This Podcast Will Kill You - Ep 201 Poop Part 2: Flushed away

Episode Date: February 17, 2026

Poop is an incredibly valuable and massively underutilized resource. However, most of us don’t see it that way because of our evolutionarily ingrained disgust towards poop. Flush toilets and intricate sewer systems have revolutionized health and hygiene by whisking our poop far away where we don’t have to think about it. But that poop has gotta go somewhere, and eventually, not thinking about it isn’t going to be an option. Similarly, not thinking about our individual poop is asking for disaster, since what we produce can reveal a great deal about our gut and overall health. In this episode, we explore the problems that poop can cause on both the individual and population level. From constipation to fiber, and the Great Stink to communal poop sponges, we’re continuing our journey into the curiously fascinating world of poop. Support this podcast by shopping our latest sponsor deals and promotions at this link: https://bit.ly/3WwtIAuSee omnystudio.com/listener for privacy information.

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The greatest to ever play the game. Return to finish what they started. Welcome to Survivor 50. I wanted one more shot to play the game that I fell in love with 25 years ago. I want to win against the best of the best. I chickened out at the final tribal. Season 50, it's an honor. Light your torch.

I've got some unfinished business. Be part of history. I have more to play for this time. Bigger than ever. Survivor 50. New milestone season begins CBS tonight at 87 Central. Sir, I traverse this day by Steamboat, the space between London and Hungerford Bridges, between half-past 1 and 2 o'clock.

It was low water, and I think the tide must have been near the turn. The appearance and the smell of the water forced themselves at once upon my attention. attention. The whole of the river was an opaque, pale brown fluid. In order to test the degree of opacity, I tore up some white card into pieces, moistened them so as to make them sink easily below the surface, and then dropped some of these pieces into the water at every pier the boat came to. Before they had sunk an inch below the surface, they were indistinguishable, though the sun shone brightly at the time. And when the pieces fell edgeways, the lower part was hidden from sight before the upper was underwater. Near the bridges, the feculents rolled up in clouds so dense that they were

visible at the surface, even in water of this kind. The smell was very bad, and common to the whole of the water. It was the same as that which now comes up from the gully holes in the streets. the whole river was for the time a real sewer. Having just returned from out of the country air, I was perhaps more affected by it than others, but I do not think I could have gone on to Lambeth or Chelsea, and I was glad to enter the streets for an atmosphere, which, except near the sinkholes, I found much sweeter than that on the river. I have thought it a duty to record these facts that they may be brought to the attention of those who exercise power or have responsibility in relation to the condition of our river. There is nothing figurative in the words I have employed, or any approach

to exaggeration. They are the simple truth. If there be sufficient authority to remove a putrescent pond from the neighborhood of a few simple dwellings, surely the river which flows so many miles through London ought not to be allowed to become a fermenting sewer. The condition in which I saw the Thames may perhaps be considered as exceptional, but it ought to be an impossible state, instead of which, I fear, it is rapidly becoming the general condition. If we neglect this subject, we cannot expect to do so with impunity, nor ought we to be surprised, if, ere many years are over, a hot season gives us sad proof of the folly of our carelessness. I am, sir, your obedient servant, M. Faraday, Royal Institution, July 7th, 18th,

55. There's just so many good parts, Erin. So many good parts. Seculence. The smell was very bad. The smell was very bad. Like I have no more synonyms for feculence. And so I'm just going to have to go with the sheer reaction of very bad.

Very bad. Very bad. I mean, and also this is not an exaggeration. Oh. I am not being figurative with this. There is no figurative language in this. Sir. I love it. I love it so much. I love it too. I love it. It's ridiculous. And it will, I will touch more on the specific situation that this became the center focus of in this episode. Can't wait. It's going to be great. And I already said in the first hand where that came from, M. Faraday. There you go. Okay. Hi, I'm Erin Welsh. And I'm Aaron Elman Update. And this is, this podcast will kill you.

Welcome to Poop Part 2. To poop number two. Poop number two. We're way too pleased with ourselves. We just think we're so clever. We do. Okay, so if you have not tuned into the first episode in this poop series, two-part series, do it.

Do it. You know, what are you waiting for? Just go listen to it. You don't have to listen to it in order, but it will make sense. It'll still make sense. Yeah. But you should do it. it. It's a great episode. I'm really proud of it. Yeah. You're going to learn a lot. Yeah. Just like you will in this episode. So last episode, we went over sort of how we make poop. Right. And why poop is actually a gold mine rather than like the waste that we presently view it as. And today we're going to go over what happens when our poop doesn't go to plan. Right. And I guess. Yes. And also why poop is actually gross. And

what we do about it. The flip side of the coin. You know, poop is many things. It is so many things. Poop contains multitudes. It does. It really does. It really, truly, truly, truly does. Thank you. Yeah, it's going to be a great episode. I'm really excited about it. But first, it's quarantine time. What are we drinking this week? Same thing we drank last week. Drink number two. The drink number two. We're actually drinking water, which is also important for your poop. It is. As we learned. If you want to drink a quarantini, it's poop number two. It's poop number two.

I mean, drink number two. We keep saying that. Yeah, yeah, yeah. You know, it's basically a chocolate mint martini. It's great. It's pretty easy to make. You can do it at home. As you can with all of our quarantinis, I would assume.

We'll post the full recipe for that quarantini on our social media channels. Are you following us there? Because you should definitely check it out and follow us. You should. Our website, which we may be putting quarantini stuff on, Maybe we'll try that out tonight, you know. You can find other things, though. You can find so many things.

You can find transcripts. You can find links to our bookshop.org affiliate page, our Goodreads list, which needs some updating. Links to music by Bloodmobile. First-hand account form. Contact us form. Sources for each and every one of our episodes. I was like, I know it starts with an S.

And also YouTube videos. You can find links to that. Including this one, which we are very excited. to be bringing you from the exactly right network studios. Yes, yes, yes. Yeah. The end. The end.

Follow us on YouTube. Follow us on social media. Check out our website on the reg. On the reg. What are we? Let's just do it. Let's just do it? Yeah.

Okay. Fantastic. Let's take a quick break. And then you'll tell us about. Suewers. Sewers. Give it to me. Okay.

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You can order meals when you want them and skip when you don't without adding another recurring charge. Order now at blue apron.com. Get 50% off your first two orders plus free shipping with code this podcast 50. Terms and conditions apply. Visit blue apron.com slash terms for more information. Anyone who works long hours knows the routine. Wash, sanitize, repeat. By the end of the day, your hands feel like they've been through something.

