Grunt (20 page)

You can imagine what might happen to the open wounds of a soldier lying on a battlefield for any length of time. Most likely you would be wrong.

T
HE SOLDIERS,
two of them, are not named, nor is the battlefield on which they were hit. We know that it happened in France during World War I, sometime in 1917. We know that it wasn’t winter, because the men arrived at an army hospital having lain “in the brush” for seven days. And because it was fly season.

On removing the clothing from the wounded part, much was my surprise to see the wound filled with thousands and thousands of maggots. . . . The sight was very disgusting and measures were taken hurriedly to wash out these abominable looking creatures. Then the wounds were irrigated with normal salt solution and the most remarkable picture was presented. . . . these wounds were filled with the most beautiful pink granulation tissue that one could imagine.

That’s US Expeditionary Forces surgeon William Baer relating the story of how he came upon the unseemly idea of intentionally infesting wounds with maggots to help them heal. Filth fly larvae—blowfly maggots, most notably—prefer their meat dead or decaying. When the meat is part of an open wound, the act of eating performs upon the meal a kind of natural debridement. Debridement—the removal of dead or dying tissue—fights infection and facilitates healing. Because dead tissue has no blood supply and thus no immune defenses, it’s easily colonized by bacteria. This encourages infection of the healthy tissue and inflammation, which slows healing.

Baer was impressed that the soldiers had no fever or signs of gangrene. The mortality rate from the type of injuries the men had—compound fractures and large, open wounds—was about 75 percent with “the best of medical and surgical care that the Army and Navy could provide.” In 1928, a decade after the war had ended, Baer summoned his courage and experimented on civilians. His inaugural patients were children, four of them, all with recurrent bone infections from blood-borne tuberculosis, a condition that antiseptics and surgery sometimes failed to quell. Raymond Lenhard, the author of a biographical monograph on Baer, recalled hearing the great surgeon tell the story. Lenhard had been a student of Baer’s at Children’s Hospital School in Baltimore and, reluctantly, a dining companion. (“Often during lunch he would make us lose our appetites.”) Using the offspring of blowflies trapped near the hospital, Baer “loaded up” a wound and proceeded to watch the results. After six weeks, the wound had healed. As did the wounds of the other three children.

What sort of person experimentally infests a child with maggots? A confident sort, certainly. A maverick. Someone comfortable with the unpretty facts of biology. Someone who is perhaps himself an unpretty fact of biology. “The Chief was overweight, breathed audibly, and snorted in the fashion of a tic,” wrote Lenhard. Baer would sometimes go from operating room to lecture hall without changing, delivering his talks in baggy, bloodstained surgical trousers. He bred Chow Chows at his home, bringing yet more snorting and audible breathing to the Baer household.

Beneath the earthy exterior, Baer was an exacting and dedicated practitioner. He considered his “maggot treatment” far less abhorrent than the alternative: amputation. To Baer, the removal of a limb was “the ultimate in destruction,” wrote Lenhard, showing a flair for video game marketing eighty years premature.

So impressed was Baer by the work of his larval “friends” that he designed and built a thermostat-controlled wood and glass fly incubator at the hospital. Only thrice in an ensuing eighty-nine cases did the maggots fail and the patient succumb to infection. Fearing that the larvae may have introduced the offending bacteria, Baer devised a protocol for raising sterile specimens. Remnants of his technique live on today at Monarch Labs, in Irvine, California. Their Medical Maggots are also sterile, as required by the Food and Drug Administration (FDA), which in 2007 approved live blowfly larvae as a medical device.

While the majority of modern “maggot therapists” treat the hard-to-heal foot ulcers of diabetics, WRAIR’s George Peck has been seeking to take medicinal maggots back to their roots in the military. In 2010, he was funded for a study looking into the efficacy of blowfly larvae in treating chronically infected IED wounds. More recently, Peck received a grant to genetically modify blowfly maggots such that they produce antibiotics. Though maggots already prevent infection, these “supermaggots” could be tailored for specific bacterial infections.

Peck offered to hatch a “clutch” of maggots for me, taking care to time things such that when I arrive at his and his wife’s home for dinner, the larvae will be the size of Medical Maggots at the time they’re released in a wound (about two millimeters long). I don’t have any wounds. Just questions.

