by Rose George
Unless you know better. Unless you are a plastic surgeon. When the surgeon Iain Whitaker did a telephone survey of all the sixty-two plastic surgery units across the UK in 2002, 80 percent of the fifty that replied had used leeches postoperatively in the salvage of compromised free flaps or digital replants within the last five years. Three units had used leeches more than sixteen times a year; fifteen had used them up to five times.57 There are abundant leech papers in journals of plastic surgery, maxillofacial surgery, and microsurgery detailing proper leech procedure. Leeches are judged to be effective in the salvage of various essential body parts such as fingers, ears, nipples, nasal tips, and penises. (Leeches were not used in the famous penis reconstruction of John Wayne Bobbitt but were apparently on standby.)58
By now, leeching is most commonly used in flap surgery, the transfer of a living piece of tissue from one part of the body to help another part, used in breast reconstruction, open fractures, large wounds, and improving cleft palates. Unlike a graft, the flap comes with its blood vessels attached, and the incoming blood vessels must be attached to the existing ones, an intricate and infernal weaving. Attaching tiny blood vessels calls for a microsurgeon, and if the blood vessels get congested, the microsurgeon calls for a leech. It is unquestioned practice now. Biopharm sends out leeches every day. Today’s packages are going to Cyprus and Finland.
Things have changed since Upton’s fly-by-night leech delivery. Both Hirudo medicinalis and Hirudo verbana are now endangered species, listed in Appendix II of the Convention on International Trade in Endangered Species of Wild Fauna and Flora.59 To export a leech you need a permit from CITES, and a permit can take six weeks to organize. This seems odd, in a building where leeches are breeding like, well, leeches. “Ours aren’t endangered at all,” says Carl. “We’ve got plenty.”
“We had an instance,” says Bethany, “where a Saudi doctor rang and said, look, this five-year-old boy is going to lose his foot, we really, really need them. It was frantic, it was just constant work between us speaking to the CITES authorities, and speaking to the airline trying to get all the air freight organized. We are two and something hours away from Heathrow. Our courier has gone away with everything and we had to speak to customs and say, can we get it done today rather than in two or three weeks. They actually held the Saudi Airlines flight for two hours for our courier to get up there.” As further proof that the boy was probably the well-connected kind of Saudi, the leeches were carried by the wife of one of the owners of Saudi Airlines.
CITES is a frustration. “I’m just waiting for somebody from CITES to cut his arm off,” says Carl, “and they say, you have to wait for the permit.” Airlines are another trouble. There aren’t many medical devices that are alive, so while leeches are medical devices, airlines treat them as livestock, and they don’t like carrying livestock. Some airlines are better than others at keeping their hold temperatures cool in the summer. Boiled leeches are always a possibility.
* * *
It’s time for the handling. Carl doesn’t have any appropriate Europeans, so we are invited to pick up a buffalo. He fetches a leech that looks big and black and, though I know better, a lot like a slug. He says, “This species is slimy. It’s super, super slimy.” Is that relish in his voice? He invites the first junior nurse to put her hands out. He will put his hands underneath in case the shock makes her drop it, but she is not shocked. She is entirely sanguine, in the English sense (the French have decided it means fiery and excitable). This is a nurse who won’t balk at bedpans. Carl gives an audio tour of the leech while it moves on her hands, sniffing and looking for a bite. “This is the biting end. That’s the holding end. The reproductive organs are there.” He tells us the color means that the leech is pregnant, and the nurse nearly drops it. “Don’t worry. They’re as tough as old boots.”
Will it splat?
“No. And they take quite a long time to bite.” An attached leech can bite in six seconds; a handled leech is slower. “You’d be surprised how much time you’ve got.” He estimates twelve to fifteen seconds, although he no longer needs to count. “I can see where the muscles are, when it’s about to bite. I can see exactly.” He also knows which leech it is, and who its parents were: this one has two stripes, and his and her parents had one each. I ask him if he gives leeches names and his expression says that is a very stupid question. “No. But they definitely have traits. Some are more aggressive than others, some are faster than others. Some are really placid.”
The second nurse takes the leech. She squeals. “Don’t worry,” says Carl. “The head is nowhere near. Chill out!” I ask her what it feels like and she says, “Like there’s a leech on my hand.” One more nurse, one more period of fewer than fifteen seconds of leech holding, and then it’s my turn.
I have blanked out what it felt like. My recording tells me that I said, “It’s all right, actually.” Then, immediately, “You can have it back now.” A picture shows my face screwed up in a classic expression of disgust. I remember something that felt not like slime but like nothing else. Cool. Alive. Something I didn’t want on my hands. I have no idea how I’d tolerate them on a ravaged ear, a reconstructed breast, a torn-off finger. I have no idea how I could be persuaded.
