In the 1990s, about twenty years before the topic of fecal transplants entered into polite conversation, my friend, Kate, made a comment that stopped me in my tracks.

One sunny afternoon while we walked along the Santa Fe River, Kate bent over to examine the pile of poop her dog deposited among the willows. She said, “Erica, come look at this shit. I wish mine looked this healthy. Do you think it would help my chronic gut problems if I ate some of my dog’s shit?”

I had held Kate’s intelligence and creative problem solving in high regard. But eating her dog’s shit did not sound like a good idea to me.

When I realized Kate was not joking, I gave her question some serious thought and answered, “I think you’re on to something, Kate, but the poop would have to come from a healthy human, not from a dog.”

As I spoke, I imagined Kate mixing her husband’s poop into some applesauce and having it for a snack. Yuck! The thought provoked waves of nausea and feelings of revulsion. Yet, at the same time, the idea piqued my curiosity. Could poop from a healthy human donor actually serve as a medical treatment?

After our walk, I went to the medical library and did some research on the subject of medical feces, a topic with a long and fascinating history. Archeologists had discovered a document from Ancient Egypt, written on papyrus dating back to 1500 BC that contained prescriptions for 50 remedies in which the active ingredient required human feces.

Traditional medical practitioners from 4^th century China used a fecal solution referred to as “yellow soup” for severe diarrhea and food poisoning.

Fecal transplants have been used in veterinary medicine for over one hundred years. The words fecal transplant refer to a procedure that involves diluting and straining fecal matter from a same-species donor and then delivering the fecal medicine to the recipient’s intestines by colonoscopy, upper endoscopy, “bowel lavage” (“colonic” in common parlance), enema, or by swallowing feces-filled capsules.

Some animals perform their own fecal transplants without the help of a vet. For example, on my trip to Thailand, I learned that baby elephants eat their mothers’ poop as they exit the birth canal. The beneficial bacteria from the mother elephant’s poop colonize the baby elephant’s intestines before the bad bacteria have a chance to stake their claim.

My search found reports about some less developed countries where midwives give a tiny amount of the mother’s stool to the newborn baby. This practice probably helps to jumpstart the baby’s immune system.

The beneficial bacteria are known to play a significant role in training the immune system to only attack substances that pose a threat to both the beneficial bacteria as well as the human host, while not responding to that which poses no threat. This modulation of the immune system can help lower the risk for allergies and autoimmune disease.

Many countries have been using fecal transplants for decades as the first line of defense for severe diarrhea caused by antibiotics.

The purpose of the fecal transplant is to replace the good bacteria that has been killed or suppressed—usually by antibiotics. The antibiotics cause our microbiome—the assortment of organisms that live in the intestines and keep each other in check—to get dangerously out of balance.

When the beneficial bacteria are suppressed, pathogenic organisms, including bacteria such as Clostridium difficile—commonly referred to as C.diff—can overtake the intestines and lead to multiple medical conditions, the most common one being severe and sometimes fatal diarrhea.

The Center for Disease Control (CDC) reported that about 500,000 people in the US were diagnosed with C. diff in 2012 and 14,000 died. Some other sources show that these numbers are likely even higher because of all the unreported cases.

Even though C. difficile infections are caused by antibiotics, they are also treated—often unsuccessfully—by several courses of powerful antibiotics such metronidazole (Flagyl) and Vancomycin. These series of antibiotics continue to cause more devastation to the gut microbiome, resulting in a downward spiral, putting the patient at risk for multiple medical conditions.

Fecal transplants can bring a rapid halt this downward spiral. The success rate is estimated to be 94%.

The first modern fecal transplant in the US took place in 1958, performed by a brilliant surgeon, Ben Eiseman, on four patients with pseudomembranous colitis, an inflammatory bowel condition that can cause life-threatening diarrhea. Dr. Eiseman suspected that the patients’ prior use of antibiotics had wiped out the beneficial bacteria, allowing the overgrowth of vicious pathogens. The surgeon flushed each patient’s colon with an enema solution of feces from healthy donors. All four of the patients regained their health within days.

For the next three decades, fecal transplants were performed sporadically in the US without much regulation or oversight. Most of the transplants were do-it-yourself procedures due to the lack of physicians knowledgeable about this unusual form of treatment.

Are fecal transplants potentially dangerous?

Dating all the way back to 4^th century China, there has not been a single documented case of a serious adverse reaction from fecal transplants.