G
EORGE PECK
and his future wife, Vanessa, worked together in the basement insectary at WRAIR. An insectary is a facility for rearing insects—insects used, in this case, for testing vaccines and repellents against whatever has been lately plaguing troops. Vanessa cared for a colony of sand flies,
‡
while George was down the hall with his filth flies. It’s a setting that might dampen the ardor of another pair, but Peck remains besotted. You hear it behind his words when he talks about her. Peck is a man easily taken by emotion. At Mi Rancho a few nights earlier, as we were getting ready to leave, the topic turned briefly away from flies. As I rose from my chair I heard Peck say, to no one specific, “I just love bees.” The word
love
breathy with feeling.

Peck abandoned a career in solar physics, because he felt it was taking him too far away from the natural world. He and Vanessa share their home with more of that world than most. They keep as pets a tarantula (Henrietta) and a small community of Madagascar hissing cockroaches. Like William Baer, Peck is a man some might find eccentric, but those who know him even slightly can see that it all comes down to a generous and open heart.

Vanessa clears the dinner plates while I finish my wine. The children are doing homework in the living room. George sets a glass dessert dish in front of me.
Chocolate pudding,
my brain offers optimistically, but it’s not that. It’s raw liver.

“These are about one day old.” Peck points out a cluster of maggots, maybe twenty or thirty, feeding side by side, packed in close. They’re easy to miss, because all that can be seen of them is their tail ends. Insects take in oxygen through openings in the exoskeleton called spiracles. In the larvae, these are, specifically, anal spiracles. On top of its other charms, the maggot breathes through its ass. It is a handy evolutionary adaptation if, as Peck puts it, “you spend your whole day with your head buried in slimy dead flesh.” Compared to lungs and a diaphragm, it’s an inefficient system, which is one reason the Insecta class never evolved to be as large as Mammalia. Having several minutes ago viewed a fly under George Peck’s home microscope, I assure you that’s a good thing.

William Baer likened clusters of feeding maggots to litters of puppies. “So voracious are they in their struggle for food that they will stand upright on their heads with their tails in the air, as puppies do . . . around a basin of food where the basin is too small for the number of puppies.” Baer had dogs on the brain. To me, they look like a set of tiny accordion buttons being played by some ghost polka virtuoso. The important thing, especially for someone being treated with them, is that they don’t look like maggots. So if a patient peeked beneath the trademarked Monarch Labs LeFlap dual-layered maggot cage dressing, he would not be slammed with a squirming Halloween horror visual.

Peck transfers three outliers to the tip of my index finger. They rear up and wave their heads like happy
Sesame Street
puppets. Peck says they’re searching for food. Now two are lifting the third up above them. They remind me of jubilant teammates after a sporting victory.

Peck isn’t reading joy in the scene. “They do cannibalize,” he says gently.

Upon closer inspection, they are, yes, attacking—
eating!—
their clutch mate. They were away from the liver for maybe two minutes! The maggot lives to eat. That is what it does, all it does, for the four or so days before beginning the energy-intensive, deeply sci-fi project of rearranging itself into a fly.

Peck puts a maggot under the microscope he has set up on the kitchen table, so I can get a closer look at the mouthparts: the showpiece of maggot anatomy. They are rasping, curved scythe-like things. They’re the only piece of the maggot formed from chitin, hard and brown in contrast with the creature’s moist, pale, flexible self. Fortunately for maggot debridement therapy patients, the tissue deep inside a wound—dead or alive—has no sensory nerves; those are up in top layers of skin. Provided the Medical Maggots recommended “dosage”—5 to 8 maggots per square centimeter of wound surface—hasn’t been exceeded, there should be enough dead tissue to go around, and no ravenous maggot will shift its gaze to live skin.

“Those little mandibles,” Peck says as I look through the eyepiece, “can do what no surgeon or scalpel can do. No robotic laser can bend its light into a hidden crevice from an IED blast like that can.
That
is the master surgeon.” If you want to destroy every last bacterium and shred of dead tissue, a maggot is your man. He’s a small man, though, so it takes a while. A course of maggot debridement therapy—up to six rounds of fresh larvae—may take weeks. Whereas surgical debridement can be done in a matter of hours. And if a patient’s immune system is healthy, as a young soldier’s tends to be, it’s not necessary to get every last cell of bacteria and necrotic flesh.