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available in Canada, too. That's Q-U-I-N-C-E-com slash this podcast to get free shipping and 365-day returns. Quince.com slash this podcast. Poop is gross. I love that that's a sentence that you wrote down. Love said. Oh, yeah. I was like, how do I start this? Poop is gross. Poop is gross. It is. It is. There is no getting around it. No. Like, okay, yeah, we can talk about how important it is as a resource. We can break it down into like what makes up poop. How do we make poop? Everyone poops. Pooping is not shameful. I'm behind all that. Yeah. The fact remains, poop is gross. It's gross. It's gross. After all, it can contain pathogens or it can signal your

presence to a predator or it can attract flies that lay eggs that hatch maggots. Speaking of which, if you are tuning in to the YouTube, we have maggot art displayed. Yes, somewhere here. Yep. Anyway, yeah, you can see it. It's incredible. But maggots are also gross. You know, it's just it is what it is. Poop, the disgust that poop evokes in us is probably evolutionarily ingrained because we don't want to be near it. You know, it's that, that's all again, the pathogens, all that stuff. And this aversion that we feel for poop, it's not new, right? It's not a product of our modern sanitation system or like a remnant of prudish Victorian sensibilities. That's good to know. It's, yeah, right. It's not just like, it is, it is normal to feel disgusted by poop. Okay. Charles Darwin even called disgust one of the six universal, universal emotions. Oh, that's so interesting. Yeah. And this disgust for poop, it's not specific to humans. Many animals go out of their way to avoid poop, like having designated latrines far away from their burrows, or grazing only in areas uncontaminated by poop. This was a real issue in Australia after

the poop, cow poop mounted. Yeah, because they were like, I'm not, I'm not eating here. 33 million tons, I believe. Yeah. Yes. Every year. Yeah. For much of human history, poop didn't pose too much of a logistical issue. Okay. For humans, right? We were living in small groups. We were moving around a bunch. It was a simple matter to just like, oh, the, you know, the call of nature and you just take a little step. You go away from the river. You go away. You poop? Oh, actually, you didn't go away from the river necessarily. Yeah. Okay. But it's, you know, but it. You It wouldn't have mattered all that much. Because you were going to move on.

You were going to move on. It was someone else's problems. Yep. And that is how Garty is everywhere. And now it's all of our problem. But yeah, and also in addition to like it not being a huge issue in terms of like having to constantly be around your own poop, you're moving on. And our poop was an essential part of that nutrient cycle and seed dispersal. You know, you eat some berries here.

You walk for a while. You poop over there. Now you have a new berry plant. Yeah. And then it was also not just seeds for, you know, berry plants. It was also we're providing material for decomposers. We're fertilizing the ground. It's the typical circle of poop like we talked about. But then, of course, humans begin to live in larger groups and for longer periods. We developed agriculture. We bred livestock. We built permanent settlements. And poop became a problem. Yeah. Okay. We used as much as we could to fertilize crops, aka night soil. We dug poop pits on the fringes of our settlements. We designated communal pooping areas. We pooped on riverbanks and near stream so that the water would wash the poo away and out of sight.

But every fix proved to be a temporary one as human populations grew and grew. Pit toilets filled to the brim. Poop shoots didn't always extend to the cess pit that collected sewage. Sorry, sorry, sorry. A poop shoot is a real thing? Is that a technical that I don't know? I was just imagining like a tube. Like what they used for construction? Exactly. I always thought your poop shoot was your butt. Well, yeah. I think that's synonymous.

But I love the idea of a poop. Multiple meanings. Shoot. Like that was a thing they really had. I mean, there were, I'll get into it. But yes, there were pipes more or less that, you know, or they would be uncovered. essentially gutters. Guttors. Poo gutter, but poop shoot just sounds better. I love it.

Yeah. And then there were indoor chamber pots that required frequent emptying at locations not within a quiet or a quick walk. You know, this was, there were a lot of different ways that poop just, you can't, you turn your back and suddenly there's a massive pile of poop that you have to do. Of course. Yeah. It's just like laundry. Okay. It is.

I'm like, how does it accumulate? It is just like laundry. Okay. So to do it, to put the poop over. overload into perspective, let's consider Canosis, which is the largest city of the Minoan civilization, older than ancient Greece, located on the island of Crete. Around its peak, say, 700 BCE, there were 100,000 people living in Canossa, each pooping every day, of course, well, on average, for a total of 50 tons of poop per day. Wow. That's a lot of poop. Even in 1700 BCE, that's a lot of poop. And it, of course,

pales in comparison to what the city of New York makes in a single day today. And I singled out New York because that is where the data are available. Give it to me. Okay, so poop and pee combined to about 1,200 tons or 2.4 million pounds daily. Every day. Every day. Two point four million pounds of waste from our bodies. Is it waste though, Aaron? I thought we learned that it wasn't. It's a synonym for poop and pee. Tirds. turds. And P. We can't forget the P.

We can't forget the P. Yeah. It's a substantial portion. It is. Yeah. Okay. So it's not New York today. But you could see why it would quickly become a pressing matter in need of an effective

solution. Right. For the Minoans, that solution turned out to be water. A handful of engineering-minded individuals realized the power of water as transportation, and they devised water supply systems that piped in rainwater to flush toilets. toilets. They had flushing toilets in 1700 BCE. Yeah. I mean, so the toilets were pretty much like localized to the Minoan civilization. Okay. And, but they were not just in palaces. Like, they started out just in palaces. But yeah. I mean, and it wasn't like continuous supply.

Okay. You had to, you know, dump it. You've ever been somewhere you had to dump in water to the top. Yeah. Yeah. It's like that. Wow. That's so cool. And then they had pipes. I mean, and also the seats were like really wooded and splintery looking. sure. I mean. Where did the poop go? Okay, so the water flushed the poop out of the building and down into the sewers that ran into the streams that ran into the sea.

So it was all just sort of like connected. Just downstream. Yep. Part of the water cycle. And since then, the world has never been the same. Wow. And remarkably, 4,000 years later, those drains still function perfectly after a large rain shower. Are you serious?

They still wash every, they still wash right down like to the streams to the sea. Yeah. For thousands of years. now, though, we have used water to do our dirty work, separating us from the poo that we produce so that we don't have to look at it or smell it or have it contaminate the water that we use. The invention of flush toilets and sewers, which I'll talk about the modern flush toilet, because this wasn't one that was like, this didn't go everywhere. Yeah, exactly.

