The word sciatica has been in use from Greek times, and is derived from "ischias" or pain around, or coming from, the hip and thigh. It was only with modern ideas of pathology that it came to mean pain in the distribution of the sciatic nerve.
Hippocrates (460-370 bc) noted that "ischiatic" pain mainly affected men aged 40-60 years. In younger men it usually lasted 40 days. Contrary to modern ideas, radiation of pain to the foot had a good prognosis but pain that stayed in the hip was dreaded. (This was probably tuberculosis or other serious disease of the hip joint.) Areteus (150 ad) first distinguished nervous and arthritic "schiatica." He blamed nervous sciatica on an excess of cold and suggested that the remedy was local heat - spas, soothing ointments, counterirritants, and cautery.
Hippocrates first mentioned cautery and it appears throughout the ancient writings (Fig. 4.4). "Dung cautery" was in use by 100 ad and probably came from Arabic use of goat's dung. Albucasis (1100 ad) described local and wrist cautery for sciatica and drew a number of the instruments.
Domenico Cotugno (1765) wrote the first book on sciatica (Boni et al 1994). He combined new knowledge of anatomy and pathology with clinical observation. He separated nervous and arthritic sciatica and divided nervous sciatica into anterior and posterior types. He knew that the condition could be continuous or intermittent. He noted that sometimes
the continuous became intermittent but never the other way around. Apart from a comment by Hippocrates that most attacks recover in 40 days, this was one of the first observations on the natural history of recovery. Cotugno thought that sciatica was due to an excess of fluid surrounding the nerve, which is perhaps not surprising as he was first to describe the dura and the cerebrospinal fluid. His treatment was to remove the excess fluid by cupping, blistering, and aquapuncture (sic), which put needles into the nerve itself to draw off the excess fluid. For many years sciatica was known as Cotugno's disease.
In the 19th century, sciatica was again thought to be a kind of rheumatism. Inflammation of the sciatic nerve might be primary or secondary. Primary causes included gout, rheumatism, syphilis, neuromata, poisons, trauma, and cold. Secondary causes included pelvic tumors, a distended rectum and bone disease, especially hip joint disease. This shows the new emphasis on identifiable pathology, but
Figure 4.5 Hugh Owen Thomas (1834-1891), the father of English-speaking orthopedics. From a sketch made about 1884 (Keith 1919), with thanks to the Royal College of Physicians and Surgeons of Glasgow.
still no one understood sciatica itself. Fuller (1852) concluded that "the history of sciatica is, it must be confessed, the record of pathologic ignorance and therapeutic failure."
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