When maggots appear

Aural myiasis, a maggot infestation of the human ear, was described in Roman medical literature as early as 2000 years ago. Aurelius Cornelius Celsus was a Roman author whose De Medicina catalogues medical knowledge of his own time, from diet and exercise to bone fractures and cataract surgery. While the treatise has reached considerable renown in the history of medicine, little is known of its author.

The rhetorician Quintilian described Celsus as mediocri vir ingenio (‘a man of mediocre mind’, Institutio Oratoria, XII, 9, 24), who published a large encyclopaedia covering several disciplines, from agriculture and military science, to rhetoric, philosophy and medicine.^{Reference Prioreschi5,Reference Daube8} The term ‘encyclopaedia’ in the classical literature did not have today's connotation of a work of universal scope, but rather described a collection of books dealing with various practical subjects presented for the purpose of giving instruction on the whole circle – ἐν κύκλῳ – in other words, a system of all the known arts. Today, unfortunately, only the eight books on medicine have survived.^{6,Reference Guthrie7}

In book VI, Celsus describes the common diseases of the ear, which, compared with the less ‘mischievous’ eye diseases, have the potential to ‘drive the patient to madness and death’:

Among the different kinds of ear conditions, Celsus reports a case of aural myiasis, and suggests some remedies to remove maggots from the ear:

Celsus also recommends pouring wine into the ear to easily remove dead maggots from the concha:

In addition to this, Celsus suggests that, if the ear passage has been narrowed and thick matter collects within, you should drip honey of the best quality. If this does not help, there must be added 8 g of verdigris scrapings to 65 cm³ of honey; they must be boiled together and so used. Iris root with honey has the same efficacy. So also has galbanum (8 g), myrrh and ox bile (1.33 g each), and wine in enough quantity to dissolve the myrrh (De Medicina, VI, 7, 6).

Beyond maggot infestation, Celsus gives general instructions on how to remove a foreign body that occasionally slips into the ear, such as ‘a small stone or some living thing’ (calculus aliquodve animal). Insects, such as a ‘flea’ (pulex), are removed by engaging them in a flock of wool (lanae paulum) soaked, if necessary, in resin (De Medicina, VI, 7, 9). Irrigation, a blunt hook or probe may be employed for solid objects. In addition, sneezing is said to be useful.

Another technique is to have the patient lie down with their ear on a plank which is then struck with a mallet, causing a vibration that dislodges the object or insect (De Medicina, VI, 7, 9). This procedure had already been described by the Alexandrian physician Apollonius Mys a century earlier.^{Reference Mettler and Mettler9} In fact, De Medicina was influenced profoundly by, and may have translated directly from, earlier Greek sources, such as the Hippocratic Corpus and the works of Asclepiades.^{Reference Mettler and Mettler9} Further remedies for aural myiasis are mentioned in another famous source from the ancient Mediterranean medical tradition that is Pliny's Natural History (Naturalis Historia), where the author listed children's urine (Naturalis Historia, XXVIII, 65, 7) and human breast milk (Naturalis Historia, XXVIII, 75, 5–6) as treatments.^{Reference Rackham, Jones and Eicholz10}

While some remedies described in De Medicina may be supported by modern medicine, these are the rare exceptions. Today, alcohol is an agent that can be used to immobilise insect foreign bodies, although it is not the first-line choice.

The ‘Cicero’ of medicine

Past and present scholars have debated whether Celsus wrote from personal experience as a physician, or rather compiled the knowledge of others as an encyclopaedist, in the same way Varro and Pliny did, and whose works – respectively, Varro's Antiquities, Pliny's Natural History and On the Arts by Celsus – were grouped together as a genre by later writers in search of antique precedents. If we were to ask the question, ‘Did Celsus consider himself a physician?’, the answer is an unambiguous ‘yes’. Discussing medical matters, he always writes in first person; he never says, ‘in this case, physicians do such and such’, but always ‘in this case, I do such and such’, as in the following example:

It is difficult to deny that Celsus practised medicine when we are confronted with a passage like the one quoted above. Yet, his contemporaries did not consider him a physician, nor did they refer to him often. Galen does not even mention him.^{Reference Prioreschi5} Further to this point, it is important to keep in mind that, at the time, a physician was somebody, usually Greek, who practised medicine for money. Celsus was certainly not Greek, and he did not take any money while dealing with medicine, as he clarifies in several passages of his work (e.g. De Medicina, III, 4, 9–10).

