Medical History

3. At the dawn of the sixteenth century, European scholars could gain only a crude understanding of the anatomy of humans and animals. At the handful of universities where students trained in medicine�such as Bologna or Paris�professors read from the books of the Roman physician Galen. Galen had combined the philosophical work of Aristotle and other Greeks with his own lifetime of dissections, creating a system that explained not just the structure of the human body, but how the body worked. After the fall of Rome, Galen�s legacy lived on in Arab cities like Baghdad, where his work was translated, pored over, and encrusted with interpretations and commentaries. In the 1100s, Europeans began to translate Galen from Arabic and made his work the basis of medical training. But in the many steps of translation, much of the spirit of Galen�s work�especially his emphasis on observing for oneself rather than relying on authority�was lost. A tradition had emerged in which professors read Galen to their students, while a surgeon dissected an executed criminal to show the relevant parts of the body. There was no point in the professor looking for himself at the body, since everything worth learning could be found in Galen�s books. The Greek physician Galen (131-200 CE) used Aristotle's theories in his monumental work De usu partium, which served as a standard medical text for nearly a millennium and a half. Some of his discoveries -- the function of the kidneys, for instance, and the realization that severing the spinal cord causes paralysis -- were advances based on empirical observation. But Galen performed no human dissections, and perpetuated a number of errors. His model of the circulatory system, for instance, although it showed the arteries carried blood rather than air, made the liver the source of blood. His system depended on the coexistence of three "spirits" in the body: the liver was the seat of the natural spirit, the heart of the vital spirit, and the brain of the animal spirit. At the dawn of the sixteenth century, European scholars could gain only a crude understanding of the anatomy of humans and animals. At the handful of universities where students trained in medicine�such as Bologna or Paris�professors read from the books of the Roman physician Galen. Galen had combined the philosophical work of Aristotle and other Greeks with his own lifetime of dissections, creating a system that explained not just the structure of the human body, but how the body worked. After the fall of Rome, Galen�s legacy lived on in Arab cities like Baghdad, where his work was translated, pored over, and encrusted with interpretations and commentaries. In the 1100s, Europeans began to translate Galen from Arabic and made his work the basis of medical training. But in the many steps of translation, much of the spirit of Galen�s work�especially his emphasis on observing for oneself rather than relying on authority�was lost. A tradition had emerged in which professors read Galen to their students, while a surgeon dissected an executed criminal to show the relevant parts of the body. There was no point in the professor looking for himself at the body, since everything worth learning could be found in Galen�s books. The Greek physician Galen (131-200 CE) used Aristotle's theories in his monumental work De usu partium, which served as a standard medical text for nearly a millennium and a half. Some of his discoveries -- the function of the kidneys, for instance, and the realization that severing the spinal cord causes paralysis -- were advances based on empirical observation. But Galen performed no human dissections, and perpetuated a number of errors. His model of the circulatory system, for instance, although it showed the arteries carried blood rather than air, made the liver the source of blood. His system depended on the coexistence of three "spirits" in the body: the liver was the seat of the natural spirit, the heart of the vital spirit, and the brain of the animal spirit.

5. While it is the paintings of Leonardo that have brought him fame over the years, the full range of his talent can best be seen in his drawings.� His many drawings and notes, at least the ones that have survived, have become the basis for the modern scientific illustration, especially important in the field of anatomy.� Leonardo's anatomical studies, while great works of art in themselves, were used not only as tools to aid in his artistic understanding of the human form, but also as a means of scientific exploration of human functions.Leonardo da Vinci was born on April 15, 1452, in the town of Vinci, Italy.� He was the illegitimate son of Ser Piero da Vinci, a public notary, and a young peasant girl named Caterina, about whom little is known.� From a very early age, Leonardo is said to have shown exceptional ability in geometry, music, and artistic expression (Leonardo da Vinci: Anatomical Drawings, 10).� Noticing this, Ser Piero took his son's drawings to Andrea del Verrocchio in Florence.� Verrocchio was so struck by Leonardo's brilliance that he immediately took him in as his apprentice, and by 1472, at the age of twenty, Leonardo had joined the painters' civic guild in Florence.� However, little more is known about the education and training of Leonardo da Vinci, and it is assumed by many that much of his learning came not from traditional sources, but from his personal observations and the practical application of his ideas (Leonardo:� Anatomical Drawings, 10).� Giorgio Vasari, the artist who was also the first modern historian of art, described Leonardo da Vinci as a "unique genetic mutation", and believed that "his genius was a gift from God" (Keele and Blunt, 11).� Furthermore, he believed that Leonardo's approach to the anatomy of the human body was significantly influenced by his own remarkable physical attributes.During the time of the High Renaissance, the artist was primarily interested in the external details of the human form, while the anatomist was mainly concerned with the internal systems of the body.� These two seemingly different areas of study were unified as one by Leonardo da Vinci.� His anatomical drawings show a knowledge of the anatomy of human beings and animals, based on actual dissection, which exceeds that of his contemporaries in the medical profession (Keele and Blunt, 9).� Because of Leonardo's gifted artistic ability, he was able to observe these dissections, and describe what he saw not only in words, but in accurate scientific drawings.� In fact, a comment on one of his anatomical sketches states his belief that his drawings give "knowledge that is impossible for ancient or modern writers to convey without an infinitely tedious example and confused prolixity of writing and time" (Leonardo:� Anatomical Drawings, 6).��� Thus, Leonardo's greatest contribution to anatomy lay in the creation of a system of drawing which enabled anatomists, and even modern-day physicians, to transmit their findings to students.