The fecal enema treatment gained momentum slowly over the next three decades. By the late 1980s fecal transplants became known for their effectiveness in treating severe infections caused by Clostridium difficile.

At this point in my research, I became whole-heartedly convinced of the benefits of fecal transplants and continued to follow the latest research on the subject.

By 2013, the prestigious New England Journal of Medicine published an article about the benefits of fecal transplants, called “Fecal Microbiota Transplantation—An Old Therapy Comes of Age.” The study showed overwhelmingly positive effects of fecal transplants when compared to antibiotics for curing C. difficile. Fifteen out of sixteen patients who participated in the study were cured of their C. difficile infections after one or two fecal transplants, delivered through “bowel lavage.” No serious side effects were reported. The researches concluded that the fecal transplants were more effective than the antibiotics at curing C. difficile.

After the New England Journal of Medicine article appeared in early 2013, the FDA announced that feces would be classified as “an Investigational New Drug” (IND) and that physicians would have to apply for approval and jump through a number of tedious bureaucratic hoops in order to use this “new drug.”

Under pressure from the public, the FDA eventually reversed their ruling and allowed qualified physicians to continue performing fecal transplants, but only for recurrent C. difficile, and only with signed consents from patients and with tested donor stools.

The FDA reversal resulted in a growing number of physicians who were willing to perform fecal transplants for C.difficile, but there were still not enough of those physicians to serve the large population of people with antibiotic-induced problems. On top of that, many patients and their doctors are not aware of the fecal transplant procedure and simply give their patients with C.difficile one antibiotic after another.

One of the patients who came to me for help for her chronic diarrhea had been on a series of antibiotics for over one year for her resistant C.difficile infection. Her overall health crashed from the devastation to her intestinal microbiome. She asked me to help her get well using natural methods, but the special diet, herbs, and supplements I recommended proved to be only partially effective against the long-standing damage done to her intestinal tract. With some guidance from me, the patient took the initiative to get a fecal transplant performed by a gastroenterologist at a teaching hospital in New York City. The results were immediate. The same day of the procedure, the diarrhea stopped and she began the journey back to good health.

At present, fecal transplantation is officially sanctioned only for treating C.difficile. Currently experimental trials are being done using fecal transplants for treatment of inflammatory bowel diseases, such as Crohn’s Disease and Ulcerative Colitis. Other informal research projects are investigating the benefits of fecal transplants for many other medical conditions, including irritable bowel syndrome, chronic constipation, food allergies, chronic fatigue syndrome, and even dementia. The exploding research on the human microbiome is revealing the powerful connection of our microbial ecology to our general physical and mental health.

A few years ago, Lance, a gaunt-looking man in his forties and a former athlete, came to my office asking for help with his longstanding ulcerative colitis. Lance said that he could no longer tolerate the side effects from his medications for his UC and wanted to try a more natural approach.

Ulcerative colitis is a chronic inflammatory bowel disease that can cause painful abdominal cramps, frequent bouts of bloody diarrhea, a sense of urgency to use the toilet, nausea, weakness, and weight loss. The immune system attacks the mucous membranes that line the colon, also know as the large intestine. The immune system attack results in inflammation and ulceration. The ulcers in the colon produce pus and mucous and sometimes blood in the stools. The person with active UC makes frequent trips to the bathroom with bouts of diarrhea up to 8-10 times a day.

Lance slowly and carefully weaned himself off his medications while he followed a strict dietary protocol, including avoidance of all known irritants like caffeine, chocolate, alcohol, and spicy foods. He agreed to avoid common problematic foods such as gluten, dairy, soy, corn, and sugar. He switched to all organic, pesticide-free and GMO-free foods. Because his intestines were full of ulcers, he ate foods that were easy to digest, like white fish from Alaska, overcooked vegetables, rice, quinoa, olive oil, coconut milk and coconut oil, nuts in the form of nut butters or homemade nut milk, and herbs. Because of his ulcerous condition, he agreed to avoid raw foods like salads and fruits (except cooked apples) until his gut had healed. His regimen included probiotics. He tested each bottle for viability of the beneficial bacteria.

After six weeks on the special diet, Lance was able to get off all of his medications and felt significantly better. His bouts of diarrhea were less frequent and the abdominal pain less severe. Although he continued faithfully on the program, his symptoms never resolved completely.

Lance said he was willing to consider other possibilities like a fecal transplant. I encouraged him to thoroughly research the subject and then come back for a follow-up appointment so we could discuss his options.