It has saved countless lives, and it has made our day-to-day's much more pleasant, right? But in allowing us to flush and forget, we have become divorced from the reality of poop, not as a waste product, but again, as a resource. From those first splintery wooden minoan toilets to the seatwarming, water spraying, high-tech toilets of today, we've been moving poop from here to way over there, radically upsetting the balance of nutrients like phosphorus and nitrogen across the landscape. And just as the early Minowans confronted the mounting poop problem in their city and devised a solution, we finally seem to be coming to terms with the fact that it's time for a new solution or suite of solutions to contend with our growing poop issue. Our cockatastrophe as we made it. I can't let that one go. I'm very proud. No, that was really good.

It was in the moment, too. It was. We have proof of that. We didn't take a break and then edit that out. brainstorm. Now it sounds like we did, but we really didn't. So what I want to do now is take us through how we've dealt with our poo and pee and other liquid waste throughout history, and how a change in how we think of and deal with poop is really the only path forward. The Minoans were not the first or the only group in the ancient world to devise ways to manage the sewage that was produced in large cities. Around the same time, the Harappan civilization in what is now.

India also had a similar drainage system using deep gutters, which remove with removable covers. So you could like get rid of any. Yeah, exactly. Connected from house to house, similar to the way that many of our modern sewage systems work today. Yeah. And so for cities that numbered in the tens of thousands, these Minoan and Harappan sewage systems, they did a decent job. No doubt things were still stinky, especially if there wasn't a lot of rainfall and like cesspits probably got. clogged, but it did all right considering.

Unfortunately, they were no match for the more than one million occupants of ancient Rome. I mean, really the history of sewage systems and poop comes down to like, oh, no, there's too much poop. Oh, we fixed it. Oh, no, there's too much poop again. Oh, we fixed it again. Oh, no. You know, it just like repeats forever forever.

Yeah. Okay. So how did ancient Romans? fix it. Okay. With something called the cloaca maxima. Cloaca. Now that's a great word.

It is a great word. Okay. Cloaca maxima, trachima. I know. I feel like we should define because some people might not be. Yeah, yeah, yeah. No, I mean, we can, so my first exposure to the word cloaca came from what we use it, the biological term, meaning the single orifice through which many animals

do all their business, poop, pee reproduce, cloaca. Cloaca. That usage only came into existence in like the 1800s. Okay. So the word cloaca existed before then, and it was, it translates, it was, it basically translates into the word sewer. So cloaca maxima, greatest sewer. Greatest sewer of all time.

I think meaning like biggest, like largest. I love imagining ancient Rome being like, this is the greatest. It's like very in line with how I think about ancient Rome. Which might be totally inaccurate. Yeah. Okay, but cloaca comes from the Roman goddess, Cloacina, based on the word to clean. Oh, okay. So, yeah. So sewers are cleanage. Clean, yeah. Yeah. Yeah. So yeah, the Cloaca maxima. It really did live up to its name, though, in terms of its size. It was so big that entire wagons filled with hay could travel through it. It was massive. So it's like storm drain, like rivers that we have here in Southern California.

California today. Like those. Like you could take a boat, like a small boat. Okay. Throughout it. Wow. Isn't that amazing? But it was just for sewage. It was just for, well, no, actually. So every day, it would handle a lot. Millions of gallons of water and a million pounds of poop probably flowed through the cloaca maxima every day. Mm-hmm. Something around there. Okay. But like our sewer systems of today, it was not created necessarily to just handle human waste. Okay. It was mostly to prevent, to remove excess water during a rainstorm, and Rome was built on a swamp, basically. Oh, okay. It's the Houston of the ancient world. Okay.

Oh, of the ancient world. The Houston. Someone's going to get real mad about that. Houston is on a swamp. Yes, I know that. Okay. I'm just dating facts here. It's true.

And so you have to drain, you have to drain the swamps to prevent flooding. Okay. And so that is what the clovers. cloaca maxima also did. It was mostly to just drain the swamps. I don't know why this is so funny, but it is. It really is. But the cloaca maxima, I'm just going to say it as many times as possible, was an engineering marvel. And the Romans poured money into its construction and its upkeep. It was a real like, it's a real testament to how much they cared about sewage and sewer systems is that the cloaca maxima parts of it are still standing where many, many, many other buildings have fallen. But they were like, this shall stand. Yes. Okay, do you want to hear more about what the toilet experience might have been like for someone in ancient Rome? Of course.

All right. So if you're wealthy, you would have your own private latrine in your big house likely situated over a dugout pit or you'd be like, no, I'm going to get a chamber pot and have someone just get that away from here. I don't want even this in my house. I'm going to pay someone to do that. Okay. Yeah, pay someone nothing. Many wealthy citizens didn't want to connect to their house to the clothing. Wake a maxima because the smell, it wasn't also like there wasn't water piping continuously through.

Okay. And so you kind of, it wasn't, it wouldn't, things just would have hung out there. And then vermin. Yeah. You know, it's, I get it. But so they were really the only people to enjoy privacy while pooping, were the wealthy. Everyone else, that was a luxury for them. Public toilets were constructed, used almost exclusively by men.

it was not a safe place for women. They were found throughout the city, paid for often by the wealthier citizens who wanted to avoid poop in the streets. And that happened all the time. Poop in the streets? Yeah. There are so many inscriptions warning people against pooping in this alley or against this building or whatever. So there's one found in Pompeii that warned, quote, defecator, watch out for what might happen to you in an alley. In an alley.

Oh, stop pooping here. Deficator. Deficator. If you poop, you will be cursed. By the way. Yeah. We should call more people. But everyone is a defecator.

That's true. But to use it as a dis feels intentional. It does. It does. Okay, so these public toilets were housed under a low ceiling with small windows. So like not a very pleasant, you know, place to be. And they were essentially marble benches carved with rows of holes. Just was hole after hole after hole. No dividers between the holes. So close that you could hold hands. You could carry on a whispered conversation or make after work plans with your pooping partner. People weren't really wearing pants. It was more like a toga vibe situation. As far as I read, you know, I don't know how widespread togas were. That's just like my image of ancient Rome. But you weren't totally exposed. So like you weren't drop and trow the way that you would be.

today. Yeah. Okay. And so for wiping your hiny, there were, which I love wiping. Hiney is another great word. For wiping your hiney, there were communal, communal sea sponges on a stick. They were called tersoorium or wiping thing. Yeah.

So they just was like a few of them scattered about. I don't know the number. Yeah, I don't know how many there were. Was there like water? Yes. So there was a bucket of water that you rinsed? A gutter of clean water to clean the sponge in between uses. Okay.

