History of the Cast

Intrigued, eh? I could be referring to cast members of a play, an archaeology cast, the casting of magical spells,  computer programming casting, or maybe I made a typo and I meant caste. Nope, none of these…

Today’s cast lesson is on the early history of orthopedic casts. Yes, there was a recent break/fracture in my household. My wife had the misfortune of breaking her radial neck (no, not her neck…keep reading) in her left arm. As my old Spanish teacher would say, “¡Pobrecita!”; but with a little TLC, administered by myself, I think she will pull through this okay.

In case you are not familiar with what an orthopedic cast is, it is a shell or outer casing, usually of a limb, that is intended to hold a broken bone(s) in place while it heals. After a bone has been diagnosed as broken and properly reset (if necessary), a cast is formed around the fractured bone to protect it and allow it to heal–unimpeded.

In a way, when I find that today’s technology, science, math, and ways of life are not too different from that of time three-thousand years ago, I feel a sense of disbelief. It doesn’t seem possible to me that the history of medical techniques used today can go back three-hundred years, let alone three-thousand years! But in fact, for today’s lesson, it does.

Orthopedic casts date back to the times of Ancient Egyptians. The Egyptians used a primitive, bark tree splint, that was tightly wrapped in linens, as the earliest known method of treating bone fractures. This technique required that the Egyptians used their embalming techniques to construct a tight set of splints around the affected area. Hippocrates of Cos, an ancient Greek physician from 400 BCE, left behind detailed writings discussing how important splinting a break was, coupled with proper exercise during immobilization. This “exercise” would come to be what we refer to as physical therapy. He believed that exercise (to prevent muscle atrophy), with stiffened bandages (constructed from waxes and resins), was the proper medicine to help heal a fracture. Aulus Celsus, a Roman encyclopedist (specifically known for his medical research and writings) from 50 CE, had complied text taken from Hippocrates and added that the usage of starch to further stiffen the splint was essential.

Over the next 1500 years, the only changes to be made to the theory of cast improvement would be the different remedies concocted to use as hardening agents. Casts would be hardened with flour, eggs, and animal fat. The last cast in use before the invention of the modern cast was constructed of wax, cardboard, cloth, and parchment. This cast type, created by Ambroise Pare, in the 1500’s, would be used until the 1800’s when four military surgeons (not fighting for the same team) would build on each others’ work to create the modern cast.

It is important to realize that up to this point, the standard healing protocol for a fracture was bed rest and restriction of activity. There was A LOT of lying around…waiting to heal. Imagine: the hassle of a full body cast for just a broken arm. It is from this point, that more modern medicine would allow a person suffering from a break to live their life. Dominique Jean Larrey, a French naval surgeon,  had given medical attention to an officer in the battlefield and decided that the officer’s arm must be amputated, once he was safely home. After giving the wound the proper medical attention to stave off infection, Larrey wrapped the wound and the officer was transported from Russia, through Poland and Germany, and made it safely into France. Upon the officers’ arrival in France, the cast was removed and to the shock of everyone, the arm had healed itself. This marked the inception of casting to heal and not to support a break. Up until now, a splint or cast was merely to allow the bones to rest safely and protect them while they mend from rest. No one had ever thought of a cast as the actual cure for broken bones. This proved that if given ample and undisturbed time, a fracture could heal itself because of a cast.

A large issue with this cast, as well as the old casts, is that they took an incredibly long time to dry. The current implementation of cardboard splints, with a wet starch solution, took two to three days to dry. Louis Seutin, a military surgeon in the Belgium army, would discover dextrin as a substitute for starch and cut the drying time down to six hours. As most of these casts were put on in the battlefields, time was of most importance. As six hours was an incredibly long time to require someone to sit around with gunfire from all four sides, imagine trying to do it for forty-eight hours. Another remarkable technique that Louis Seutin pioneered was the application of the cast based on the mold of the limb to be cast. Allowing the cast to form uniquely to each wearer, before wrapping it in a starch coat, allowed early mobilization of patients and reduced time spent in hospitals.

Plaster casts, constructed from gypsum plaster (plaster of Paris), would be used by hospitals in the early 1800’s, but its first use was not very practical and confined patients to their beds. The traditional use of plaster of Paris was to have the patient place their broken leg (for example) in a long wooden box and fill it with plaster. While plaster of Paris cast were ideal for the healing process, it wouldn’t be until Antonius Mathijsen, a medical officer in the Dutch army, made the plaster of Paris cast a real possibility. Mathijsen took linens that had been soaked in plaster of Paris and quickly wrapped them around the fractures. This provided a snug and exact fit and allowed patient mobility again.

Nikolai Ivanovich Pirogov, a Russian Professor of Surgery at the Academy of Military Medicine, had seen Louis Seutin demonstrate his application of the cast as a mold of the limb and decided to branch off using Seutin’s idea and Antonius Mathijsen’s idea of plaster of Paris. Although his cast was very similar to Mathijsen’s cast, Pirogov had some issues involving side-effects and potential problems with patients. Pirogov bowed out, allowing Mathijsen’s cast to be the cast that revolutionized the world, but as time passed on, he made some improvements to it. Pirogov would make cast dressing that would be resistant to water and he also made necessary steps in application that allowed mass production for commercially sold bandages and casts.

In the last thirty to forty years, synthetic materials (such as knitted fiberglass bandages with polyurethane or thermoplastic) have been used to construct lighter and cleaner casts. However, at this time, there is no easier molded, more comfortable, smoother cast available. While it have a few drawbacks (mainly its weight..and itchiness), a simple plastic of Paris cast still seems the way to go.