Lance understood that his insurance would only pay for officially sanctioned fecal transplants specifically for persistent C. difficile infections. He decided to take matters into his own hands and do a home-based treatment on himself. I described the ideal fecal donor—a healthy child, born by vaginal delivery, breast fed, with no history of vaccinations or antibiotics, and fed a healthy, GMO-free diet. Lance could not think of anyone he knew  that fit that description. Instead, he thought about asking his best friend to be the fecal donor. He knew that his friend had been in excellent health, with no gut problems and no high-risk sexual behavior. The friend ate a moderately healthy diet, and had not used antibiotics since he was a child. I suggested Lance invite his friend to come with him for a consultation with me.

The appointment began with a crash course in fecal transplants—making sure to point out the absence of adverse reactions—followed by Lance’s unusual proposal to his friend. His friend found Lance’s request quite amusing and really weird. After he stopped laughing, he said with a smile on his face that he would agree to supply the “drug” at no charge. He even agreed to go to his primary care provider and ask for the screening tests recommended for all fecal donors, including tests for hepatitis, parasites, HIV, syphilis, the C. difficile stool antigen, giardia and other common intestinal pathogens.

Lance had no problem finding fecal transplant protocols on the internet from Do-It-Yourself entrepreneurs who demonstrate on YouTube in great detail everything needed for a home fecal transplant enema, including the dedicated blender, the kind of enema bag to buy, and how to clean out the colon the day before the procedure.

Three weeks after our prior appointment, Lance came for follow-up. He reported that he had done two fecal transplants, one week apart—just to make sure. He enthusiastically proclaimed that he was free of symptoms for the first time in many years—and on no medications. After reveling in the good news, we spent the rest of the appointment discussing measures to assure that his gut remained healthy, including the suggestions made in the recent blog post about microbiomes. The link is https://www.musingsmemoirandmedicine.com/2016/07/microbiomes-making-friends-with-our-colonies/

Here are a few of the suggestions I made to Lance:

• In order to maintain the health of the gut, it’s important to limit one’s exposure to substances known to upset the delicate balance or our internal ecosystem. Once disrupted, we become susceptible to overgrowth of fungus and pathogenic bacteria.

• Antibiotics and an unhealthy diet are known to cause devastation in our ecosystem. Practice prevention and use antibiotics only when absolutely necessary.

• If you use antibiotics, be sure to follow them with a month of Saccharomyces Boulardii, a harmless yeast that helps fight C. difficile quite effectively. Take the capsules as directed on the bottle. At the same time, take a probiotic daily for several months. Be sure to check each bottle for the viability of these fragile organisms. I have discussed a quick and easy method for testing viability in past blog posts, including the cancer series.

• Fungus thrives on sugar. Avoid sugars, excess fructose, and simple carbohydrates. Simple carbs turn immediately to sugar once they hit the saliva in the mouth, e.g., breads, pasta, crackers, cookies, boxed cereals, and other milled grains. (“Milled” means the grains have been to a factory and processed.)

• Avoid GMO foods. The genetic material in the genetically-modified foods can sometimes get incorporated into the genes of the bacteria in our intestines where they have the potential to become little pesticide-producing factories.

• Since the GMO labeling issue is confusing and misleading, stick to organic foods and avoid processed foods where genetically-modified foods are most likely to be found.

• Avoid pesticide-laden and genetically-modified foods when eating out at restaurants, especially corn and soy products, including corn oil commonly used with fried foods. Canola oil has also been genetically modified.

Fecal transplants have evolved from low-tech operations dating far back into medical history, to outlaw do-it-yourself home procedures, to major clinical trials published in peer-reviewed medical journals, to insurance-covered medical procedures performed in hospitals. Although the procedures are officially sanctioned only for treating C. difficile infections, research is underway at various institutions to determine the effectiveness of using fecal transplants for ulcerative colitis, Crohn’s Disease, irritable bowel syndrome, and many other conditions. So far, the results look quite promising.

Take good care of your microbiome. We don’t want the beneficial bacteria to become endangered species. Someday, if you take really good care of your internal ecosystem, your healthy feces might become a substantial source of income from underground markets, seekers on Craig’s List, and from medical institutions desperately in search of healthy fecal donors! This possibility gives new meaning to the expression about alchemists turning shit into gold. And a new meaning for the expletive “Holy Shit!”

Here’s to your good health—including the health of your microbes.