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Larval Therapy from Antiquity to the Present

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Larval Therapy from Antiquity to the Present 409 View metadata, citation and similar papers at core.ac.uk brought to you by CORE REVIEW provided by Cronfa at Swansea University Larval therapy from antiquity to the present day: mechanisms of action, clinical applications and future potential Iain S Whitaker, Christopher Twine, Michael J Whitaker, Mathew Welck, Charles S Brown, Ahmed Shandall ................................................................................................................................... Postgrad Med J 2007;83:409–413. doi: 10.1136/pgmj.2006.055905 When modern medicine fails, it is often useful to draw ideas Testament being the oldest written piece to cite the infestation of an infected wound of a man by from ancient treatments. The therapeutic use of fly larvae to fly larvae (myiasis).6 debride necrotic tissue, also known as larval therapy, maggot Evidence exists that larvae have been used for debridement therapy or biosurgery, dates back to the the last thousand years by various ancient cul- beginnings of civilisation. Despite repeatedly falling out of tures, such as the aboriginal Ngemba tribe of New South Wales,7 the Hill people of Northern Myanma favour largely because of patient intolerance to the treatment, (Burma)8 and the Mayan healers of Central the practice of larval therapy is increasing around the world America.9 Anthropological research suggests that because of its efficacy, safety and simplicity. Clinical indications the Maya soaked dressings in the blood of cattle for larval treatment are varied, but, in particular, are wounds and exposed them to the sun before applying them to certain lesions, expecting the dressings to infected with multidrug-resistant bacteria and the presence of squirm with maggots.7 significant co-morbidities precluding surgical intervention. The The French surgeon, Ambroise Pare (1510– flies most often used in larval therapy are the facultative 1590), was the first doctor to note the beneficial calliphorids, with the greenbottle blowfly (Lucilia sericata) being effect of fly larvae for wounds. His early descrip- tions, however, emphasised the destructive nature the most widely used species. This review summarises the of the maggot, and he conscientiously tried to fascinating and turbulent history of larval therapy from its origin protect the wounds of his patients from infesta- to the present day, including mechanisms of action and tion.10 11 The turning point came when he observed a case of a deep wound that had penetrated a evidence for its clinical applications. It also explores future patient’s skull. A number of months after the research directions. injury, a large number of maggots emerged from ............................................................................. the wound. Although a piece of bone the size of a hand was lost, the patient nevertheless recovered.10 After this, Pare would allow maggots to continue n the twenty first century, when modern to survive in wounds for extended periods in an medicine fails, it is often useful to draw ideas 10 from ancient treatments. The therapeutic use of attempt to facilitate recovery. I Another French surgeon, Baron Dominique- fly larvae to debride necrotic tissue, also known as larval therapy,1 maggot debridement therapy2 or Jean Larrey (1766–1842), who treated the injured biosurgery,3 dates back to the beginnings of of Napoleon’s army, observed that during the civilisation. Despite repeatedly falling out of favour Egyptian expedition in Syria, maggots of the ‘‘blue and the persistent public disdain which hampers fly’’ only removed dead tissue and had a positive 12 its acceptance, the practice of larval therapy is effect on the remaining healthy tissue. Larrey’s increasing around the world because of its efficacy, written observations clearly described the role of 8 safety and simplicity.4 The flies most often used in fly larvae in wound cleaning. larval therapy are the facultative calliphorids, with The first officially documented application of the greenbottle blowfly (Lucilia sericata) being the maggots was performed by John Forney Zacharias most widely used species.5 Clinical indications for (1837–1901), a surgeon from Maryland during the larval treatment include infected or necrotic American civil war (1861–1865): wounds of all types. Candidates for the treatment generally have non-acute external wounds for ‘‘During my service in the hospital at Danville, which one or more courses of alternative treat- Virginia, I first used maggots to remove the ments have failed. See end of article for decayed tissue in hospital gangrene and with authors’ affiliations ........................ eminent satisfaction. In a single day, they HISTORY OF LARVAL THERAPY would clean a wound much better than any Correspondence to: agents we had at our command. I used them Iain S Whitaker, 8 Avonlea Road, Sale M33 4HZ, UK; ‘My body is clothed with worms and scabs, my afterwards at various places. I am sure I saved [email protected] skin is broken and festering…’ many lives by their use, escaped septicaemia, The Holy Bible, Old Testament, Job 7:5. and had rapid recoveries.’’13 Received 27 November 2006 Accepted 23 January 2007 Larval association with infected wounds has been William Williams Keen (1837–1932), who was a ........................ reported since ancient times, with the Old surgeon of the army of the North States, also www.postgradmedj.com 410 Whitaker, Twine, Whitaker, et al reported the presence of fly larvae in wounds and noticed that, onwards, and the development of new antiseptics led to a rapid despite their sickness-inducing appearance, they had no decline in the use of larval therapy. With the exception of disadvantageous effect.14 sporadic publications of hopeless cases where the use of fly At this time, popular scientific belief was that maggots were larvae was successful,20 21 the academic interest was lost. The ‘‘dirty’’ and introduced infections to wounds. The germ theory public showed distain,22 and in 1988 Wainwright brought the of the microbiologists, Robert Koch and Louis Pasteur, during majority opinion to a point: the second half of the 19th century finally stopped any willingness of doctors to apply contaminated matter to an ‘‘…Fortunately maggot therapy is now relegated to a open wound. By the end of the 19th century, there were hardly any doctors left who would support the use of non-sterile fly historical backwater, of interest more for its bizarre nature larvae for the public. than its effect on the course of medical science … a therapy 23 During World War I, mortality from open wounds increased the demise of which no one is likely to mourn…’’ to 70%.15 The available antiseptic tools were often not sufficient. 24 In 1917, William S Baer, a military surgeon in France, reported At the same time, Craig described in the US Army Special his treatment of open fractures and stomach wounds with Forces Medical Handbook that the use of fly larvae in military life- maggots. In 1929, during his appointment as Professor of threatening situations was a useful alternative. Here the Orthopaedic Surgery at the Johns Hopkins University, Baer treatment of wounds with fly larvae was seen as a last 25 recalled and utilised his experiences during the war.15 He chose therapeutic tool only in extreme situations. 21 patients with failed primary treatment for osteomyelitis. He Larval therapy’s renaissance in clinical practice started much 26 exposed the wounds to maggots and found that, 2 months after sooner after this particular decline. In the USA, Ronald the initiation of treatment, all of the patients’ wounds had Sherman and Edward Pechter have been strong advocates of 427 healed.15 the technique. At the beginning of the 1990s, Sherman Larval therapy was subsequently the fastest and most established a small fly-culturing facility in the Veteran successful mode of treatment for chronic osteomyelitis. To Administration Hospital Medical Centre in Long Beach minimise the disgust of patients, as well as staff, and to avoid (California) to meet the need for the production of sterile the migration of larvae, doctors created net-cage bandages to larvae. In prospective controlled studies during the 1990s, cover and hide the larvae. To reduce the strong itching effect maggot therapy was compared with conventional therapies in 2 that larvae caused on healthy skin, Baer covered the border of the treatment of wounds in patients with decubitus ulcers. wounds with a special bandage. However, the contamination of Maggot therapy led to a more rapid removal of debris than all some wounds with Clostridium tetani and Clostridium perfringens other non-surgical treatments, and had a faster healing rate. In 2 led him to the conclusion that sterile maggots needed to be necrotic wounds with an average surface area of 13 cm (5– 2 applied. Baer worked together with some colleagues to create 30 cm ), the healing rate was about 1.5 weeks on average, as specific flies for use in therapy and they developed a number of assessed by the successful removal of debris, in comparison 2 different methods to sterilise the eggs.16 with 4 weeks for conventional methods. Wounds that were A large number of Baer’s colleagues disliked the use of increasing by 22% surface area per week before treatment with maggots in wound healing as there was little knowledge of the larvae reduced their area on average by 20% per week after its 28 mechanism of action. Once Baer died, Stanton Knowlton use. Furthermore, Sherman experimented with different Livingston, one of Baer’s students, became the authority in the bandages in order to ensure optimal controlled clinical use of field of maggot therapy.17 Livingston was such a strong maggot therapy. advocate that he used an extract as a vaccine for his patients, The renaissance of larval therapy in the United Kingdom can who often reacted badly.18 be attributed to John Church, a retired orthopaedic surgeon ‘‘Maggot therapy’’ experienced a real boom from then on who, with Stephen Thomas, set up the Biosurgical Research despite some doubtful experiments.
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