� Leonardo introduced a system involving the presentation of four views, so that every angle of a subject could be shown at once.� He also introduced the technique of cross-sectional representation (Wallace, 105), which he used to display the systems of veins, arteries, and nerves, as well as many cross sectional skull studies.� His method began with close observation, followed by repeated testing of the observation from various viewpoints, and concluded with a drawing of the object so that all the world could understand with brief explanatory notes (Wallace, 103).� While it is the paintings of Leonardo that have brought him fame over the years, the full range of his talent can best be seen in his drawings.� His many drawings and notes, at least the ones that have survived, have become the basis for the modern scientific illustration, especially important in the field of anatomy.� Leonardo's anatomical studies, while great works of art in themselves, were used not only as tools to aid in his artistic understanding of the human form, but also as a means of scientific exploration of human functions.Leonardo da Vinci was born on April 15, 1452, in the town of Vinci, Italy.� He was the illegitimate son of Ser Piero da Vinci, a public notary, and a young peasant girl named Caterina, about whom little is known.� From a very early age, Leonardo is said to have shown exceptional ability in geometry, music, and artistic expression (Leonardo da Vinci: Anatomical Drawings, 10).� Noticing this, Ser Piero took his son's drawings to Andrea del Verrocchio in Florence.� Verrocchio was so struck by Leonardo's brilliance that he immediately took him in as his apprentice, and by 1472, at the age of twenty, Leonardo had joined the painters' civic guild in Florence.� However, little more is known about the education and training of Leonardo da Vinci, and it is assumed by many that much of his learning came not from traditional sources, but from his personal observations and the practical application of his ideas (Leonardo:� Anatomical Drawings, 10).� Giorgio Vasari, the artist who was also the first modern historian of art, described Leonardo da Vinci as a "unique genetic mutation", and believed that "his genius was a gift from God" (Keele and Blunt, 11).� Furthermore, he believed that Leonardo's approach to the anatomy of the human body was significantly influenced by his own remarkable physical attributes.During the time of the High Renaissance, the artist was primarily interested in the external details of the human form, while the anatomist was mainly concerned with the internal systems of the body.� These two seemingly different areas of study were unified as one by Leonardo da Vinci.� His anatomical drawings show a knowledge of the anatomy of human beings and animals, based on actual dissection, which exceeds that of his contemporaries in the medical profession (Keele and Blunt, 9).� Because of Leonardo's gifted artistic ability, he was able to observe these dissections, and describe what he saw not only in words, but in accurate scientific drawings.� In fact, a comment on one of his anatomical sketches states his belief that his drawings give "knowledge that is impossible for ancient or modern writers to convey without an infinitely tedious example and confused prolixity of writing and time" (Leonardo:� Anatomical Drawings, 6).��� Thus, Leonardo's greatest contribution to anatomy lay in the creation of a system of drawing which enabled anatomists, and even modern-day physicians, to transmit their findings to students.� Leonardo introduced a system involving the presentation of four views, so that every angle of a subject could be shown at once.� He also introduced the technique of cross-sectional representation (Wallace, 105), which he used to display the systems of veins, arteries, and nerves, as well as many cross sectional skull studies.� His method began with close observation, followed by repeated testing of the observation from various viewpoints, and concluded with a drawing of the object so that all the world could understand with brief explanatory notes (Wallace, 103).�

6. Observing the Human BodyA young Flemish anatomist changed all that when he realized that Galen was dramatically wrong. Andreas Vesalius (1514-1564) started out his career as a defender of �Galenism� at the University of Paris. But when he moved to the University of Padua, he began dissecting corpses for himself to show his students the fine details of anatomy. He drew charts for the students to study, and the exquisite quality of the charts made Vesalius famous�so famous that the criminal court judge of Padua made sure he had a steady supply of cadavers from the gallows. As he grew more familiar with the human body, Vesalius began to notice that here and there, Galen had made mistakes. The human breastbone is made of three segments; Galen said seven. Galen claimed that the humerus (the upper arm bone) was the longest bone in the body, save only the femur; Vesalius saw that the tibia and fibula of the shin pushed the humerus to fourth. Over the centuries, anatomists sometimes had minor quibbles with Galen, but Vesalius began to suspect that there was something seriously wrong with his work. Vesalius widened his scope, dissecting animals, and reading over his Galen more carefully. The source of the mistake dawned on him. Galen had never dissected a human. The traditions of Rome did not allow such a practice, and so Galen had had to make do with dissecting animals and examining his patients during surgery. Instead of humans, Galen was often writing about oxen or Barbary macaques. Observing the Human BodyA young Flemish anatomist changed all that when he realized that Galen was dramatically wrong. Andreas Vesalius (1514-1564) started out his career as a defender of �Galenism� at the University of Paris. But when he moved to the University of Padua, he began dissecting corpses for himself to show his students the fine details of anatomy. He drew charts for the students to study, and the exquisite quality of the charts made Vesalius famous�so famous that the criminal court judge of Padua made sure he had a steady supply of cadavers from the gallows. As he grew more familiar with the human body, Vesalius began to notice that here and there, Galen had made mistakes. The human breastbone is made of three segments; Galen said seven. Galen claimed that the humerus (the upper arm bone) was the longest bone in the body, save only the femur; Vesalius saw that the tibia and fibula of the shin pushed the humerus to fourth. Over the centuries, anatomists sometimes had minor quibbles with Galen, but Vesalius began to suspect that there was something seriously wrong with his work. Vesalius widened his scope, dissecting animals, and reading over his Galen more carefully. The source of the mistake dawned on him. Galen had never dissected a human. The traditions of Rome did not allow such a practice, and so Galen had had to make do with dissecting animals and examining his patients during surgery. Instead of humans, Galen was often writing about oxen or Barbary macaques.

