主题：这个外科医疗术值得讨论讨论。 -- 九霄环珮

Because several thorough reviews have been published recently (14, 49, 70, 94,

114, 139), this section focuses only on the highlights of maggot therapy history.

Some societies have recognized for centuries that the larvae of certain flies can

have beneficial effects upon the healing of infected wounds. There is evidence

that maggot therapy has been used by aboriginal tribes of Australia , the Hill

Peoples of Northern Burma , and possibly the Mayans of Central America

. Yet, the beneficial aspects of myiasis have not always been appreciated

universally.

Possibly the first written mention of human myiasis is in the Bible, where Job

complained, My body is clothed with worms and scabs, my skin is broken and festering.

Like many surgeons who followed, Ambroise Pare´ (1509–1590), chief surgeon

to Charles IX and Henri III, observed in 1557 at the battle of St. Quentin that

maggots frequently infested suppurating wounds (43). Hieronymus Fabricus (35)

also described the presence of maggots in wounds. In 1829, Napoleon’s surgeon

in chief, Baron Dominic Larrey, reported that when maggots developed in wounds

sustained in battle, they prevented the development of infection and accelerated

healing (69). The beneficial effects of wound myiasis were noted by the Confederate medical

officer Joseph Jones, quoted by Chernin :

I have frequently seen neglected wounds . . . filled with maggots . . . as far

as my experience extends, these worms only destroy dead tissues, and do

not injure specifically the well parts. I have heard surgeons affirm that a

gangrenous wound which has been thoroughly cleansed by maggots heals

more rapidly than if it had been left to itself.

According to Baer (4), the Confederate surgeon J Zacharias, may have been

the first western physician to intentionally introduce maggots into wounds for the

purpose of cleaning or debriding the wound. Baer (4) quotes Zacharias as stating:

Maggots . . . in a single day would clean a wound much better than any

agents we had at our command. . . . I am sure I saved many lives by their

use. . . .

Crile & Martin (22) also noted that soldiers whose wounds were infested with

maggots did far better than wounded soldiers not infested.

The founder of modern maggot therapy is William Baer (1872–1931), clinical

professor of orthopaedic surgery at the Johns Hopkins School of Medicine in

Maryland. During the First World War, Baer treated two wounded soldiers who

had lain overlooked on the battlefield for a week. Although they had sustained

serious injury and their wounds swarmed with maggots, Baer noted that the soldiers

had no fever, no evidence of systemic infection, and no pus; instead, they

had the ‘‘most beautiful pink granulation tissue that one can imagine.’’ Drawing

upon his wartime experiences, Baer treated four children with intractable bone

infections (osteomyelitis) at the Children’s Hospital in Baltimore (3). His initial

use of unsterilized maggots was very successful and the wounds healed within

six weeks. Encouraged by these results, Baer used the technique more widely.

However, several of his patients developed tetanus, and he concluded that ‘‘it

would be necessary to have sterile [viz. germ free] maggots’.

In the absence of any equally effective alternative for the treatment of osteomyelitis

or infected soft tissue injuries, the use of maggots spread quickly during

the 1930s, particularly in the United States where Lucilia sericata larvae were

produced by Lederle Corporation and sold for five dollars per 1000 (now

equivalent to about $100). By the mid-1930s, Robinson surveyed 947 North

American surgeons known to have employed maggot therapy (104). Of the 605

responding surgeons, 91.2 percent expressed a favorable opinion; only 4.4 percent

expressed an unfavorable view. The most common complaints raised by surveyed

practitioners were the cost of the maggots, the time and effort required to construct

the maggot dressings, and the discomfort to patients. Other than Baer’s cases of

tetanus and one case of erysipelas (141), which were thought to be associated

with the use of non-sterile larvae, no other serious adverse reactions were

reported.

The early maggot therapy literature describes the successful treatment of

chronic or acutely infected wounds, including bone infections (osteomyelitis) (9,

72, 75, 141), abscesses, carbuncles, and leg ulcers (36). Although the larvae were

unable to liquify dead bone, they did appear to cleave the pieces of dead bone

(sequestra) at their interface with normal bone, leaving behind clean healthy granulation

tissue (141). Based on clinical outcomes and wound cultures, Weil and

colleagues (141) believed that medicinal maggots treated many soft tissue infections,

including Clostridium welchii (Cl. perfringens). In addition, they reported

maggots to be of value in the management of some tumors, including two cases

of inoperable breast cancer. More recently, Bunkis et al (10) and Reames et al

(100) described the benefits of debridement and odor control resulting from accidental

myiasis of head and neck tumors. Seaquist and colleagues (111) also reported benefits from naturally occurring Phormia regina myiasis in a malignant lesion; however, this infestation was accompanied by pain.

During the 1930s, attempts to isolate the ‘‘maggot active principle’’ generated

several reports of the successful topical application of maggot extracts to promote

wound debridement and disinfection (73–75). An injected maggot extract ‘‘vaccine’’

was reportedly successful (73, 75), but was associated with significant

systemic reactions, and eventually was abandoned.

These years also marked the beginning of the antibiotic era. By 1940, sulfonamides

were already available, and Chain et al (12) had discovered the methods

for mass producing Flemming’s penicillin. By the mid-1940s, maggot therapy

nearly disappeared from use, probably because of (i) the emergence of antibiotics

as a readily available alternative to maggot therapy; (ii) the reduced incidence of

bone and soft tissue infections, as a consequence of widespread antibiotic use;

(iii) improved wound care and aseptic techniques; (iv) improved surgical techniques;

(v) the expense of medicinal maggots; (vi) the cumbersome maggot dressings;

and (vii) the unacceptability of live maggot dressings, relative to the newer

alternatives.

Subsequently, maggot therapy rarely was used, except as a last resort (64, 130).

In 1988, maggot therapy was described by some as being beneficial in modern

military and survival medicine (21); while others wrote:

. . . Fortunately maggot therapy is now relegated to a historical backwater,

of interest more for its bizarre nature than its effect on the course of medical

science . . . a therapy the demise of which no one is likely to mourn

. . . (139).

Meanwhile, an infectious diseases fellow at the University of California was

planning clinical trials of maggot therapy for treating pressure ulcers and other

chronic wounds. Preliminary evaluation of this study suggested that maggot therapy

offered several advantages over other wound treatments currently employed

(117–20). By 1995, dozens of patients with pressure ulcers, diabetic foot wounds,

and chronic leg ulcers were being treated also at the Biosurgical Research Unit

in Bridgend, South Wales (135), and at the Hadassah Hospital maggot therapy

center in Jerusalem (85). In 1996, the International Biotherapy Society was founded ‘‘to investigate and develop the use of living organisms, or their products,

in tissue repair.’’ The society is now one of the sponsors of an annual International

Conference on Biotherapy. Thus, the revival of maggot therapy is well under way.