But Peck never suggested that maggots be used for the initial debridement of a blast wound. For military personnel, maggots would come into play further down the road, should a recalcitrant infection set in—some antibiotic-resistant strain, perhaps something exotic and stubborn that lurked in the dirt that was blasted so deeply and voluminously into the wound. These complications set in often enough that Peck received military funding for a rodent study to measure the effectiveness of maggot debridement therapy for soil-infected IED wounds. The experimental protocol presented challenges. It required Peck’s team to surgically mimic, in a rat, the typical injuries caused by a bomb blast. To meet the requirements of the animal review board—and Peck’s own personal ethics—no part of the process could be painful to the rat. The nerves supplying feeling to that portion of the body had to be identified and severed.

Peck’s funding was not renewed, for reasons that are fairly easy to guess at. Modern hospital culture is technology-driven and forward-looking. To those unfamiliar with the studies and success rates, maggot therapy sounds primitive, anachronistic. Peck recalls presenting some promising preliminary findings to a roomful of colleagues and listening while a disapproving colonel talked about the thirty years of advancements he’d seen in his time at WRAIR. The man shook his head. “And we’re using
maggots.
”

A 2012 survey of US Army physicians suggests that the colonel’s opinions are not those of the majority. While only 10 percent of those surveyed had prescribed maggot debridement therapy, 85 percent felt that having access to practitioners would be a good resource. Their reservations were mostly just practical: They didn’t know where to obtain the maggots or how to use them or what the billing code might be.
§
In a smaller survey, practitioners voiced concerns that the medical facility they worked for wouldn’t allow maggots, and that patients would be likely to balk.

They are wrong about the patients. The surgeon who runs the Southern Arizona Limb Salvage Alliance,
¶
David Armstrong, has applied maggots to more than a thousand patients. “I can count on one hand the number of people who have refused,” he told me. The Medical Maggots FDA approval summary cited a “complaint and adverse event” rate of 1 percent, many of these occasioned by “late or lost” (or perhaps hurled into a Dumpster by the driver) FedEx shipments. The yuck factor of these wounds—and their resistance to more conventional treatment—well overrides the yuck factor of hosting live blowfly larvae. Also, Medical Maggots are less off-putting than you might imagine. Straight out of the vial, they’re the size of cupcake sprinkles. When they’re not eating each other alive, they’re kind of adorable. They move like inchworms, like something you might see humping along the pages of a children’s book.

“People take an interest in the cute little guys,” Armstrong said, quickly amending his statement with “. . . and gals.” You mean, I asked him, the way one might follow the progress of seedlings one has planted, or guppies one is raising? “Exactly,” he said. “And then, in turn, the progress of the healing going on. It’s hard to describe it, but the larvae draw people into the wound emotionally.” Medical Maggots patients, some anyway, are sufficiently positive and cavalier about their infestations that they go around wearing Monarch Labs t-shirts that proclaim, “Maggots on Board!”

Hospital staff are less charmed. “A lot of doctors and nurses find it repulsive,” Armstrong told me. Colonel Pete Weina, former director of the Complex Wound and Limb Salvage Center at WRAIR and now their chief of research programs, agrees. Around 2009, Weina had a William Baer moment. “I had a patient who’d passed out in an alley and flies had come by and laid eggs in his wound. The nurses were all, ‘Oh my God, this is terrible, get the maggots out of there!’” Recalling what he’d read about the blowfly larvae’s talent for debridement, Weina improvised a cage dressing to keep them from straying and left them in. The wounds healed nicely, but Weina backed away from the practice. “The entire hospital was pretty much grossed out by what I was doing.”

While not discounting what he calls “the gross factor,” George Peck sees cost as the main hurdle. How is it, you might ask, that maggots are more expensive than surgeons? It’s not the creatures themselves; a vial of Monarch Labs maggots is priced at $150. It’s the time demands on medical staff—staff who have to be trained to monitor the maggots and change the dressings. Peck shows me a second bowl of liver and maggots, hatched two days earlier. “See how foamy and goamy it is in there?” With, say, a hundred maggots, he explains, the breathable mesh of the cage dressing quickly becomes nonbreathable. The larvae suffocate. The nurses are repulsed.