7. Medieval Human Anatomy Before Vesalius

8. Vesalius� Images

12. William Harvey What would it have been like to be a scientist in the time of Shakespeare? Best seats at the Globe Theater and invitations to command performances alongside the King and Queen? Why not, if you are married to the daughter of the Queen's physician? Better yet if you have been appointed physician to the King himself. By all accounts, William Harvey led a charmed life. Harvey, oldest of seven children, was born in 1578 in Kent, England, at the halfway point of the reign of Queen Elizabeth I. He was a voracious student, earning his bachelor's degree in 1597 from Cambridge University. He continued his schooling at the University of Padua, the foremost medical school of the time, where he studied under the esteemed scientist and surgeon, Hieronymus Fabricius. Fabricius, an ardent anatomist, had observed the one-way valves in veins, but had not figured out exactly what their role was. The popular belief of the day held that blood was circulated by a sort of pulsing action of the arteries. Harvey returned to England in 1602 and married Elizabeth Browne, who was the daughter of one of the Queen's physicians. Harvey himself obtained a fellowship at the Royal College of Physicians. In 1618 he was appointed as a physician to the court of James I. His research into the circulatory system and his other lines of inquiry were generously sponsored and encouraged by James I's successor, King Charles I, to whom Harvey was later appointed personal physician. By studying animals given to him by his regal employer, Harvey eventually developed an accurate theory of how the heart and circulatory system operated. He published his theories in 1628 in his famous book "On the Motion of the Heart and Blood in Animals," which made him notorious throughout Europe. But William Harvey was not satisfied with being the foremost anatomist of his day. He was intrigued by everything about the body, and at some point turned his attention to reproduction. He speculated that humans and other mammals must reproduce through the joining of an egg and sperm. No other theory made sense. It was 200 years before a mammalian egg was finally observed, but Harvey's theory was so compelling and so well thought out that the world assumed he was right long before the discovery was finally made. Harvey remained a physician at St. Bartholomew's until 1643. He maintained his college lectureship until 1656, the year before his death, missing by a moment the dismantling under Cromwell of the monarchy that had supported his research throughout his life. What would it have been like to be a scientist in the time of Shakespeare? Best seats at the Globe Theater and invitations to command performances alongside the King and Queen? Why not, if you are married to the daughter of the Queen's physician? Better yet if you have been appointed physician to the King himself. By all accounts, William Harvey led a charmed life. Harvey, oldest of seven children, was born in 1578 in Kent, England, at the halfway point of the reign of Queen Elizabeth I. He was a voracious student, earning his bachelor's degree in 1597 from Cambridge University. He continued his schooling at the University of Padua, the foremost medical school of the time, where he studied under the esteemed scientist and surgeon, Hieronymus Fabricius. Fabricius, an ardent anatomist, had observed the one-way valves in veins, but had not figured out exactly what their role was. The popular belief of the day held that blood was circulated by a sort of pulsing action of the arteries. Harvey returned to England in 1602 and married Elizabeth Browne, who was the daughter of one of the Queen's physicians. Harvey himself obtained a fellowship at the Royal College of Physicians. In 1618 he was appointed as a physician to the court of James I. His research into the circulatory system and his other lines of inquiry were generously sponsored and encouraged by James I's successor, King Charles I, to whom Harvey was later appointed personal physician. By studying animals given to him by his regal employer, Harvey eventually developed an accurate theory of how the heart and circulatory system operated. He published his theories in 1628 in his famous book "On the Motion of the Heart and Blood in Animals," which made him notorious throughout Europe. But William Harvey was not satisfied with being the foremost anatomist of his day. He was intrigued by everything about the body, and at some point turned his attention to reproduction. He speculated that humans and other mammals must reproduce through the joining of an egg and sperm. No other theory made sense. It was 200 years before a mammalian egg was finally observed, but Harvey's theory was so compelling and so well thought out that the world assumed he was right long before the discovery was finally made. Harvey remained a physician at St. Bartholomew's until 1643. He maintained his college lectureship until 1656, the year before his death, missing by a moment the dismantling under Cromwell of the monarchy that had supported his research throughout his life.

