the seashore,
entwined in a willow tree, points to the death of the sun and rebirth.
The early springtime Fa}Mi\iGov (the time of Marriage) in February
fits in with that very well. In fact, Pausanias informs us that the
Argivan Hera became a maiden again by a yearly bath in the spring
of Canathos. The significance of the bath is emphasized by the
information that in the Plataeian cult of Hera Teleia, Tritonian
nymphs appeared as water-carriers. In a tale from the Iliad, where
the conjugal couch of Zeus upon Mount Ida is described, it is said:66
" The son of Saturn spake, and took his wife Into his arms, while
underneath the pair, The sacred Earth threw up her freshest herbs:
The dewy lotos, and the crocus-flower, And thick and soft the
hyacinth. All these Upbore them from the ground. Upon this couch
They lay, while o'er them a bright golden cloud Gathered and shed
its drops of glistening dew.
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SYMBOLISM OF MOTHER AND OF REBIRTH 275 So

slumbered on the heights of Gargarus The All-Father overcome by
sleep and love, And held his consort in his arms." — Trans, by W. C.
Bryant. Drexler recognizes in this description an unmistakable
allusion to the garden of the gods on the extreme western shore of
the ocean, an idea which might have been taken from a Prehomeric
Hierosgamos hymn. This western land is the land of the setting sun,
whither Hercules, Gilgamesh, etc., hasten with the sun, in order to
find there immortality, where the sun and the maternal sea unite in
an eternally rejuvenating intercourse. Our supposition of a
condensation of the Hierosgamos with the myth of rebirth is
probably confirmed by this. Pausanias mentions a related myth
fragment where the statue of Artemis Orthia is also called
Lygodesma (chained with willows), because it was found in a willow
tree; this tale seems to be related to the general Greek celebration
of Hierosgamos with the above-mentioned customs.67 The motive of
the u devouring " which Frobenius has shown to be a regular
constituent of the sun myths is closely related to this (also
metaphorically). The "whale dragon'1 (mother's womb) always
"devours" the hero. The devouring may also be partial instead of
complete. A six-year-old girl, who goes to school unwillingly, dreams
that her leg is encircled by a large red worm. She had a tender
interest for this creature, contrary to what might be expected. An
adult patient, who cannot separate from an older friend on account
of an extraordi 
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276 PSYCHOLOGY OF THE UNCONSCIOUS narily strong

mother transference, dreams that " she had to get across some deep
water (typical idea!) with this friend; her friend fell in (mother
transference) ; she tries to drag her out, and almost succeeds, but a
large crab seizes on the dreamer by the foot and tries to pull her in."
Etymology also confirms this conception : There is an Indo-Germanic
root velu-, vet-, with the meaning of u encircling, surrounding,
turning." From this is derived Sanskrit val, valati = to cover, to
surround, to encircle, to encoil (symbol of the snake) ; valli =
creeping plant; uluta = boa-constrictor = Latin voliitus, Lithuanian
velu, velti = wickeln (to roll up); Church Slavonian vlina — Old High
German, wella = Welle (wave or billow) . To the root velu also
belongs the root vivo, with the meaning " cover, corium, womb."
(The serpent on account of its casting its skin is an excellent symbol
of rebirth.) Sanskrit ulva, ulba has the same meaning; Latin volva,
volvula, vulva. To velu also belongs the root ulvord, with the
meaning of " fruitful field, covering or husk of plants, sheath."
Sanskrit urvdrd = sown field. Zend urvara = plant. (See the
personification of the ploughed furrow.) The same root vel has also
the meaning of " wallen " (to undulate) . Sanskrit ulmuka —
conflagration. Fa\ea, Fs.\oL) Gothic vulan = wallen (to undulate).
Old High German and Middle High German walm = heat, glow.68 It
is typical that in the state of " involution " the hair of the sun-hero
always falls out from the heat. Further the root vel is found with the
meaning 41 to sound,69 and to will, to wish " (libido!).
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SYMBOLISM OF MOTHER AND OF REBIRTH 277 The motive