Celsus’ De Medicina was lost until the fifteenth century, when many authors used it to describe anatomical structures in Latin at a time when Latin became the lingua franca of science, until the end of the nineteenth century. It is not surprising that, in 1478, De Medicina was the first medical text to be printed and widely distributed.^{Reference Donaldson11,Reference Nutton12} His treatise represents, in a large part, a Latin translation of earlier Greek works.^{Reference Donaldson11,Reference Nutton13} Nevertheless, the impact of the work is clear, as nearly fifty editions were published between the late fifteenth and early twentieth centuries.^{6,Reference Nutton12} Celsus’ professional skills were excellent and his knowledge of medicine was exhaustive. He was also endowed with superior literary skills. Indeed, De Medicina is considered a masterpiece for the ‘elegance’ of its Latin prose. Often called the ‘Cicero of medicine’,^{Reference Dunglison and Dunglison14} Celsus has been considered responsible for the genesis of medical Latin.^{Reference Langslow, Sabbah and Mudry15,Reference Castiglioni16}

Thus, Quintilian's remark, which has generated much discussion among historians,^{Reference Prioreschi5} may stick out as most incongruous. Given that Celsus’ contributions to medicine are major, nothing is farther from the truth than the remark that Celsus was mediocri vir ingenio.

Celsus is certainly less known for his description of ear maggots than for describing, for the first time, the four cardinal signs of inflammation: rubor, tumor, calor and dolor (heat, redness, swelling and pain; De Medicina, III, 10, 3), terms which modern physicians learn early in their training.^{Reference Prioreschi5} Although Celsus did not express great interest in pathophysiology, he did acknowledge the importance of understanding the ‘nature of things’ to become a more capable practitioner.^{Reference Prioreschi5} To him, practice rather than discussion was paramount. He also underlined the need that ‘each person has knowledge of their physical nature’ to adapt their diet more effectively (De Medicina, I, 3, 13):

Celsus’ medical tradition in the West

The influence of Celsus’ description of ear maggots on ancient and modern medical practice is unclear, as no commentary about its reception is yet available. ‘Myiasis’, a term derived from ancient Greek (i.e. μυῖα, mya, ‘fly’), was first proposed in the English medical literature by entomologist FW Hope to define diseases of humans caused by dipterous larvae, as opposed to those caused by insect larvae in general: ‘I suggest that the term… Myasis (or the fly-disease) is given to those which originate in Dipterous larvae’ (1840;258). He described two cases of young men with ear maggots in the Caribbean islands.^{Reference Hope17}

Today, aural myiasis is certainly better understood and less common, with fewer than 50 cases reported in the literature between 1992 and 2012.^{Reference Jervis-Bardy, Fitzpatrick, Masood, Crossland and Patel18} Attracted to warm, moist environments, the female fly migrates from chickens, sheep and other livestock to lay her eggs in the human external ear canal. Larvae grow quickly, feeding on skin and underlying tissue. The resulting odour attracts more flies, each of which may deposit up to 150 additional larvae.^{Reference Jervis-Bardy, Fitzpatrick, Masood, Crossland and Patel18,Reference Francesconi and Lupi19} Found in the Mediterranean region of Europe and North Africa, Wohlfahrtia magnifica, the most common species responsible for aural myiasis, is perhaps the fly that Celsus described in his passage.^{Reference Francesconi and Lupi19}

If left untreated, patients with aural myiasis can develop eardrum perforation, middle-ear infection and hearing loss.^{Reference Hatten, Gulleth, Meyer and Eisenman20,Reference Wagner, Zabala and Choi21} Modern treatment bears some similarities to the recommendations in De Medicina. The first step is to remove visible maggots from the external ear. After manual cleaning, topical liquids are used to inactivate remaining larvae. Although alcohol is still used for this purpose, studies have shown that mineral oil is the safer option.^{Reference Antonelli, Ahmadi and Prevatt22} Twentieth century physicians also used anaesthetics like cocaine and chloroform to immobilise maggots.^{Reference Davis23,Reference Huth24} Celsus advocated removing maggots using an ear scoop (Fig. 2), a multi-purpose tool also employed in the extraction of kidney stones from the urethra.⁶ The number of maggots removed from the ear varies, from as few as 5 to as many as 190.^{Reference Davis23,Reference Keller and Keller25} Some physicians use topical antibiotics like ivermectin to paralyse remaining maggots. Patients with chronic infestation extending into the mastoid require surgical intervention.^{Reference Wang, Sun, Kong and Wang26}

Figure 2. Roman copper alloy ear scoop (scale represents millimetres). Reproduced with permission of Amgueddfa Cymru – Museum Wales.

Maggot infestation of the ear is a medical problem with importance in the ancient world that earned it a prominent place in Celsus’ description of ear disease. While its prevalence has likely waned over the past two millennia, with fewer people living in close contact with livestock, aural myiasis remains a rare but dangerous affliction of the ear.

Celsus, who was also responsible for Latinising our medical vocabulary, gave us this first description of aural myiasis in the ancient Roman medical literature. His writings retain their intellectual appeal still today, offering a glimpse into the medical landscape of a culture that dramatically influenced modern Western society. Despite the great advances in technology, scientific knowledge and technique enjoyed in the twenty-first century, a fundamental common thread joins Celsus and modern doctors: the motivation to share knowledge of disease and the treatment of patients through writing. After all, the word ‘doctor’ comes from Latin ‘to teach’. By writing stories, we as doctors aim to teach others about patients, while learning about ourselves. In this regard, there is much insight to be gained from an earnest examination of medical history.