13. Arteries & Veins

14. Circulation

15. At first blush, most trauma patients told they may become host to a slippery, blood-sucking little worm aren't particularly fond of the notion. For many, mention of leeches recalls their famous cameo appearance in "The African Queen," with the ever-less prim Katharine Hepburn bravely plucking the slimy suckers off Humphrey Bogart's bare chest. Still, patients in danger of losing a finger, part of an ear or a piece of scalp quickly warm to Hirudo medicinalis when educated about its near-miraculous ability to reduce swelling and save their body part, says Dr. Nicholas Vedder, chief of the division of plastic surgery at the University of Washington and Harborview Medical Center. "I've never had a patient say no," says Vedder, who orders leeches from Harborview's pharmacy, where several dozen wriggle around in a fish tank. "Once you understand it's the leech or you lose your finger," he says, patients get downright cozy with their little friends. HARLEY SOLTES / THE SEATTLE TIMESA prescription leech at the Harborview Medical Center pharmacy. Rick Koch, 25, was airlifted from Twin Falls, Idaho, to Harborview on July 19 after a table-saw accident at work removed the thumb and fingers of his right hand. All but one finger was reattached, including his ring finger, which sported a fat black leech. "I'm game for anything," said Koch, watching as a nurse coaxed a new leech into place after the last one had done its job. He said he hadn't heard about medical leeches before he came to Harborview, but after an all-night surgery to reattach his digits, he was willing to trust his doctors. The federal Food and Drug Administration, which considers leeches to be medical devices, recently approved a French firm's request to market them in the U.S.; two existing U.S. distributors of medicinal leeches were grandfathered into the rules. Leeches aren't the only critters to make a medical comeback. Maggots, who in literature are often associated with decay and death, are considered invaluable by some practitioners in healing certain kinds of wounds. In January, Dr. Ronald Sherman, a California doctor, received FDA approval to market "medical maggots" for use in removing dead tissue from wounds such as pressure ulcers and nonhealing traumatic or post-surgical wounds. Over the past seven years, Sherman notes, some studies and much anecdotal evidence indicate maggots can help some wounds heal more quickly, helping prevent the need for amputation. Even parasitic worms, a target of many public-health efforts, may have beneficial effects. In a small study by University of Iowa researchers presented at a prestigious gastroenterology conference earlier this year, 72 percent of patients with inflammatory bowel disease who downed a Gatorade cocktail containing parasitic-worm eggs found symptoms relieved within three months. Could it be that bugs are sometimes best? Proponents say the proof is in the healing. Leeches Used by practitioners of the healing arts as early as 1500 B.C., leeches have been employed ever since for a variety of medical purposes. In medieval Europe, they were used for general bloodletting on patients suffering from everything from malaise to cancer. Information   International Biotherapy Society: biotherapy.md.huji.ac.il/ Biopharm (leeches): www.biopharm-leeches.com/ Leeches USA: www.leechesusa.com/ King County's leech page: dnr.metrokc.gov/ Dr. Ronald Sherman's "Maggot Therapy Project": www.ucihs.uci.edu/com/pathology/ Worm therapy for inflammatory bowel symptoms: my.webmd.com/content/Article/ In the 1800s, French physicians alone used a billion leeches a year, according to historians, draining "bad humours" and other ills. Not surprisingly, leeches got a bad reputation, sort of the crawling version of snake oil. But over the past decade, with the advent of advanced reconstructive surgery, leeches have, shall we say, crawled back into good repute as an accepted treatment for circulatory difficulties in the microsurgical reattachment of skin or body parts. Some studies say transplanted tissue flaps are much more likely to thrive when treated with leeches, compared with drug treatment or surgery alone. In the past year, Vedder estimates Harborview's leeches get credit for saving a half-dozen digits that had been surgically reattached but were in deep trouble. Typically, what happens is this: Microsurgeons have learned to reconnect small blood vessels so that a finger cut off by a saw, say, can be re-attached. But often, the trauma damages the fragile veins too much to reconnect them, or they're blocked by blood clots when they're attached. With arteries re-attached, blood comes in, but without working veins, the blood can't go out. That means oxygenated blood can't come in to heal the tissue, which will then begin to swell and turn dark. At that point, the body part is in trouble. Enter the leech, says Vedder. Leeches, marvelous "devices" that they are, carry all their medications on board in their saliva: an anesthetic, so you won't notice their tiny, sharp teeth; a substance that dilates blood vessels; and finally, hirudin, which Vedder calls the most potent anti-coagulant known to medicine. "The act of injecting that hirudin is the most important thing it does," says Vedder, because even after a half hour or so when the leech gets full and "kicks back to digest," the anti-coagulant keeps working, so the wound continues to bleed, allowing healing oxygenated blood to flow into tissues. Vedder and other surgeons who use leeches always prescribe antibiotics for patients, too, because even leeches bred specifically for medical use can't be sterile. Current interest in leeches revived after a 1985 case in Boston in which surgeons successfully re-attached a boy's severed ear with the help of leeches, said Lisa Darmo, a biologist with Carolina Biological Supply, a distributor for Biopharm. Biopharm, a Welsh company, is one of two main sources of medicinal leeches in the U.S. The company has about 100 regular hospital customers around the country, mostly trauma centers like Harborview, Darmo said. Harborview sometimes ships "emergency" leeches to other local hospitals, said Drew Edwards, Harborview's director of pharmacy operations. Darmo's company also gets calls from individual surgeons, mostly plastic or reconstructive specialists with a patient having a sudden problem with venous circulation; her company often provides emergency, same-day delivery of leeches, she said. "Sometimes they call, they've never used them before, but they're in a tough situation, and they hear from a colleague that this is a viable treatment option," Darmo said. Maggots Leeches and maggots and worms, oh my!   