A sea sponge. That's actually genius. It is. Yeah. I mean. I love it. I don't know if I love it. The communal part.

It's the communal part that really gets to me. And whether there was hand washing. Probably not. It doesn't seem to be so. Who knows? You like let me check? Right. Yeah.

Let me buy. No. Okay. So the poop and pee would flow from these public toilets away into a sewer system where they eventually emptied into the river Tiber, which is also where people got their drinking and bathing water. The filth might have been out of sight, out of mind, but it didn't mean it wasn't an issue. There was waterborne illness all over the place.

It was, I mean, based on descriptions, like, it seemed pretty overrun with poop and pee. And there was a lot of, like, issues related to disease because of that. Yes. Okay, so moving on from ancient Rome, though. Throughout the medieval period and beyond, sewage construction in most of Europe was guided by the get this poop as far away from me as possible principle. Okay. Livestock manure was spread on fields for fertilization and toilets operated under a similar logic as an ancient Rome, not the Minoan civilization. Okay.

Minus the cloaca maxima that effectively, more or less effectively drained things away. Okay. So there would be like outdoor latrines for the poor, you know, pits or barrels, which could then be like buried. are taken away, while the rich built private toilet rooms in their castles where they, like, stuck out over the moat so that the poop and pee would travel down a chute into the water. A poop shoot. Poop shoot. That always makes me think of the Game of Thrones, the guy who died on the toilet. There was a, anyways, it doesn't matter.

But there was a guy who died on the toilet. He got shot with like an arrow in the toilet. And his toilet room was like way up and off away in the castle. Just was like. Historically accurate. despite it not being a historical show. But no, I mean that I think that is, that's what I'm sort of imagining, these little rooms, like, just sort of cut out.

Yeah. And then like, boop. Yeah. Okay, cool. Into the surrounding moat. So, like, it just would just be poop or in the moat. In the moat. Just horrible.

Feeding the crocodiles or whatever. Feeding something. The carp and catfish. I don't know. And so that's where it would stay until, like, the rains grew heavy enough and then the currents could carry it away. Okay. So as European cities exploded in a population, the situation grew dire and more dire. Poop piled up. Multiple laws were passed. Like, this is how bad the poop was, right? There were many laws in many countries about public pooping. They were trying to regulate how much poop there was on the streets. So for instance, in Berlin, a 1671 law was passed that instructed every peasant visiting St. Peter's Church to take a pile of poop away. It was a popular dumping.

ground. So people would, so many people would poop there. It was like you need to take poop with you and you go. Yeah, fascinating. I know. In 1531, a law in Paris required landlords to provide a latrine for every house. Wow. Not until 1531. Yeah. Were the laws enforced? No. Many people did their business in chamber pots in their home, which they then emptied out of the window after a yelled warning. Like, look out. Look out below. Yeah. The descriptions of people pooping everywhere in the streets are alleys and waist piled high, like, there are many of them. But it's too much.

Okay, for example, quote, the Louvre was a mess. People defecated without restraint or attempt at secrecy in the courtyards on the stairs and balconies and behind doors without hindrance from palace attendance. On August 8, 1606, an order was given prohibiting any resident of the Palace of Saint-Germain from committing a nuisance therein. That same day, the king's son urinated against the wall of his room, end quote. So like, people just seem to be pooping everywhere. That is so fascinating to me. It is to me too. I don't know how. Yeah. That's like you just, I mean, I guess if you don't really have an alternative, right. If you don't have an alternative, you got to go. Nature calls. Nature calls. And so it's like, and the laws were not effective. And it just kind of, of course, the problem keeps growing. But keeping in the theme with one man's trash is another's treasure, there was an entire occupation that sprung out from these soiled streets, the so-called nightmen. Oh. Okay. And so also known as scavengers, these nightmen would walk the streets at night. They would empty out chamber pots and public toilets to either sell to farmers or just dump in the countryside. They would be like, I.

I will handle your waste. People had like signs on like carriages or like wagons that were like, I am the best at this. I will make sure to do this. Yeah. Yeah. And when transport became a challenge, like there was just too much to carry or whatever, they dug out big pits and they held the waste there. And this is when they began to experiment with different chemicals and other additives to dissipate the smell or they would heat the night soil to desicate it. Ah.

But guess what happened, Aaron? Something bad. I mean, kind of. Just populations keep growing. Yeah, there's just too much poop. And the nightmen just couldn't keep up. And so the situation was, again, becoming dire. Fortunately, a hero was about to emerge.

Who is it? Ajax, the first modern flushing toilet. Oh. It was invented by Sir John Harrington. Ajax was the name. He gave it. In England, 1584, after being sent away by the queen, whom he offended with his poetry.

That's a true story. Okay. Well, no one knows the exact details, but, like, I can imagine the gossip was just, what did he say this time? Yeah. But he embarked on some home construction projects, and out of this creative retreat sprung the toilet. And it wasn't the first, like I mentioned, the Minoans and Harappans hold that tile. But it did involve a more advanced flushing system with valves in a cistern, kind of like what we think of today, where it has that on top. And then, yeah.

He named it Ajax. wrote an ode in its honor. And then the queen, after getting over her irritation towards him, she visited, she tried it out, and she was like, I need one of these. Oh. So she had one built in her palace home castle, whatever it was, whatever it is. Over the next couple of centuries, the toilet underwent several technological improvements that made it more feasible to we installed in lots of homes. And soon, everyone, it was like, I need this. Right.

It's like a standard part of your home. Mm-hmm. Its popularity was helped along by British plumber Thomas Crapper, who did not invent the toilet, nor give his name to a slang word for poop. Sorry. But his name really was crapper? Yeah. I know. But he did a great job at marketing it. Of course.

And he kind of helped to turn the toilet into a status symbol. Oh, wow. Everyone wanted one. Good for him. I want a crapper. I mean, yeah. And guess what happened? People were so happy to flush and forget, and the problem of excess poop was solved for a very brief period of time.

Oh, dear. What the toilet had effectively done was move those individual cess pits from the home to the rivers that supplied the city with water, making one giant cesspit out of it. The situation again grew dire. How dire, you might ask. Oh, dear. Let's go to London, 1858. full picture. Okay. That summer was unusually hot and dry, but any enjoyment of sunny weather was thwarted by the shocking stench that emanated from the Thames. I've mentioned the Great

Stink of 1858 before in our typhoid fever episode, and I read a quote in that episode that I think is worth dredging up for this one. Give it to me. Okay. This is from a newspaper reporting on the Great Stink, quote. For the first, First time in the history of men, the sewage of nearly three million people had been brought to seethe and ferment under a burning sun in one vast open cloaca lying in their midst. I remember this quote now because we made it into a reel. It was like one of our first reels that we ever made. I don't know why it just kills me every time. Seath and ferment. And it's like it is the word cloaca. But it's also like poetic in a way. It is. It's beautiful and disgusting. Disgusting. It's really effective.

