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See Inside Scientific American Volume 309, Issue 2

Fear Not the Fecal Transplant

Medicine is art, science and gag suppression



Matt Collins

The long-running TV series M*A*S*H featured tireless and dedicated surgeons. ER, another long-lived series, featured heroic and complicated emergency health care workers. The recently concluded sitcom 30 Rock featured Dr. Leo Spaceman.

Usually pronounced “spah-CHEH-mun” (but occasionally astronautically), Spaceman somehow practices everything from psychiatry to transplant surgery to ophthalmology to obstetrics—when a new father asks Spaceman why the just delivered baby is “covered with goop,” the doctor replies, “Because everything about this is disgusting”.

Childbirth is especially messy. But think about medicine long enough, and you'll eventually agree with Everydoc Spaceman that it's all disgusting. Which brings us to fecal transplants. Of course.

Officially called a fecal microbiota transplantation, or FMT, the procedure involves the insertion of a small, diluted sample of stool from a donor into the colon of a recipient. (Clearly disgusting.) The swap imports a healthy community of bacteria, the intestinal microbiota, into the system of someone lacking healthful intestinal flora. (Billions on billions of microscopic organisms swimming around inside your guts.) Numerous studies have found the fecal transplant's bacterial army to be highly effective fighters against Clostridium difficile colitis, which causes terrible cramps and frequent bloody diarrhea. (Getting queasy.) The usual antibiotic treatment can disrupt the healthful diversity of gut bacteria. (Microbial mass murder.) And it is often unsuccessful. Researchers publishing in the Journal of Clinical Gastroenterology thus have suggested that the treatment should be considered as a first choice rather than a last resort. (Reading medical journals, blech.)

Unfortunately, the Food and Drug Administration recently made it harder to send in the microbial cavalry. In May the agency decided to require doctors to file an Investigational New Drug application before performing the procedure. As Judy Stone (M.D.) points out in her Scientific American blog Molecules to Medicine, the extra time and expense associated with the rule curtail the use of FMT. Stone specifically cites what she calls the “‘ick’ factor” as a barrier to more widespread acceptance of this treatment: “Thus far, resistance to transplants I have recommended has not come from patients or their families, who are desperate for relief. It has come from other health care workers, especially physicians, who seem to find the idea particularly distasteful.” Because a fecal transplant is gross, but cramps and bloody diarrhea are aesthetically pleasing?

With the intent of eradicating the fecal transplant ick factor, I reiterate that “everything about this is disgusting.”

In The African Queen, Oscar winner Humphrey Bogart could afford to be skeeved out by leeches all over him because surgeons weren't attempting to reattach a finger. In real life, leeches are routinely used at trauma centers and for microsurgical procedures to keep blood flowing, thanks to their production of natural anticoagulants.

Maggots are often used to dine on the dead flesh around various wounds because they're better at cleaning up the area than doctors are. “Maggot therapy” sounds bad, of course, so the term “larval therapy” was suggested. Finally, “biosurgery” got maggots out of the name, but they're still in the wounds.

Note to FMT proponents: for marketing purposes, you really have to downplay any reference to feces. It's no accident nuclear magnetic resonance (NMR) applied to radiological picture making became magnetic resonance imaging (MRI). Voilà, no nukes.

Leeches and maggots easily make my disgusting case. In more pedestrian examples, we have toenail fungus, bunions, hammertoe and foot funk. Dermatology is a constant stream of skin eruptions, warts and moles. Dentistry is hands in strangers' mouths. Orthopedics is cracking bones and pushing them around. Ear-nose-throat is wax-snot-phlegm. Brain surgery, transplant surgery, urology, proctology, gynecology, all nasty. Even the lollipop the pediatrician gives your kid is gonna wind up oozing a slimy trail of sugary saliva and hand schmutz down your car's dashboard on the drive home.

Attend one parasitology lecture, even glance at just one photo of a guinea worm, and you'll beg for something clean and simple like a friend's stool. So embrace the Microbiome Transplant with a smile. It belongs. Because everything about this is disgusting.

This article was originally published with the title "Embrace the Ick."

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