Yucky though they may be, these critters are very good at what they do best. In fact, advocates say, for certain jobs, they're the best alternative modern medicine can offer. Leeches There are hundreds of varieties; the most common in microsurgery is Hirudo medicinalis, a 5-inch dark-skinned native of southeast Asia and Europe. Primary use is to relieve congestion in a re-attached body part or flap of skin such as a lip, eyelid, ear, piece of scalp or finger. One leech can suck 5-15 ml of blood (about six to 10 times a leech's body weight), usually within 15 to 60 minutes. When it's "full," and detaches, the bite site may bleed for 10 hours or more, releasing as much as 150 ml of blood. A leech secretes three main substances: hirudin, which keeps blood from clotting; a vasodilator that relaxes smooth muscles of blood vessels; and a morphinelike substance that usually makes the bite painless. Maggots Specially raised, disinfected maggots, typically the larvae of Lucilia (or Phaenicia) sericata, the green blowfly, help clean wounds such as pressure sores and diabetic ulcers. They eat only dead tissue. First medical use was after World War I military surgeons noted better healing in maggot-infested wounds. In 1934, maggots were used by an estimated 1,000 American, Canadian and European surgeons. In 1940s, after antibiotics came into widespread use, maggots fell out of favor. Dr. Ronald Sherman, whose maggots recently were cleared for medical use by the FDA, has shown in studies that maggots are more effective than conventional treatment in excising dead tissue and reducing wound size in nonhealing foot and leg ulcers in diabetics. The number of practitioners or centers using maggots has swelled from fewer than a dozen in 1995 to almost 1,000, including more than 70 U.S. practitioners, says Sherman, one of two U.S. suppliers. Parasitic worms Gastroenterologist Joel Weinstock of the University of Iowa noticed there was more inflammatory bowel disease when public-health sanitation efforts improved, yet it was nearly nonexistent in less-developed countries where intestinal parasites are common. He theorized that the human immune system evolved to cope with a gut full of worms, and without them, it can become hyperactive, triggering an autoimmune response. Over 24 weeks, he studied 29 patients with autoimmune inflammatory bowel diseases, such as Crohn's disease and ulcerative colitis. Every three weeks, they drank a cocktail containing 2,500 eggs of the pig parasite Trypanosoma suis. By the 12th week, the disease was in remission for 21 of the 29 patients. Sources: Kowalczyk, "A low-tech approach to venous congestion," RN, Oct. 1, 2002; University of Michigan Museum of Zoology Animal Diversity Web (animaldiversity.ummz. umich.edu/site/index.html); Sherman, "Maggot Therapy for Foot and Leg Wounds," Lower Extremity Wounds, 1(2), 2002, Sherman, "Maggot therapy for treating diabetic foot ulcers unresponsive to conventional therapy," Diabetes Care, Feb. 2003; Knight Ridder News Service. Sharon Mendez, a registered nurse and certified wound-care specialist at Holy Family Hospital in Spokane, has used maggots in wound therapy for more than 20 patients in and out of the hospital. They're used to remove or "debride" dead tissue in a process called "maggot debridement therapy" or MDT. "My patients treated with MDT demonstrate pretty spectacular outcomes," says Mendez, who wrote the hospital's protocol for maggot use in wound therapy. Dr. Loren Engrav, a professor at Harborview in the UW's division of plastic surgery who has used maggots for difficult wounds, says they're a "marvelous debriding device, because they only debride what's dead and not what's alive." No surgeon, even the most skilled, can excise dead tissue with the precision of maggots, Vedder agrees. Sherman, the California doctor, has been sharing medical-grade maggots with other medical practitioners for the past decade. Sherman, who had a lifelong interest in insects, began his focus on maggots during his medical training in the 1980s. "After seeing the miraculous results, I have continued to do everything in my power to help others who want to try maggot therapy," he said. In a journal article in 2002, Sherman noted that there are no formal guidelines for the medical use of maggots. "Practitioners' treatment decisions have been made primarily on the basis of available medical literature, personal experience, and sheer desperation." One patient who became a believer is Pam Mitchell, an Akron, Ohio, diabetes patient who got a cut that wouldn't heal on her foot about five years ago. A break in the skin on her other foot led to another nonhealing wound. Many rounds of antibiotics later, she had two toe-tips amputated. Later, an infection in her heel became so bad doctors told her foot amputation would soon be her only option. "Then by chance I was talking to a co-worker who had seen maggot therapy on the Learning Channel and how well it worked in Europe," she said, and she persuaded her doctor to try it. "My orthopedic surgeon was amazed," said Mitchell, whose foot now has only a small scar. Engrav, at Harborview, stopped using maggots about a decade ago because of the disconnect between the hospital environment and maggots. It's the "yuck" factor, Engrav said. On a scale of 0 to 10, "a