It is. Great imagery. Language right there. So, okay, the Thames had been getting more disgusting for years, but the Great Stink really galvanized many Londoners. Something had to be done about this, not just because of the unpleasantness of having to breathe that vile air, but also because that air was thought to spread disease. Myasma was sort of the leading idea at the time. and it wasn't the air itself, but it certainly was the water, as John Snow revealed in his investigations of the London cholera outbreaks from a few years before, which was, of course, caused by the nasty and poorly functioning drainage systems in the city, those cholera outbreaks. So it took a few decades. I'm skipping over so much here in terms of like the history of sewage. It's okay.

But eventually a massive and intricate sewer system was built to manage London's waste. The project was spearheaded by visionary engineer Joseph Basilgett, and the completed system, truly a modern marvel, still serves the city today. Wow. And there's a whole book about its design and Basilgett and The Great Stink, if you'd like to learn more. It's on one of these shelves here. The London sewer system, which acted as inspiration for many other cities, it operates with the goal of using water to wash away the city's poop and liquid waste. And in the brainstorming phase of this design, several options were presented and dismissed before landing on this present layout. One of these ideas involved transporting the waste to farms in the surrounding countryside to use as fertilizer.

The annual value of 4 million people's excrement, which is in the city of London, was estimated to be worth about 1.7 million pounds in the 1880s, which is 178 million pounds today. Oh, wow. In terms of fertilizer. Yep. But England, not seeing the tremendous worth of this substance, opted to flush it away, a strategy in keeping with the sentiment of past centuries that poop was waste and nothing more. And this sentiment wasn't universally shared, even across Europe. In his book, Le Miz, Victor Hugo, questioned to the similar approach that Paris took with its sewers.

Quote, what do we do with all this golden dung? It is swept into an abyss. All the human and animal manure which the world wastes if returned to the land instead of thrown into the sea would suffice to nourish the world, end quote. Truth. Yeah, he's not wrong. Truth. And he wasn't just discussing a hypothetical strategy. For millennia, many cultures had a much different perspective on how best to deal with the amount of poop and pee that a growing city produced.

Where the ancient Romans and modern Londoners saw the value of poop in its absence, other cultures. saw its value as a fertilizer. Why did some parts of the world adopt the view of human excrement as a valuable thing and others as a thing to get as far away from as possible? One aspect was need. How many livestock you had or how fertile your soil already was or how much pasture land was even available. Maybe you were land limited, right?

You couldn't just clear more land when all the nutrients were leached out of your soil. Or maybe you didn't have and didn't have the land to have these ample amounts of livestock that were producing manure that could be used as fertilizer. And so you're just like, I'm going to use what's right in front of me. This is fertilizer right here. I'm already making it. Yeah, yeah. Throughout Japan's history, for instance, both poop and urine was sold to farmers to fertilize their crops called nightsoil.

Japan didn't really have acres and acres of pasture land or many large livestock, and so night soil was highly valued. If you rented an apartment, your landlord technically owned the night soil that you produced, And so the rent was adjusted based on the number of people living in a room. How many people are pooping here? Yeah. Oh, that's so interesting. How much can I get for their poop? So if five people lived in one room, rent was free, for example.

Yeah. That's hilarious. Pooping at a friend's house was considered a generous act. Because you're like, thank you for that. Oh, my God. I love that. I know. So you might wonder how this practice, which the use of night soil is still used in many parts

around the world today, how it didn't lead to the spread of pathogens transmitted by poop. You know, we just talked about the great stink and cholera outbreaks and all of that. And a big part of it was how you process the poop composting, right? You have to, what is the word? Ferment. Ferment the poop, I guess. And so this, what would happen is, like, in this composting process, it would help to reduce the proliferation of pathogenic bacteria in the poop and break it down into its raw components,

which were more readily used by plants. Yeah. It's a part of the, it's the decomposition cycle, you know? Right, right, right. And the second was just like standard hygienic practices, right? Washing hands, boiling water, cooking vegetables, things like that. Japan wasn't alone in seeing the value of night soil. China was also well ahead of the curve when it came to seeing poop as a resource rather than waste.

One strategy that people used in China was to let all the refuse from humans, animals, other parts of agriculture all mixed together with water in covered tubs and pits. And then after the fermentation process was complete, they would either pour this liquid manure directly onto the roots or let it dry in the sun, forming cakes, which would desiccate and then they could sell. Yeah, mix with water and there's instant fertilizer. Poop was so valued that in 1737 in China, there was an imperial treatise that commanded treasure night soil as if it were gold. Wow. Yeah. 1700s, you said. 1700s for that. But it had been going on for much longer, yeah. And so while most of Europe treated poop as a waste product exclusively, there were a few pockets that saw it differently.

Some places that paid for poop rather than paying to have it be taken away. In parts of Belgium and in the Netherlands, farmers utilized night soil for crop fertilization. They constructed specialized casks that could hold over 100 gallons. The casks were loaded onto carts where they were dragged around by a horse. the farmer on the horse lifting the rope that controlled a lever to be like, now release some more. Now release some more. Okay. It's pretty ingenious.

And even in the U.S., in the late 1800s, there was a very successful night soil company based in New Jersey who got paid twice for their labor, first to remove the poop in the first place, and then the second to sell fertilizer. Love it. And so inspired by their success, a few sewage farms sprung up around the U.S., but, but... But eventually they fell out of favor by the end of the 19th century, as did night soil almost across the board. What changed? The invention of commercial fertilizer and the introduction of germ theory whereby poop became the enemy and nothing more. And I think it's important to note, and I feel like we didn't cover this in an actual episode, like a regular episode. But in a there was the devil's element book club book.

He talked about fertilizer and guano, these islands of guano, and then people harvesting like bones from battlefields, like old battlefields to use as fertilizer. And I just find that so, because a lot of that was happening in like the 1800s or so, and there was this huge rush prior to the introduction of commercial fertilizer. And poop was there all along. It's just, yeah. It is really, really interesting. Right. Especially to think about that alongside the rise of germ theory, which like we talk about so much on this podcast. And it is like so important. And your poop can make you quite sick. And so it's it is just really interesting to think of those things as like side by side and like how. Yeah. Right. To see it in one, like one one angle. Right. One perspective of poop is just that it is waste and nothing more in the enemy and it's going to make you sick. The end. And that's it. And that is true. And two things can be true. Uh-huh.