of encoiling is mother symbolism.70 This is verified by the fact that
the trees, for example, bring forth again (like the whale in the
legend of Jonah). They do that very generally, thus in the Greek
legend the Mshiai vvjjupai* of the ash trees are the mothers of the
race of men of the Iron Age. In northern mythology, Askr, the ash
tree, is the primitive father. His wife, Embla, is the " Emsige," the
active one, and not, as was earlier believed, the aspen. Askr
probably means, in the first place, the phallic spear of the ash tree.
(Compare the Sabine custom of parting the bride's hair with the
lance.) The Bundehesh symbolizes the first people, Meschia and
Meschiane, as the tree Reivas, one part of which places a branch in
a hole of the other part. The material which, according to the
northern myth, was animated by the god when he created men 71 is
designated as ire = wood, tree.72 I recall also v\rj = wood, which in
Latin is called materia. In the wood of the " world-ash," Ygdrasil, a
human pair hid themselves at the end of the world, from whom
sprang the race of the renewed world.73 The Noah motive is easily
recognized in this conception (the night journey on the sea) ; at the
same time, in the symbol of Ygdrasil, a mother idea is again
apparent. At the moment of the destruction of the world the " world-
ash " becomes the guardian mother, the tree of death and life, one
te fyxolmorf9 1 74 This function of rebirth of the " world-ash " also
helps to elucidate the representation met with in the Egyptian Book
of the *Mdian Virgins. t Pregnant.
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278 PSYCHOLOGY OF THE UNCONSCIOUS Dead, which is

called u the gate of knowledge of the soul of the East " : " I am the
pilot in the holy keel, I am the steersman who allows no rest in the
ship of Ra.76 I know that tree of emerald green from whose midst
Ra rises to the height of the clouds."76 Ship and tree of the dead
(death ship and death tree) are here closely connected. The
conception is that Ra, born from the tree, ascends (Osiris in the
Erika). The representation of the sun-god Mithra is probably
explained in the same way. He is represented upon the Heddernheim
relief, with half his body arising from the top of a tree. (In the same
way numerous other monuments show Mithra half embodied in the
rock, and illustrate a rock birth, similar to Men.) Frequently there is a
stream near the birthplace of Mithra. This conglomeration of symbols
is also found in the birth of Aschanes, the first Saxon king, who grew
from the Harz rocks, which are in the midst of the wood 77 near a
fountain.78 Here we find all the mother symbols united — earth,
wood, water, three forms of tangible matter. We can wonder no
longer that in the Middle Ages the tree was poetically addressed with
the title of honor, " mistress." Likewise it is not astonishing that the
Christian legend transformed the tree of death, the cross, into the
tree of life, so that Christ was often represented on a living and fruit-
bearing tree. This reversion of the cross symbol to the tree of life,
which even in Babylon was an important and authentic religious
symbol, is also considered entirely probable by Zockler,79 an
authority
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CHRIST ON THE TREE OF LIFE

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SYMBOLISM OF MOTHER AND OF REBIRTH 279 on the

history of the cross. The pre-Christian meaning of the symbol does
not contradict this interpretation; on the contrary, its meaning is life.
The appearance of the cross in the sun worship (here the cross with
equal arms, and the swastika cross, as representative of the sun's
rays), as well as in the cult of the goddess of love (Isis with the crux
ansata, the rope, the speculum veneris 9 , etc. ) , in no way
contradicts the previous historical meaning. The Christian legend has
made abundant use of this symbolism. The student of mediaeval
history is familiar with the representation of the cross growing above
the grave of Adam. The legend was that Adam was buried on
Golgotha. Seth had planted on his grave a branch of the " paradise
tree," which became the cross and tree of death of Christ.80 We all
know that through Adam's guilt sin and death came into the world,
and Christ through his death has redeemed us from the guilt. To the
question in what had Adam's guilt consisted it is said that the
unpardonable sin to be expiated by death was that he dared to pick
a fruit from the paradise tree.81 The results of this are described in
an Oriental legend. One to whom it was permitted to cast one look
into Paradise after the fall saw the tree there and the four streams.
But the tree was withered, and in its branches lay an infant. (The
mother had become pregnant.82) This remarkable legend
corresponds to the Talmudic tradition that Adam, before Eve, already
possessed a demon wife, by name Lilith, with whom he quarrelled
for mastership. But Lilith raised herself into the air through
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28o PSYCHOLOGY OF THE UNCONSCIOUS the magic of the