leech is maybe a 3 or a 4. But a mass of crawling maggots is maybe a 9." Sherman, in a journal article, noted "patient anxiety," as well as anxiety among nursing and medical staff, which he says can be addressed by education. "We have not found any successful methods of relieving the anxiety of hospital administrators," he conceded. For patients with a nonhealing wound, says Mendez, the Spokane nurse, the "yuck" factor is relative: "What's yuckier than an ugly, smelly wound on your body that's affecting your life and health?" she asks. "Or the doc saying 'I'm gonna have to amputate?' " In some cases, even 48 hours of treatment can do "amazing things," Mendez says. "And when you take that dressing off and see a clean, healthy, healing wound that completely turns a person's life around � it's great." A few years ago, the Hollywood blockbuster Gladiator had audiences squirming in their seats as the grievous wounds of the film's Roman gladiator protagonist, played by Russell Crowe, were treated (successfully, one might add) by the application of live maggots. Think it was Tinseltown hyperbole, or perhaps a brief star-turn for an ancient folk remedy? It might be surprising to hear, then, that maggot therapy is enjoying a revival as a modern medical technique�with apparently promising results. Today doctors use medicinal maggots to clean wounds by dissolving dead tissue and to disinfect them by killing bacteria. These actions stimulate proper healing. "I call them microsurgeons," said Edgar Maeyens, Jr., a doctor in Coos Bay, Oregon, who employs maggot treatment. "They can do what we can't do with scalpels and lasers." Only a few species of fly larvae, primarily blowflies, are suitable for such duty. Five to ten maggots are placed on each square centimeter (0.2 square inch) of a wound, which is then covered with a protective dressing that allows the maggots to breath. For the next 48 to 72 hours, the maggots dissolve dead tissue by secreting digestive juices and then ingesting the liquefied tissue and bacteria. The maggots grow from about two millimeters (0.08 inch) to nearly ten millimeters (0.4 inch) while doing the doctor's dirty work. "I'm just a supporting actor here," Maeyens said. "The maggots are marvelous." When Other Treatments Fail Maggot medicine isn't applied to just any case. It's employed on wounds that don't respond to more conventional methods. "After two or three failures of conventional medical or surgical therapy, maggot therapy should be considered for non-healing wounds, especially those which are infected or contain dead tissue [gangrene]," said Ronald Sherman, a doctor at the department of pathology at the University of California at Irvine. Wounds commonly treated include foot and leg ulcers, burns, and post-operative wounds that have become infected and re-opened. There is no shortage of patients eager to give the creatures a try. Suffering the maggots for a few days is small price to treat messy, painful wounds that have lingered for months or even years, doctors say. At first blush, most trauma patients told they may become host to a slippery, blood-sucking little worm aren't particularly fond of the notion. For many, mention of leeches recalls their famous cameo appearance in "The African Queen," with the ever-less prim Katharine Hepburn bravely plucking the slimy suckers off Humphrey Bogart's bare chest. Still, patients in danger of losing a finger, part of an ear or a piece of scalp quickly warm to Hirudo medicinalis when educated about its near-miraculous ability to reduce swelling and save their body part, says Dr. Nicholas Vedder, chief of the division of plastic surgery at the University of Washington and Harborview Medical Center. "I've never had a patient say no," says Vedder, who orders leeches from Harborview's pharmacy, where several dozen wriggle around in a fish tank. "Once you understand it's the leech or you lose your finger," he says, patients get downright cozy with their little friends. HARLEY SOLTES / THE SEATTLE TIMESA prescription leech at the Harborview Medical Center pharmacy. Rick Koch, 25, was airlifted from Twin Falls, Idaho, to Harborview on July 19 after a table-saw accident at work removed the thumb and fingers of his right hand. All but one finger was reattached, including his ring finger, which sported a fat black leech. "I'm game for anything," said Koch, watching as a nurse coaxed a new leech into place after the last one had done its job. He said he hadn't heard about medical leeches before he came to Harborview, but after an all-night surgery to reattach his digits, he was willing to trust his doctors. The federal Food and Drug Administration, which considers leeches to be medical devices, recently approved a French firm's request to market them in the U.S.; two existing U.S. distributors of medicinal leeches were grandfathered into the rules. Leeches aren't the only critters to make a medical comeback. Maggots, who in literature are often associated with decay and death, are considered invaluable by some practitioners in healing certain kinds of wounds. In January, Dr. Ronald Sherman, a California doctor, received FDA approval to market "medical maggots" for use in removing dead tissue from wounds such as pressure ulcers and nonhealing traumatic or post-surgical wounds. Over the past seven years, Sherman notes, some studies and much anecdotal evidence indicate maggots can help some wounds heal more quickly, helping prevent the need for amputation. Even parasitic worms, a target of many public-health efforts, may have beneficial effects. In a small study by University of Iowa researchers presented at a prestigious gastroenterology conference earlier this year, 72 percent of patients with inflammatory bowel disease who downed a Gatorade cocktail containing parasitic-worm eggs found symptoms relieved within three months. Could it be that bugs are sometimes best? Proponents say the proof is in the healing. Leeches Used by practitioners of the healing arts as early as 1500 