But what have, so that when these, when these things change, the introduction of commercial fertilizer and then germ theory, things, even places that had long used night soil, it just, they kind of stopped. Like many places stopped. Commercial fertilizer took over in the 20th century and that decree of treasure night soil, if it were gold, became a relic of the past. Poop was no longer a commodity. It was a thing to rid yourself of, a thing. to fear. And today, most of the world is still stuck in that mentality, the really we should be following that 18th century decree, because it is wild how much waste we let go to waste. Functioning sewage systems are foundational to public health, and everyone should have access to

clean water because waterborne disease kills so many people every year. But it's also clear that our massive sewage plants have solved one big problem, removal of poop from our immediate proximity, while simultaneously creating another. Too much poop in all the wrong places. We raise livestock on large-scale farms where their manure leeches into the waterways near the farms. Meat and other food gets shipped to our local stores, removing those nutrients from where they were grown.

Then we eat the food and poop it out, and that gets flushed into waterways, again, far from the original source of these nutrients. Yeah, and then it goes into the ocean. It goes into the ocean. You get alga blooms, marsh decay, barren farmland, eroding soils, ecosystem collapse. Like, these are the consequences of nutrient redistribution across the landscape. Oh, man. The situation is again becoming dire. Dyer. What do we do about it this time? Do you have an answer? I don't. I mean, I don't have an answer personally, but there are so many people,

so many people who are working on this problem from many, many different angles. They're designing more efficient toilets, revisiting the idea of sewage farms, transforming human waste into fuel or fertilizer, even just rebranding poop into something that's like not shameful, props to the poop emoji for that one. It doesn't mean, it was really funny. It's like a very popular emoji. Oh, I love the poop emoji. It's a great emoji.

Yeah. And it doesn't mean, like, there are many people working on this. And it doesn't mean that we have everything under control right now. But we do have possible paths forward and a ton of amazing innovators that are dedicated to this work and really passionate about it. poop is a valuable resource as a fertilizer as a source of public health data like wastewater can tell us what pathogens are currently circulating huge huge and it's also a valuable resource on an individual level like what does your poo say about you such a good question well aaron this is where i pose that question to you so you can tell me all about what we can learn from our poop i cannot wait to do that Anyone who works long hours knows the routine. Wash, sanitize, repeat. By the end of the day, your hands feel like they've been through something. That's why O'Keeffe's Working Hands hand cream is such a relief.

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So I ended last week's episode, mostly just talking about what is typical when it comes to our poops. Right? Yeah. Yeah. And you talked us through in last week's episode, if anyone missed it, all of the different ways that animals use our poop, poop as a resource. And poop on a landscape level scale tells us so much about how we're dealing with our poop can tell us a lot. Yeah. But you're right. On an individual level, our poop can also tell us quite a lot. And I think there's an interesting balance, I guess, where a lot of us don't think about our poop at all.

Like we poop and it's done. It is out of our mind. We're not worried about it. We're not looking at it. We're not thinking about it. we're just maybe trying to think about it as little as possible. Right, right, right. And there are also many people who maybe spend a little too much time thinking about their poops or worrying about their poops.

Or what is this one poop? Did I eat beats or is this colon cancer? I mean, that's a reasonable question to ask after a beat. After a beet poop? After a beet poop. Unless it's beats. But it is true that our poops can tell us so much about our health. And a lot of times changes in our bowel moves.

movements might actually be an indicator of an underlying disease. Though my point with today is not necessarily to make everyone worried about their poops. It's more just to kind of understand the spectrum. Okay? Yes. And since we already covered the range of typical, we can look back at our Bristol stool scale to understand the ways in which our poop can become atypical, if that makes sense. Love this.

So if a perfect poop on that Bristol scale, which again goes from one to seven, where one are these hard, separate lumps, kind of like a nut of poop, chunk, chunk, plop, plop. And type, sorry. I appreciate that extra little. A little too much. And a type seven is entirely liquid. Those are our two extremes, constipation and diarrhea. Yes. And so that's what I'm going to kind of focus on.

Constipation and diarrhea. Concipation and diarrhea. Cool. So, and there's a lot of different ways to classify. Those are not the only poop problems that you can have. But constipation and diarrhea, I think, give us a lot of insight because that does kind of cover that whole spectrum, right? So there's a lot of different ways to classify or define both of these things. And I'll start with constipation because I love talking about constipation.

Has that word been uttered in the history? I say it in the office all the time. Okay, great. I love talking about constipation. How we actually define it, it's either with this Bristol stool scale, but it's never just exclusively with the Bristol stool. So it's usually hard or lumpy stools or needing to strain during a bowel movement. Or sometimes feeling like, I just can't completely evacuate. Like you poop and you just feel like there's something still there that needs to come out, but it cannot come out.

Okay. That feeling. If those things are happening usually more than 25% of your poops. that's what's considered constipated. Huh. Okay. Or sometimes it can be if you're having fewer than three bowel movements per week, that might also be considered constipated. Okay. How often, like, okay. I love that you're asking questions already. I know, I know. Well, you said fewer, you said more than, or 25%?

25% of your poops. So who's watching that? That's such a great question. Who, like, how many of us are paying that much? much attention to our poop. Right. I don't know. Unless maybe you're dealing with constipation, and then you probably are because a lot of times it's maybe more than 25 percent, right? It has to be at least that for us to call it constipation according to the like Rome criteria, which is the criteria that we use. But a lot of people who deal with constipation have been dealing with it for a really long time. It's estimated most of the studies cite that in the U.S., something like 12 to 15 percent are dealing with constipation. And a lot of times,

unless we can identify the cause of constipation, it gets lumped under what's called like functional constipation, which really just means that we don't necessarily have an idea of what the mechanisms are. But it's estimated that up to 30% of people deal with constipation at least on an occasional basis. So they like sometimes have issues pooping. And that is thought to be an underestimate because these are data that are based on people who seek care. Right, of course. Right. Are you going to talk about the causes of?

constipation because I want to talk about functional constipation? Yeah, give it to me. What's your question? What are the causes of constipation? Great question. And at what point do you go, we don't know, but you're clearly constipated? Yeah, I mean, it totally depends on the scenario and also depends on how well it responds to the various treatment options, right?

