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History of Wound Care

History of Wound Care: Maggots: An Extraordinary Natural Phenomenon

The soft-bodied larva of the fly, otherwise known as the maggot, has played many roles throughout history, including that of the healer.  The medical use of maggots has gone by many names — biotherapy, biosurgery, larval therapy, and maggot debridement therapy — and their use in wound care dates back to mentions in antiquity, observations during wars, analyses in the 20th century, and (more recently) a vast resurgence in healthcare settings. Even though the thought of larva may seem revolting to some patients (and perhaps even to healthcare practitioners), it cannot be argued that maggots hold an extraordinary place in wound care’s history as well as promise in its future.

Maggots During Antiquity

Even though a small amount of cases were recorded during antiquity, the invasion of human wounds by maggots has been known about for centuries. Also documented are the extraordinary healing powers of certain fly larva to clear away necrotic tissue. 

Reportedly, the earliest documented case may be in the Old Testament’s story of Job,1,2 who’s traditionally presented as a good and prosperous family man beset with horrendous disasters that took away all that he holds dear, including his offspring, his health, and his property. Job struggled to understand his situation and began a search for the answers to his difficulties. During his many trials to test his faithfulness to God, Job states that his body is “clothed with worms and clods of dust,” his skin “broken and loathsome.” — King James Version. 

The use of maggots in wound care has also been reported in various ancient cultures. The Aboriginals of Australia and Mayan tribes in Central America used larva frequently to clean wounds.3 Mayans were also believed to have soaked their dressings in cattle blood and expose them to the sun before applying them to certain lesions; the people watched for the bandages to squirm with maggots.4   

Wartime Maggots

The chief surgeon to France’s Charles IX and Henri III, Ambroise Paré (1510-1590), reported on the Battle of Saint Quentin (1557). During this battle, he realized the maggot-infested patients often recovered much quicker than others. However, Paré did not attribute this quick recovery to the maggots, nor did he realize that the “worms” were fly larva.5 Similar to his contemporaries, Paré believed the maggots developed spontaneously as part of the putrefaction process of devitalized necrotic tissue.5

During an expedition to Egypt (1799), Napoleon’s surgeon, Baron Dominique-Jean Larrey, observed that only “blue fly” maggots removed dead tissue on the soldiers. Larrey and his medical officers also tried to convince the other soldiers of this natural phenomenon.5

The first therapeutic use of maggots is believed to have taken place during the American Civil War. John Forney Zacharias, a Confederate medical officer during the war, is arguably the first physician to intentionally expose his patients’ festering wounds to maggots. Fleischmann et al5 note that when comparing the Confederate wounded to the Union wounded, most Confederate soldiers’ wounds were left unkempt and maggot-borne. Reportedly, the maggot-infested wounds of the Confederate soldiers healed more quickly than those of the Union army.6 Fleischmann et al5 also wrote that Confederate soldiers were more likely to survive their wounds than their counterparts. The germ theory of microbiologists Robert Koch and Louis Pasteur in the 1880s revolutionized medicine by introducing the practice of good hygiene; unfortunately, this theory also forbade doctors from intentionally exposing wounds to nonsterilized maggots.5,7

In 1917, during World War I, William S. Baer, an American orthopedic surgeon, treated two soldiers who lay injured on the battlefield for seven days before they were discovered.5 

With the mortality rate at 70% for similar types of wounds suffered by soldiers at this time, their recovery was considered remarkable. So much so, in fact, that Baer went on to challenge the medical community’s perception of maggots after the war.

Rise & Fall of Maggots

As a professor of orthopedic surgery at the Johns Hopkins University, Baer started the first known experiments with the blowfly maggot in 1929. He selected 21 patients living with chronic osteomyelitis, surgically removed all the dead tissue he could, stanched the bleeding, and applied as many blowfly maggots as the wound would hold.8 Baer would replace the maggots every four days for six weeks. Two months later, all 21 patients received complete wound healing.5,7,8 However, the results of this study were not published until after Baer’s unexpected death due to stroke in 1931.

With the publication of Baer’s study, the use of larva reached high popularity in the 1930s.7 This even led to the mass production of the sterilized green bottle fly by Lederle Laboratories7,8  — a company that once operated as a subsidiary of the one-time conglomerate American Cyanamid Company, which was acquired by the pharmaceutical company Wyeth in 1994 that today operates as Pfizer Inc. More than 300 hospitals in the United States regularly used maggots in wound care by the early 1930s, and more than 100 publications appeared in medical literature between 1930 and 1940.