B.C., leeches have been employed ever since for a variety of medical purposes. In medieval Europe, they were used for general bloodletting on patients suffering from everything from malaise to cancer. Information International Biotherapy Society: biotherapy.md.huji.ac.il/ Biopharm (leeches): www.biopharm-leeches.com/ Leeches USA: www.leechesusa.com/ King County's leech page: dnr.metrokc.gov/ Dr. Ronald Sherman's "Maggot Therapy Project": www.ucihs.uci.edu/com/pathology/ Worm therapy for inflammatory bowel symptoms: my.webmd.com/content/Article/ In the 1800s, French physicians alone used a billion leeches a year, according to historians, draining "bad humours" and other ills. Not surprisingly, leeches got a bad reputation, sort of the crawling version of snake oil. But over the past decade, with the advent of advanced reconstructive surgery, leeches have, shall we say, crawled back into good repute as an accepted treatment for circulatory difficulties in the microsurgical reattachment of skin or body parts. Some studies say transplanted tissue flaps are much more likely to thrive when treated with leeches, compared with drug treatment or surgery alone. In the past year, Vedder estimates Harborview's leeches get credit for saving a half-dozen digits that had been surgically reattached but were in deep trouble. Typically, what happens is this: Microsurgeons have learned to reconnect small blood vessels so that a finger cut off by a saw, say, can be re-attached. But often, the trauma damages the fragile veins too much to reconnect them, or they're blocked by blood clots when they're attached. With arteries re-attached, blood comes in, but without working veins, the blood can't go out. That means oxygenated blood can't come in to heal the tissue, which will then begin to swell and turn dark. At that point, the body part is in trouble. Enter the leech, says Vedder. Leeches, marvelous "devices" that they are, carry all their medications on board in their saliva: an anesthetic, so you won't notice their tiny, sharp teeth; a substance that dilates blood vessels; and finally, hirudin, which Vedder calls the most potent anti-coagulant known to medicine. "The act of injecting that hirudin is the most important thing it does," says Vedder, because even after a half hour or so when the leech gets full and "kicks back to digest," the anti-coagulant keeps working, so the wound continues to bleed, allowing healing oxygenated blood to flow into tissues. Vedder and other surgeons who use leeches always prescribe antibiotics for patients, too, because even leeches bred specifically for medical use can't be sterile. Current interest in leeches revived after a 1985 case in Boston in which surgeons successfully re-attached a boy's severed ear with the help of leeches, said Lisa Darmo, a biologist with Carolina Biological Supply, a distributor for Biopharm. Biopharm, a Welsh company, is one of two main sources of medicinal leeches in the U.S. The company has about 100 regular hospital customers around the country, mostly trauma centers like Harborview, Darmo said. Harborview sometimes ships "emergency" leeches to other local hospitals, said Drew Edwards, Harborview's director of pharmacy operations. Darmo's company also gets calls from individual surgeons, mostly plastic or reconstructive specialists with a patient having a sudden problem with venous circulation; her company often provides emergency, same-day delivery of leeches, she said. "Sometimes they call, they've never used them before, but they're in a tough situation, and they hear from a colleague that this is a viable treatment option," Darmo said. Maggots Leeches and maggots and worms, oh my! Yucky though they may be, these critters are very good at what they do best. In fact, advocates say, for certain jobs, they're the best alternative modern medicine can offer. Leeches There are hundreds of varieties; the most common in microsurgery is Hirudo medicinalis, a 5-inch dark-skinned native of southeast Asia and Europe. Primary use is to relieve congestion in a re-attached body part or flap of skin such as a lip, eyelid, ear, piece of scalp or finger. One leech can suck 5-15 ml of blood (about six to 10 times a leech's body weight), usually within 15 to 60 minutes. When it's "full," and detaches, the bite site may bleed for 10 hours or more, releasing as much as 150 ml of blood. A leech secretes three main substances: hirudin, which keeps blood from clotting; a vasodilator that relaxes smooth muscles of blood vessels; and a morphinelike substance that usually makes the bite painless. Maggots Specially raised, disinfected maggots, typically the larvae of Lucilia (or Phaenicia) sericata, the green blowfly, help clean wounds such as pressure sores and diabetic ulcers. They eat only dead tissue. First medical use was after World War I military surgeons noted better healing in maggot-infested wounds. In 1934, maggots were used by an estimated 1,000 American, Canadian and European surgeons. In 1940s, after antibiotics came into widespread use, maggots fell out of favor. Dr. Ronald Sherman, whose maggots recently were cleared for medical use by the FDA, has shown in studies that maggots are more effective than conventional treatment in excising dead tissue and reducing wound size in nonhealing foot and leg ulcers in diabetics. The number of practitioners or centers using maggots has swelled from fewer than a dozen in 1995 to almost 1,000, including more than 70 U.S. practitioners, says Sherman, one of two U.S. suppliers. Parasitic worms Gastroenterologist Joel Weinstock of the University of Iowa noticed there was more inflammatory bowel disease when public-health sanitation efforts improved, yet it was nearly nonexistent in less-developed countries where intestinal parasites are common. He theorized that the human immune system evolved to cope with a gut full of worms, and without them, it can become hyperactive, triggering an autoimmune response. Over 24 weeks, he studied 29 patients with autoimmune