Yeah. But there's a lot of things that could cause it. It could be that you have slow gut transit, right? Which we know from last episode can be caused by a number of different things. Some of it might be genetics. Some of it might be medications that you're on. Some of it might be the diet that you are eating. Was that right?

The diet that you're eating? The food. Your diet. Your diet. Some of it might be diet because fiber, as we know, can increase your stool transit time. And so if your diet is very low in fiber, then you might have prolonged transit time. So you might be more prone to constipation. Also, dehydration can put you at risk of harder stools.

physical activity increases your motility of your guts. And so we all live much more sedentary lifestyles, especially like in the U.S., we're quite sedentary. And so that is actually probably contributing to constipation. I see. But then there's other things, too. There's like just actual dismotility. There's something called Hirshbrungs, which is like where it's a genetic disorder where some of your nerve endings of your colon have not developed all of the way. And so you cannot get contraction the way that you should. So that can make it very hard to poop and you can get a huge amount of stool buildup in things. There's pelvic floor dysfunction, anal sphincter issues. Like there's a lot of possibilities.

A lot of possibilities. Are there a lot of solutions? Is that a great question? I mean, yes and no, right? The main like ways that we go and deal with constipation for like a general rule are going to be using things like laxatives, which are going to hold. on to water in your stool. So that is going to make your stool softer. Is that how they work? That's how they work. Tell me everything. They just so like, okay, Miralax, which is polyethylene glycol. There's lots of different brand names of it. It's just a very large molecule. Okay. And so it just attracts water. And so you have this molecule. It doesn't get broken down in your

digestive tract. So it's sitting in your colon, holding on to water. And therefore you have more water in your poop. Therefore, it is softer and easier to pass. And other other osmotic Laxatives work the same way. Lactylose, magnesium citrate, all these things. There's also some other ones that you can use, like, stimulant laxatives. Those are things like Bicodal is one or Sena is another. And these are helping to stimulate peristalcis. They're helping to stimulate muscular contract. So it's not like a laxative in the water aspect, but in the movement. It's moving. Yeah. It's helping with movement. And so what you might use might depend on what you think the underlying issue is. So it's going to be kind of person dependent. There's also stool soft. But my favorite thing about stool softeners in medicine is that we use them all the time. And there's, like, no data that they work. Wait, what? DocuSate is, like, one of the most commonly used things in hospitals and, like, people, like tell people to use it all the time. And there's, like, very little, if any, evidence that it. It's supposed to just, like, help make your stool more slippery is the idea. Like, mucusy.

I don't know. But it doesn't, like, it doesn't work. Okay. So when you say it doesn't work, do you mean that there have been. studies that have found no effect or there have been no studies. There have been studies that have had no effect. Yeah. Unlike osmotic laxatives and things, which do work. So why would you use a stool softener over a laxative? I don't know.

I don't. Okay. But lots of people do. I don't know. It's thought to be less harsh. Okay. Right? Because it's not going to like grab onto a bunch of water and then like have you at risk

of diarrhea or something quite as much, right? Where you can easily overdo it with some laxatives. So you could end up with electrolyte and imbalance. if you overdo it on laxatives, things like that. But realistically, I don't know because I don't. What about the like prep for a colonoscopy? It's basically a huge jug of polyethylene glycol. Or sometimes we use sodium-based ones, too.

So like other electrolyte ones. So you don't electro-eat. Yeah. Yeah. Okay. But yeah, that's basically what it is, just like a huge jug of it. Wow. Chug, chug, with a lot of water because you're going to be pooping out a lot of water.

I know. Isn't that fun? Yeah. It's great. Fun, yeah. Fun. That's exactly the word that I would. use. Yeah. But so that's like, I mean, that's how, that's most of the ways that we try. And

there's other newer medicines, too. Like, there's a lot of, there's a lot of newer medicines that have mechanisms that I'm not going to get into because I'm not as familiar with it. But there's a lot of, because constipation is such an issue, there are a lot of interest in new ways to help deal with constipation when these are not effective. This is like go-to, first line, try it out. If it's not working, you need to see a specialist kind of a thing. Okay. Question about constipation and treatments. The, like, like polyethylene glycol, et cetera, of the world, are those for acute relief or is the more like chronic relief fiber? Yes. It's yes and. Do you want to talk about fiber? I could skip.

We can know. We keep your notes the way you want them to keep. Let's talk about fiber. Great. I'm always down to talk about fiber. I know. Me too. Okay. So yes, laxatives, stool softeners, motility, Agents, these are things that are going to help treat constipation. Yes. If you are constipated. Fiber does not necessarily treat constipation, but it can help prevent constipation. Right.

Okay. Because, like we talked about last episode, it's holding on to water in your stool. And so it is hugely beneficial in increasing transit time and in making your stool softer and in providing that bulking agent. And there's two major divisions of fiber. There's soluble fibers, which is like cillium, husk, oats, pectins, and then there's insoluble fibers, which is like wheat, brands, cellulose, lots of the things that are in our fruits and veggies and things. I can't believe we're getting to talk about insoluble and soluble fiber. I'm so excited.

And most of the, if you're getting your fiber from food sources and not from like a fiber drink that you're mixing, then you're getting a combination of soluble and insoluble fibers in most of the foods that you're eating. And then there's also some of the fibers are like fermentable. And I talked a little bit about this last episode. Like the bacteria in our guts can break them down and ferment them specifically to produce these like short chain fatty acids that they can then use to eat. Like the bacteria eat, break down this fermentable fiber and eat it. And then some of the cells in our colon can also use what they break down as an energy. energy source, these short chain fatty acids. Okay.

Why choose one fiber over the other? And why are they all important? They're all important. The answer is that they're all important. Some of them are increasing bulk in our stool. And some of them are helping to feed the gut microbiome. And all of them are kind of doing both, like really, if we get into it. And so that, like, that is why fiber.

That's why people get so, like, stoked about fiber and why fiber is such an important part. There's also so much interesting data on, like, fiber because of its effects on our gut microbiome in helping to treat or at least prevent the worsening of a lot of like inflammatory diseases. Colon cancer we think is involved, like our low fiber diets we think are maybe involved in the increasing incidence of colon cancer that we see, especially in early onset colon cancer. It's not one thing. It's many things.

But fiber is a part of that story. So it's huge. And part of the reason that this is important to you is because constipation, while it's an issue in and of itself, it can be very painful. It can, like, constipation can cause its own set of problems. Conspation can also cause other problems. Constipation can put you at risk of things like diverticulosis, which are these little out-pouchings of your gut wall, especially in the stigmoid colon, the part that sneaks around back before their rectum. Yep.