* * *
After months of reading papers on leeches, I notice something. Leech therapy “was well received by virtually all,” wrote Whitaker in his survey of plastic surgery units, “with only a small number of units reporting patient noncompliance within the last five years.”60 In a journal of head and neck surgery: “No patients had leech therapy stopped because of inability to tolerate the treatment.”61 A patient information leaflet on leech therapy: “The nurse will explain leech therapy to you and make sure you understand the process before applying the first leech.”62 By all these accounts, persuading a patient to undergo leeching is no more problematic than offering a needle. But the leech is not a needle, despite Carl’s analogy. It is a bloodsucking parasitic creature that has suckers and teeth. It is disgusting. Or is it?
There are good reasons that humans find things disgusting. For disgust theorists—there are such people, and they are great—it’s because things and creatures that disgust are things and creatures that are dangerous. A discarded hair that can transmit disease is more disgusting than one attached to a head. A caterpillar, which is unlikely to infest you, is less repellent than a worm, which might. This biological determinism is not fixed: what is found disgusting varies according to age, geography, and status. The disgustologist Dr. Val Curtis found that Indians were disgusted by urine, sweat, menstrual blood, cut hair, childbirth, vomit, mice and rats, lower castes, and decaying waste.63 The Dutch, meanwhile, were repelled by shit, stickiness, and fishmongers’ hands, as well as cats and dogs. When the author William Miller explored the disgust of Americans, he found them to be repelled by “feces, bodily fluids, pustules, rotting wastes, severed limbs, pubic hair, sexual fluids, graveyards, slaughter houses, compost, carrion, slugs, maggots, bloodsucking parasites and deformity.”64
Disgust is why the leech has been perverted into a symbol for malignity, parasitism, evil, and corruption, so that its secondary dictionary definition after “parasitic or predatory annelid worm” is “a person who extorts profit from or lives off others.” It is why Adolf Hitler and Nazi propaganda equated Jews with leeches, with pronouncements such as the Jew “whines for the favor of ‘His Majesty’ and misuses it like a leech fastened upon the nations.”65 It is why Dr. Peter Mark Roget, in his thesaurus, gave the leech five entries, and one is bane, subcategory “troublemaker,” along with parasite, threadworm, tapeworm. I love Roget’s thesaurus, but this seems unfair. I accept that the medicinal leech is not benign, however useful: as it lacks enzymes to digest blood by itself, it relies on bacteria in its gut to do the work of digestion. Patients’ wounds have subsequently been infected by Aeromonas hydrophila, other members of the Aeromonas genus, and Vibrio fluvialis, so antibiotics are given prophylactically as routine. But the leech
will not infest your guts like a tapeworm nor trouble you like a threadworm. A single leech will not kill you, though several hundred may. I’m not sure, given all the use and abuse that humans have made of leeches, who is the parasite and who the prey.
It’s true that leeching presents risk. Getting the leech to bite where it is wanted is not straightforward, and the literature is full of helpful suggestions of how to coax it into the needed position. A group of Mumbai doctors wrote to the Journal of Plastic, Reconstructive & Aesthetic Surgery in 2009 recommending applying the leech enclosed in a syringe tube, a method with “an obvious aesthetic advantage.”66 Cutting a square in the center of a piece of gauze and guiding the leech to it is another option. My favorite suggestion appears in an article in the Lancet of 1849 titled “Leeches Drunk Will Bite Till Sober.” Instructions: “Put the leeches that you are going to use in some warm porter, and directly they kick about in it, take them out, hold them in a cloth, and they will bite instantly, without fail, even if they have been before tried for some time without any success.”67
Leeches move more than other medical devices. In the literature, this is known as leech migration and it causes countless problems, because they can migrate both inside and outside the body. Some leeches have migrated to a patient’s throat; others to the bronchus, air passages leading to the lungs. In the past, leechers attempted to train their leeches by sewing a string to them. In a treatise on the leech, the nineteenth-century physician James Rawlins Johnson thought leeching useful for “phrenitis,” an ailment believed to derive from a retention of the menses, and, according to Zacutus Lusitanus, a sixteenth-century Portuguese physician, best treated by fastening four leeches to a piece of thread and introducing them as closely as possible to the uterus. “Lusitanus is so warm an advocate for their employment, that he declares there is no disease but will become mild under this mode of treatment, and particularly should the leeches be applied to the vessels of the anus.”68 There have been as many proposals to counter leech migration as there have been papers on repairing free flaps. But the best way to get a leech to bite accurately and to stay put is to have it watched. The people who must do the watching are nurses.
For months, I can’t find nurses in the leeching literature. They must be there, but their voices are silent. It is a puzzle. Without nurses, who would apply the leech and soothe the patient, and watch for leech migration and kill the helpful creatures when they are finished? And how do nurses overcome the disgust mechanism they must surely feel, because they are human, without conveying it to the patient? Then, late one night, I find a paper from the British Journal of Nursing, “Nurses’ Experience of Leech Therapy in Plastic and Reconstructive Surgery.” The authors are Alison Reynolds and Colm OBoyle.69 The study area was a thirty-bed plastic surgical ward in a major Dublin teaching hospital staffed by twenty-six nurses, five consultant plastic surgeons, and eight hospital doctors. The ward uses leeches about once every three months.