inflammatory bowel diseases, such as Crohn's disease and ulcerative colitis. Every three weeks, they drank a cocktail containing 2,500 eggs of the pig parasite Trypanosoma suis. By the 12th week, the disease was in remission for 21 of the 29 patients. Sources: Kowalczyk, "A low-tech approach to venous congestion," RN, Oct. 1, 2002; University of Michigan Museum of Zoology Animal Diversity Web (animaldiversity.ummz. umich.edu/site/index.html); Sherman, "Maggot Therapy for Foot and Leg Wounds," Lower Extremity Wounds, 1(2), 2002, Sherman, "Maggot therapy for treating diabetic foot ulcers unresponsive to conventional therapy," Diabetes Care, Feb. 2003; Knight Ridder News Service. Sharon Mendez, a registered nurse and certified wound-care specialist at Holy Family Hospital in Spokane, has used maggots in wound therapy for more than 20 patients in and out of the hospital. They're used to remove or "debride" dead tissue in a process called "maggot debridement therapy" or MDT. "My patients treated with MDT demonstrate pretty spectacular outcomes," says Mendez, who wrote the hospital's protocol for maggot use in wound therapy. Dr. Loren Engrav, a professor at Harborview in the UW's division of plastic surgery who has used maggots for difficult wounds, says they're a "marvelous debriding device, because they only debride what's dead and not what's alive." No surgeon, even the most skilled, can excise dead tissue with the precision of maggots, Vedder agrees. Sherman, the California doctor, has been sharing medical-grade maggots with other medical practitioners for the past decade. Sherman, who had a lifelong interest in insects, began his focus on maggots during his medical training in the 1980s. "After seeing the miraculous results, I have continued to do everything in my power to help others who want to try maggot therapy," he said. In a journal article in 2002, Sherman noted that there are no formal guidelines for the medical use of maggots. "Practitioners' treatment decisions have been made primarily on the basis of available medical literature, personal experience, and sheer desperation." One patient who became a believer is Pam Mitchell, an Akron, Ohio, diabetes patient who got a cut that wouldn't heal on her foot about five years ago. A break in the skin on her other foot led to another nonhealing wound. Many rounds of antibiotics later, she had two toe-tips amputated. Later, an infection in her heel became so bad doctors told her foot amputation would soon be her only option. "Then by chance I was talking to a co-worker who had seen maggot therapy on the Learning Channel and how well it worked in Europe," she said, and she persuaded her doctor to try it. "My orthopedic surgeon was amazed," said Mitchell, whose foot now has only a small scar. Engrav, at Harborview, stopped using maggots about a decade ago because of the disconnect between the hospital environment and maggots. It's the "yuck" factor, Engrav said. On a scale of 0 to 10, "a leech is maybe a 3 or a 4. But a mass of crawling maggots is maybe a 9." Sherman, in a journal article, noted "patient anxiety," as well as anxiety among nursing and medical staff, which he says can be addressed by education. "We have not found any successful methods of relieving the anxiety of hospital administrators," he conceded. For patients with a nonhealing wound, says Mendez, the Spokane nurse, the "yuck" factor is relative: "What's yuckier than an ugly, smelly wound on your body that's affecting your life and health?" she asks. "Or the doc saying 'I'm gonna have to amputate?' " In some cases, even 48 hours of treatment can do "amazing things," Mendez says. "And when you take that dressing off and see a clean, healthy, healing wound that completely turns a person's life around � it's great." A few years ago, the Hollywood blockbuster Gladiator had audiences squirming in their seats as the grievous wounds of the film's Roman gladiator protagonist, played by Russell Crowe, were treated (successfully, one might add) by the application of live maggots. Think it was Tinseltown hyperbole, or perhaps a brief star-turn for an ancient folk remedy? It might be surprising to hear, then, that maggot therapy is enjoying a revival as a modern medical technique�with apparently promising results. Today doctors use medicinal maggots to clean wounds by dissolving dead tissue and to disinfect them by killing bacteria. These actions stimulate proper healing. "I call them microsurgeons," said Edgar Maeyens, Jr., a doctor in Coos Bay, Oregon, who employs maggot treatment. "They can do what we can't do with scalpels and lasers." Only a few species of fly larvae, primarily blowflies, are suitable for such duty. Five to ten maggots are placed on each square centimeter (0.2 square inch) of a wound, which is then covered with a protective dressing that allows the maggots to breath. For the next 48 to 72 hours, the maggots dissolve dead tissue by secreting digestive juices and then ingesting the liquefied tissue and bacteria. The maggots grow from about two millimeters (0.08 inch) to nearly ten millimeters (0.4 inch) while doing the doctor's dirty work. "I'm just a supporting actor here," Maeyens said. "The maggots are marvelous." When Other Treatments Fail Maggot medicine isn't applied to just any case. It's employed on wounds that don't respond to more conventional methods. "After two or three failures of conventional medical or surgical therapy, maggot therapy should be considered for non-healing wounds, especially those which are infected or contain dead tissue [gangrene]," said Ronald Sherman, a doctor at the department of pathology at the University of California at Irvine. Wounds commonly treated include foot and leg ulcers, burns, and post-operative wounds that have become infected and re-opened. There is no shortage of patients eager to give the creatures a try. Suffering the maggots for a few days is small price to treat messy, painful wounds that have lingered for months or even years, doctors say.