name of God and hid herself in the sea. Adam forced her back with
the help of three angels.83 Lilith became a nightmare, a Lamia, who
threatened those with child and who kidnapped the newborn child.
The parallel myth is that of the Lamias, the spectres of the night,
who terrified the children. The original legend is that Lamia enticed
Zeus, but the jealous Hera, however, caused Lamia to bring only
dead children into the world. Since that time the raging Lamia is the
persecutor of children, whom she destroys wherever she can. This
motive frequently recurs in fairy tales, where the mother often
appears directly as a murderess or as a devourer of men; 84 a
German paradigm is the well-known tale of Hansel and Gretel. Lamia
is actually a large, voracious fish, which establishes the connection
with the whaledragon myth so beautifully worked out by Frobenius,
in which the sea monster devours the sun-hero for rebirth and
where the hero must employ every stratagem to conquer the
monster. Here again we meet with the idea of the " terrible mother "
in the form of the voracious fish, the mouth of death.85 In Frobenius
there are numerous examples where the monster has devoured not
only men but also animals, plants, an entire country, all of which are
redeemed by the hero to a glorious rebirth. The Lamias are typical
nightmares, the feminine nature of which is abundantly proven.86
Their universal peculiarity is that they ride upon their victims. Their
counterparts are the spectral horses which bear their riders along in
a mad gallop. One recognizes very easily in these symbolic forms the
type of anxious dream which,
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SYMBOLISM OF MOTHER AND OF REBIRTH 281 as Riklin

shows,87 has already become important for the interpretation of
fairy tales through the investigation of Laistner.88 The typical riding
takes on a special aspect through the results of the analytic
investigation of infantile psychology; the two contributions of Freud
and myself 89 have emphasized, on one side, the anxiety
significance of the horse, on the other side the sexual meaning of
the phantasy of riding. When we take these experiences into
consideration, we need no longer be surprised that the maternal "
world-ash " Ygdrasil is called in German " the frightful horse."
Cannegieter 90 says of nightmares : " Abigunt eas nymphas (matres
deas, mairas) hodie rustic! osse capitis equini tectis injecto,
cujusmodi ossa per has terras in rusticorum villis crebra est
animadvertere. Nocte autem ad concubia equitare creduntur et
equos fatigare ad longinqua itinera." * The connection of nightmare
and horse seems, at first glance, to be present also etymologically —
nightmare and mare. The Indo-Germanic root for mare is mark.
Mare is the horse, English mare; Old High German mar ah (male
horse) and meri'ha (female horse) ; Old Norse merr (mar a =
nightmare) ; Anglo-Saxon my re (maira). The French " cauchmar "
comes from calcare = to tread, to step (of iterative meaning,
therefore, " to tread " or press down) . It was also said of the cock
who * Even to-day the country people drive off these nymphs
(mother goddesses, Maira) by throwing a bone of the head of a
horse upon the roof — bones of this kind can often be seen
throughout the land on the farmhouses of the country people. By
night, however, they are believed to ride at the time of the first
sleep, and they are believed to tire out their horses by long
journeys.
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282 PSYCHOLOGY OF THE UNCONSCIOUS stepped upon

the hen. This movement is also typical for the nightmare; therefore,
it is said of King Vanlandi, " Mara trad han," the Mara trod on him in
sleep even to death.91 A synonym for nightmare is the " troll " or "
treter " 92 (treader). This movement (calcare] is proven again by the
experience of Freud and myself with children, where a special
infantile sexual significance is attached to stepping or kicking. The
common Aryan root mar means " to die " ; therefore, mara the "
dead " or " death." From this results mors, jwo'pof = fate (also
juofpa?93). As is well known, the Nornes sitting under the " world-
ash " personify fate like Clotho, Lachesis and Atropos. With the Celts
the conception of the Fates probably passes into that of malres and
matrons, which had a divine significance among the Germans. A
well-known passage in Julius Caesar (" De Bello Gallico," i: 50)
informs us of this meaning of the mother : " Ut matres familias
eorum sortibus et vaticinationibus 9* declararent, utrum prcelium
committi ex usu esset, nee ne." * In Slav mara means " witch " ;
poln. mora — demon, nightmare; mor or more (Swiss-German)
means " sow," also as an insult. The Bohemian mura means "
nightmare " and " evening moth, Sphinx." This strange connection is
explained through analysis where it often occurs that animals with
movable shells (Venus shell) or wings are utilized for very
transparent reasons as symbols of the female genitals.95 The
Sphingina are the twi* That these matrons should declare by lots
whether it would be to their advantage or not to engage in battle.
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