Reynolds was no leech specialist at first. She had encountered them as a student nurse, rotating around hospital departments and working on the plastic surgery ward. Then, in the early 2000s, leeching was more common because of the times. Ireland was rich. Eastern Europeans—mostly Poles—came to work in factories but without enough English to understand instructions. Poor comprehension met heavy machinery and traumatic injuries abounded. I ask Reynolds to recount her first leeching, but it was too long ago and there have been too many instances since then. She thinks she was on nights and was told, “You have someone here who’s for leeching,” and her reaction was what my reaction would be: “How am I meant to do that?” There was no official policy to give guidance. Nothing was written down. You asked your colleagues, and you took the things that looked like slugs, and you did your best.
The paper came about because she needed to write a thesis for a master’s degree. She discussed her work in plastic surgery nursing with OBoyle, a midwife who was her thesis supervisor, and when she got to the fact that in plastic surgery they used leeches, he said, “Stop!” It had to be leeches. But then she did what students are meant to do and looked at the literature. “And there was literally nothing.” Irish emphasis. Literally. Nothing. One paper written by a nurse in the late ’90s. Plenty of papers by surgeons about flaps and veins. But nothing from nurses about what having someone for leeching meant, nor how they felt about it when they set off for the patient’s room clutching a tub of annelids. She panicked and went to OBoyle. “I’ve got no foundation!” But he said, “Your foundation is that there’s nothing out there.”
She interviewed seven plastic surgery nurses. Every one disliked using leeches. “They might visibly squirm and distort their faces as they described the leeches and their need to be close to and manipulate them.” They described them as “the black slug,” “bloodsucking, slimy bugs,” and “creepy crawlies.” Other things they didn’t like: that the leech, that “dirty walking needle,” went against all their training: hygiene control was paramount, yet a live creature full of potentially toxic blood was moving around their hygienic hospital ward. Reynolds uses the anthropologist Mary Douglas’s famous definition of dirt as matter out of place. “The recasting of such matter (parasite) that is conceptually out of place […] would appear to be a challenge.” Having someone for leeching means extra care but no extra staff, or money. Plastic surgery nursing does not count as specialized, unlike oncology or midwifery. This is ludicrous, and Reynolds is indignant at it. Leeching is specialized. Not everyone can do it. It’s hard.
Migration, for example. I tell Reynolds that most surgeons gloss over this. If she were less polite, she’d snort, but her derision comes through anyway. “That’s typical surgeons. Migration is a big problem and anyone who says it isn’t clearly isn’t doing the therapy themselves.” Leeches move. They always move. “They’d be anywhere. Anywhere. Especially when you’re on nights, the lights are down, we’ve got a little nightlight, but you’re walking in watching your step because you could walk on one.” She has found leeches up curtains, on the radiator, on the floor, in the bathroom, in the shower. “You try to go in every fifteen minutes or half an hour but if it’s fallen off, it can fall anywhere, and then they just slide around, so you have trails of blood.”
It sounds so gothic and shocking. Why do patients agree to it? Because they have to. Only patients whose transplantation has failed are offered leech therapy, and the leech is the last resort. “It’s not like ‘I don’t need those tablets, I don’t need them’ and there are no repercussions.” Your repercussions are a lost finger or ear, or one reconstructed breast and one void. “You thought you were going to come in, you were going to have the surgery and you were going to go home and be yourself again, that this was going to be your identity.” No one offered leech therapy, says Reynolds, has ever refused. I press her. Even so, how do you persuade someone to submit to it? She says the surgeons come around first and suggest it. All official, like, with their white coats and terminology. “But I know that [the patient] is sitting there and I know they’re thinking, I’m going to ask the nurse later about this. The consultant will go through the medical stuff. But the itty-bitty things? They’ll ask the nurses.” She’s always right. The consultant leaves, and the patient says, “I didn’t really know what he meant, does he mean the little slug thing?” Reynolds always answered truthfully. “But I would always give my encouragement because I’ve seen this work. It might not, but at least we can say we’ve done everything.”
There are differing levels of acceptance. She delights me with a tale of a farmer. “He loved it. He thought this was amazing. He said, ‘Put them on, I’ll watch them, don’t worry, when that fella’s finished, I’ll ring the bell.’ He was watching them thinking it was the most fascinating thing ever. He’d say, that one did well now didn’t it?” His treatment was successful and he phoned all his friends to tell them about it. “But he was a farmer. A different kind of outlook.”
The Biopharm video includes a news report about a
woman named Michelle Fuller, from Bradford. She was young, she had children, and she had mouth cancer. Later, running across Yorkshire moorland with a new acquaintance, I’m surprised at her lack of surprise when I say that I’m writing about leeches. It’s because Michelle was her cousin. She tells me Michelle tried the leeches because she was sure they would save her life. No doubt about it. The leeches were placed on her new tongue, which had been constructed from a flap, four times a day for ten days. “I have never been squeamish,” Michelle told the local paper. “And I just said you have to do what you have to do.”70 The Daily Mail wrote that “bloodsucking leeches saved a woman from cancer,” but they didn’t.71 She died eight months later, aged thirty-three, a few weeks before her planned wedding, and I salute her.72