Alexander Fleming’s 1928 discovery of penicillin (commercially produced in 1944) brought about the end of the golden age for maggots in wound care.5 While maggots were still used in wound care after the availability of penicillin and other antibiotics, they were only used when antibiotics, surgery, and modern wound care failed. Most healthcare practitioners shared the negative opinion of microbiologist Milton Wainwright, who has written extensively on penicillin, in regards to the use of maggots in medicine: “The demise of which no one is likely to mourn.”9

Maggot Renaissance 

For 40 years, maggots fell out of favor in wound care mainly due to the discovery of antibiotics and their cost effectiveness. By the end of the 1980s, antimicrobial resistance had become quite common, pressure ulcers and diabetic foot ulcers increased, and conventional wound care was inadequate for an increasing number of recalcitrant wounds.10 

Ronald A. Sherman, MD, MSc, DTM&H, assistant professor of medicine at the University of California-Irvine, sought to fill the gap in wound care needs.8 Sherman encountered a patient in the 1980s who came into the UCLA Medical Center with a leg wound infested with worms. 

After overcoming their initial disgust, Sherman and his colleagues noticed the healthy, uninfected tissue growing in the wound.8 As a child, Sherman was an avid bug collector who went on to hold degrees in medicine and entomology. His general interest with insects, coupled with the aforementioned medical case, impacted Sherman’s enthusiasm to study maggots in wound care.8 Sherman went on to establish a small fly-culturing facility at the Veteran Administration Hospital Medical Center in Long Beach, CA,7 where he produced sterile larva. He also took part in numerous studies with maggot therapy. 

With low costs, minimal scarring, and few to no side effects, maggots really posed just one significant challenge for researchers and clinicians of the late 1980s and early 1990s — helping patients to overcome the “ick” factor. This has involved the development of improved adhesives and cage-like dressings to confine the maggots to the wound, such as products like BioBag® (BioMonde,® Gainesville, FL) and LeFlap™ or LeFlap Du Jour™ (Monarch Labs, Irvine, CA). The prospective controlled studies in the ‘90s proved maggots led to a more rapid removal of debris than all other nonsurgical treatments and had a faster healing rate.5,7 The International Biotherapy Society was founded in 1996 to advance the use, understanding, and acceptance of maggot therapy and other living organisms in medical treatments. By 2002, maggot debridement therapy was being used in more than 2,000 healthcare centers worldwide. In January 2004, the U.S. Food and Drug Administration granted permission to produce and market maggots as a prescription-only medical device for the treatment of debriding chronic wounds such as pressure ulcers, venous stasis ulcers, neuropathic foot ulcers, and nonhealing traumatic or post-surgical wounds. 

Video 1 and Video 2

Jaclyn Gaydos is assistant editor of Today’s Wound Clinic

References

1. Old Testament, Book of Job, 7:5 (KJV).

2.  Zumpt F. Myiasis in man and animals in the Old World. London: Butterworths;1965.

3.  Gottrup F, Jørgensen B. Maggot debridement: an alternative method for debridement. Eplasty. 2011;11:e33.

4.  Dunbar G. Notes on the Ngemba tribe of the Central Darling River of Western New South Wales. Mankind. 1944;3:140-8.

5. Fleischmann W, Grassberger M, Sherman R. Maggot Therapy: A Handbook of Maggot-Assisted Wound Healing. New York: Thieme;2004.

6. Chernin E. Surgical maggots. South Med J. 1986;79:1143-5. 

7.  Whitaker IS, Twine C, Whitaker MJ, Welck M, Brown CS, Shandall A. Larval therapy from antiquity to the present day: mechanisms of action, clinical applications and future potential. Postgrad Med J. 2007;83(980):409-13.

8. Dossey L. The Extraordinary Healing Power of Ordinary Things: Fourteen Natural Steps to Health and Happiness. New York: Three Rivers Press;2007.

9.  Wainwright M. Maggot therapy: a backwater in the fight against bacterial infection. Pharm Hist. 1988;30(1):19-26.

10.  Sherman R. Maggot therapy takes us back to the future of wound care: new and improved maggot therapy for the 21st century. J Diabetes Sci Technol. 2009;3(2):336-44.

History of Wound Care
Jaclyn Gaydos
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