Grubs up

The use of maggots was once dismissed as quackery, now they're back in modern hospitals. And drinking worm eggs could help to treat IBS. But will patients stomach it? Hugh Wilson reports
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It's a familiar Hollywood tale. The blizzard, the plane crash in the barren mountainside, the travails of the wounded pilot, and finally the tense but oh-so-predictable rescue. There is just one horror left. As the medic cuts away the tattered denim from around the wound, the camera zooms in to reveal a mass of mangled flesh and bone, alive with the wriggling of a thousand hungry maggots.

It's a familiar Hollywood tale. The blizzard, the plane crash in the barren mountainside, the travails of the wounded pilot, and finally the tense but oh-so-predictable rescue. There is just one horror left. As the medic cuts away the tattered denim from around the wound, the camera zooms in to reveal a mass of mangled flesh and bone, alive with the wriggling of a thousand hungry maggots.

And it's the wrigglers who are the real heroes. As the doctor later explains, the maggots have eaten away the gangrene and saved the leg. They should all be given medals.

Hollywood has actually got it half right. Maggots have been used to clean infected wounds for centuries, and their therapeutic qualities were exploited by battlefield surgeons from Waterloo to the Somme. As the use of antibiotics gathered pace in the early 20th century, the medicinal maggot was discarded. But now, despite seeming like the very antithesis of 21st-century science, maggot therapy has staged something of a comeback.

With reason. Anecdotal evidence and small-scale trials suggest that, for ulcer wounds in particular, a compress of sterilised maggots can be more effective than conventional treatments. Now, the largest clinical study into maggot therapy ever mounted aims to find out just how beneficial it can be.

It's serious stuff. The study will take three years, involve about 600 patients and cost going on for a £1m. It will be co-ordinated by the University of York Department of Health Sciences and involve health trusts in northern England, the Midlands and Northern Ireland. Its goal is to reduce the annual £600m the NHS spends on treating leg ulcers, and improve the quality of life for thousands of patients with a debilitating, unsightly and painful condition.

"Maggot therapy is being used already," says Dr Pauline Raynor, who's leading the study. "But we want to actually test its efficacy in the cleaning and healing of wounds. It's also about patient quality of life. Does it heal more quickly, compared to conventional treatments? Does it mean that, for example, patients have to make fewer visits to their GPs? These wounds can be severely debilitating, and maggot therapy seems to work well."

Phyllis Hulme, 81, agrees. Nothing would heal the weeping ulcer on her leg until she applied a "tea bag" of maggots. "I was in some unbelievable pain," she says. "But the first night I had the maggots on was the first decent night's sleep in months. I had a second treatment and it cleaned out the wound completely. They were chubby little things when they came out of there. They'd fed well."

Someone else who needs no convincing is Dr Ronald Sherman, assistant professor of medicine and pathology at the University of California and the man credited with re-introducing maggot therapy to modern clinical practice. "The primary advantage is its efficacy," he says. "Several studies revealed that maggot-treated wounds were debrided [cleaned] faster than those treated conventionally, and the wounds filled in faster with healthy 'granulation' tissue. Additionally, they're relatively safe, low cost, and have a simple application."

The Americans are so convinced of the therapeutic qualities that, last year, the humble maggot became the first live animal to gain approval as a medical treatment by the Food and Drug Administration.

It was quickly followed by the second: leeches. Doctors have discovered that severed veins and skin, and even limbs, have a greater chance of successful reconnection if treated with the little bloodsuckers first. They do what leeches do best: "They suck congested blood from the site of a trauma, and they're very good at it," says Carl Peters of Biopharm UK, which sells 50,000 medicinal leeches globally every year. They also excrete a blood-thinning enzyme to avoid further coagulation. Like maggots, leeches are back on the medicinal menu because they do the job better than anything invented by man.

This renaissance of medieval medicine doesn't stop here. According to the International Biotherapy Society, which aims to support the use and understanding of living organisms in disease treatment, several research programmes are under way to test the value of bee venom therapy on a range of ailments, from asthma to arthritis. There's talk of fish therapy for wounds. But what is really grabbing the attention of doctors is the therapeutic potential of a pesky little parasite called the pig whipworm.

The theory is simple enough. Our immune systems have evolved to live with parasites and can become overactive without them, triggering a range of digestive diseases such as Crohn's disease and irritable bowel syndrome (IBS). The pig whipworm lives in the digestive tract and gives our natural defences something useful to do. In an experiment last year by Dr Joel Weinstock, a gastroenterologist at the University of Iowa, 70 per cent of Crohn's sufferers went into remission after treatment with a drink containing thousands of whipworm eggs. A version of the concoction is in production in Germany, pending approval by the European Agency for the Evaluation of Medicinal Products.

While the results did not surprise Weinstock - IBS is rare, he'd noted, in countries where digestive parasites are common - a few of his colleagues were taken aback. "A lot of researchers couldn't believe this treatment was effective, but people are always sceptical when confronted with new ideas," he said.

Which is just the sort of reaction the new generation of biotherapists are getting used to. However, that reaction rarely comes from patients. "A patient desperate to find a solution for a chronic wound is usually ready to try any method that gives new hope," says Dr Kosta Y Mumcuoglu, senior research scientist in the Department of Parasitology at the Hebrew University in Jerusalem.

"Patients are usually happy to start MDT (maggot debridement therapy) as soon as their doctor explains the details of the treatment, the changes that will occur in cleaning the wound, and the increased chances of healing. We have much more trouble with the doctors and nurses than with the patients regarding any 'yuck' factor," Mumcuoglu says.

Sherman, too, is unequivocal. Patients want biotherapy; it's the medical profession that must get over its creepy-crawly hang-up. "The people I hear saying that they would not want maggots on them, or that maggots are too disgusting to use, are hospital administrators and those who have no idea what it is like to have a chronic, limb-threatening wound.

"Patients with pressure ulcers, diabetic foot ulcers, chronic leg ulcers, gangrene, and other non-healing wounds that drain blood and pus all day, and smell bad, and stop them going out; people who look at their own disfiguration know what is really disgusting, and it's their skin and their body - it's not a germ-free, gangrene-eating maggot. Maggots save lives and limbs. Patients know this, and patients are choosing it."

This is borne out to some extent by an early result of the York study. "We've had plenty of patients ringing up wanting to take part in the study," Raynor says. "They take the attitude that if it works, they'll do it. What we need more of is practitioners and primary care trusts coming forward to take part. I don't think medical staff are against anything that will be effective. The resistance is in terms of getting used to using and applying the treatment."

Occasionally, patients report feeling the maggots wriggling or nipping, but usually maggot therapy is as unobtrusive as any. As with Phyllis Hulme, the maggots are in a "tea bag" of porous material, covered by a bandage. "I didn't feel them moving around at all," she says. "I was a bit apprehensive, but now I'd d recommend the treatment to anybody. I can't understand why it's not more widely used."

This might not be the hi-tech future of robot doctors and magic pills we were promised, but the time of maggots - and leeches, bees and worms - has come round again.

To take part in the York study, call 0800 138 3461