A man named Phil, according to a story in The Washington Post this July, spent years being found in a stupor. Slurring. Unsteady. Sleeping it off in emergency rooms. Everyone assumed the obvious, because everyone always does. The obvious, in his case, happened to be wrong. It took a fall, and eventually a gastroenterologist named P.C. Wickremesinghe, known to his patients as Dr. Wick, to work out that Phil had not been drinking at all. His gut had been doing the drinking for him.
The condition is called auto-brewery syndrome, and it is exactly what it sounds like. The wrong microbes take up residence in your intestines, you eat a dinner roll, and they ferment it into alcohol on the spot. Phil was, in the most literal sense, his own distillery. What finally settled the matter was not a pill or a lecture on temperance. It was a fecal microbiota transplant. Somebody else’s poop, delivered into Phil’s colon, evicting the tenants who had been running an unlicensed bar in there.
I read a great many articles about the indignities of the body these days. There was a time when I read them the way one reads about the weather in a country one never intends to visit. That time has passed. And this one stopped me, because it turns on something I spent a career quietly underestimating: the astonishing, unruly, hundred-trillion-strong civilization living in the human colon.
So let us take a look at what happens down there. I promise to keep at least one hand on the rail of good taste, though I make no guarantee about my grip strength these days.
The colon. What a place! A flexible tube, five to six feet long and two to three inches in diameter, which, I cannot help noticing, makes it longer than I am tall and considerably more flexible. It sits just north of where the sun does not shine, in a neighborhood where oxygen is hard to come by. It has more twists and turns than an Agatha Christie mystery and more nooks and crannies than a dozen English muffins. And it is home to roughly one hundred trillion microorganisms, collectively known as the microbiota. That number has fourteen zeros in it, more zeros than the average human can comprehend, and certainly more than I can, since I now struggle to remember a four-digit PIN.
Living in that jungle are hundreds upon hundreds of different kinds of bacteria, along with viruses, fungi, and assorted other little fellers. It is a bug-eat-bug world down there that somehow, in the normal course of events, manages to stay in balance, which is more than I can say for myself getting out of a low chair. These are the good guys. They keep each other in check, produce vitamins, break down the fiber I keep forgetting to eat, and generate a respectable slice of the energy I burn every day. In other words, a meaningful portion of my daily pep is manufactured by tenants I have never met, who earn their keep many times over and who are, frankly, more productive than I am.
Trouble arises when we mess with their food and their environment. Not enough fiber. Not enough water. Not enough of the kimchi and sauerkraut our gastroenterologists keep urging us to eat, as if a man my age is going to develop a sudden enthusiasm for fermented cabbage.
And then there is the big one for those of us in the golden years. Antibiotics.
Infections are common in the elderly. Urinary tract infections, pneumonias, and other souvenirs of a long life. We treat them with powerful antibiotics, which dutifully kill the offending organism. Unfortunately, antibiotics are not precision weapons. They are carpet bombers. They also wipe out the good guys, those trillions of loyal microbes who have kept the peace in my gut since Elizabeth II became queen.
Into that scorched earth march the opportunists. Chief among them is a nasty character called Clostridioides difficile, or C. diff to its victims, who understandably do not have the energy for five syllables. It attacks the lining of the colon, causes severe inflammation, and lays down ugly patches on the wall called pseudomembranes, which sounds like a prog-rock band but is considerably less entertaining. The first line of treatment? More antibiotics. Yes. We fight the fire that the fire department started by sending in a bigger fire department. Medicine is a humbling profession, and I say that as a man who spent a career in it.
Which brings us back to Phil. Wipe out the sensible tenants and you do not get an empty building. You get whoever shows up next. Sometimes it is C. diff. Sometimes it is a brewery. No liquor store, no pub crawl, no bartender to cut you off. You simply eat lunch and wait. At my age I would consider this a cost saving measure, except that the afflicted get all of the hangover, and occasionally the DUI, with none of the party. Worse, they get the suspicion. Years of it. Phil was disbelieved by people who had no idea they were accusing a man of a crime committed entirely by his intestines.
For severe, stubborn cases, the cure is elegantly logical. Reestablish the normal flora. Simply reintroduce the good bacteria. But wait. Where does one get healthy gut bacteria? Well. One gets them from the colons of healthy people. Which is a polite, medical way of saying you need a donation of somebody else’s poop.
Now, you might reasonably ask, why not just swallow the stuff, perhaps in a capsule, with a very stiff drink? Getting microbes in through the front door means running a gauntlet of defenses honed over millennia. Enzymes in the mouth. Hydrochloric acid in the stomach. Bile salts in the small intestine. It is a hostile immigration process, and a great many microbes do not survive the paperwork. So our innovative gastroenterologists often go around the back, bass ackwards if you will, and deliver the transplant directly into the colon through a flexible scope. Right up the tradesman’s entrance.
What follows is a battle worthy of the Second Punic War. An army of microbes bearing Latin and Greek names fit for Scipio Africanus sweeps in to take on Hannibal, elephants and all, and reclaim the lost real estate. And here is the astonishing part. For recurrent C. diff, a single treatment succeeds in eighty to ninety percent of cases. Eighty to ninety percent! I have hobbies with worse success rates. I have knees with worse success rates.
So impressed was I by all this that I looked into becoming a donor myself. A way, I thought, to finally give back, quite literally. I even heard they pay forty dollars a go, which would have been the easiest money of my life, and by some distance the shortest commute. It turns out the screening is ferociously strict. Health questionnaires, blood tests, stool tests, the lot. The good stool banks reject the overwhelming majority of applicants. Harvard has a higher acceptance rate.
So there it is. After eight decades of accumulating degrees, titles, and what I generously call wisdom, I have discovered the one credential I cannot earn. My poop is not good enough. The hottest commodity in gastroenterology today is manufactured daily by twenty-five-year-olds who eat kale, kimchi, and sauerkraut and jog voluntarily, and it gets flushed away as though it were nothing.
I took this personally, and I went looking for someone to blame. Naturally I blamed my microbes. But it turns out the average gut bacterium lives only a few days, which means the hundred trillion currently in residence are the youngest things about me. Billions of them were born this morning. They have no memory of the antibiotics, no part in the rejection, and no interest whatever in my grievance.
They just work here. The landlord is old.