And those little out-pouchings can trap poop and then can get infected or can burst or can burst into a blood vessel and cause a lot of bleeding. So diverticulosis can be a problem and constipation is a big contributor to diverticulosis is not the only thing, but it's one. Also, hemorrhoids. Mm-hmm. Okay. Hemorrhoids are basically, everyone actually has hemorrhoids. Can I, before you go on to hemorrhoids, because I do want to talk about hemorrhoids. But I want to go back to fiber, unless we're done.

Are you, is there more fiber? Yeah, tell me your question. The relationship between fiber, I'm just stuck on these different insoluble, soluble, it's fermentable. Don't ask me more details. I know. But like when we talk about a low fiber diet, it is of course across the board. But are we getting like is the low fiber diet more low in soluble, insoluble? That's a good question.

And are there relationships between these different fiber types and colon cancer, for instance, or like other outcomes? It's a good question. It's beyond. I don't know. Okay. And then how much. So no one's getting enough fiber. How much is enough fiber?

what does that look like? Are fiber, do, do, do, fiber, what do you call them? Fiber. Fiber cereals, fiber bars, fiber supplements. Fibers powders. Yeah. Yeah. I love these questions. Okay. The recommended amount in the U.S. is like 28 to 35 grams of fiber a day. Okay. Okay. A cup of raspberries as an example. I can't believe I know this in my head because I didn't write any of the time. We've talked about this because raspberries especially are very high and fibrous. Of all the fruits, they're one of the best. Because a cup of raspberries. I can't. raspberries is like eight grams or so of fiber. A cup of, okay.

So it's like pretty deece. Kiwis also have a lot of fiber. Broccoli has a ton of fiber. Beans, especially white beans, so much fiber. White beans. Interesting. Navy beans have more fiber than most other beans. Don't ask me why.

No clue. Oh, lentils. Lots of fiber. Don't know how much. I don't have the rest of them memorized because I usually just give people a chart. Ooh. It's one of my, that's my standard handout. If you come see me for a physical, that's literally part of my handout.

Bring one. Bring one next time. I should. Next time we're together. I just got it from the like NIH website or whatever. Okay. Yeah. Still.

I didn't make it. But no, so that's a recommended amount. And most of us are probably getting much less than that. Like if you, but your question about like fiber supplements and things like that can be really helpful. Especially some of those soluble fibers like Cillium husk and things like that, you tend to tolerate really well. Because they're not going to be as fermentable, you're going to get a little bit less bloating potentially with those. But you could get bloating with anything, especially if you're going from like no fiber. Right.

To some fiber. Start small baby steps. Baby steps always. This is not a medical advice podcast. Let me remind you all. We're just talking generalities. But yeah, so that's, did I answer all those questions? Those count.

But of course, it is better if you're getting your fiber from Whole Foods because then you are getting a mix. And I don't know the answer as to like what percentage should be this or that. And like there's probably people who. are doing those studies to kind of really look into it. But I don't know the answer to that. I know. And this, like, we haven't said this yet, which I'm shocked that we haven't said this, but there are so many other topics that are related to poop that we will cover. There's so many that I'm like, I will say this word, and then we need to do a whole episode on it. Colon cancer. Colon cancer. Early onset colon cancer. So many things. Huge. Yeah.

Dieticulosis. Speaking of hemorrhoids. Hemorrhoids. So this could be a whole episode. Oh, my God. It actually would be a really fun episode. I was thinking about the development of laxatives. Oh, interesting. Right? Okay, so we should do a whole episode on. And then also the development of hemorrhoid cream. And whether it is true that you should put it under your eye for puffiness.

I'm not going to recommend that anyway. I feel like that was something in miscongeniality. Really? Is where I learned that. I mean, it's just like a low potency steroid usually. Anyways, we're getting off the point. Listen. Hemorrhoids.

Everyone has hemorrhoids. They're just collections of blood vessels that are in your rectum and your anus. So they function like cushions, basically, that help keep your anal canal closed because we want it closed most of the time. They help soften the transit of poop. So your poop has like do, doop. Think of it as like boinging off. Like a little pinball machine? Like a pinball game?

Gently off. But they also, they are basically collections of blood vessels. and because they are venous vessels, like their veins, not arteries, our veins can get swollen. And as they get swollen, they can sometimes burst open and bleed, either in small amounts or sometimes in larger amounts. And depending on where they form in the anal canal, your anal canal is so interesting. Because some of it has sensory sensation, the external part you can feel, it has a lot of nerve endings, and the inner part does not. So if you have internal hemorrhoids, they generally don't have any like pain or discomfort or itching. But external hemorrhoids can cause quite a lot of itching and pain because especially they don't tend to burst open though they can.

But they can get very large and very, very painful because they're like external. So you're basically like sitting on them. So those can be quite painful, like little water balloons filled with blood basically right around your anal opening. And so those are, you are at higher risk for those with constipation, like big, big, big time. Because it is all of that increased pressure and the straining, straining to poop really puts a lot of pressure on that anal canal. And so it really increases the pressure in those veins. So then blood pools up in there. I'm just, I'm thinking of as someone who listens to a lot of like books on tape and in my car and when I'm running and walking the dog.

and when someone gets in the car with me and I have like, you know, like a colorful scene in one of my books that I'm imagining of all of our episodes. Someone is playing this and they walk in this. And they're like, I don't know, brother-in-law gets in the car. He's like, you know. What exactly are you listening to?

They have on the Bluetooth speaker. Yeah. Yeah. This is one to share with your family. Please do. Because I'll keep going to tell you about anal fissures, which are another consequence of constipation. consequence of constipation, not related to hemorrhoids?

Not directly related, except that they're both like an anal disease, basically. But anal fissures are also this increased pressure sitting constipation issue. They're just teeny tiny little paper cuts almost in the skin of the anus. And so they're super, super painful. So treatment for that is really to like avoid constipation. And sometimes you need surgeries and things like that to kind of help treat those. So, yeah, so constipation is a big deal, right? because it can be a problem in and of itself and it can cause all of these other problems.

There's something called stercule colitis. We won't even get there because it's quite extreme. But on the other end. Now I'm like, what do you do is? On the other end of the spectrum is diarrhea. Yes. And we've talked a lot about diarrhea. I spent more time on constipation because we don't ever really cover it on the podcast.

We've talked quite a lot about diarrhea. You define acute diarrhea as like three. loose or watery stools in 24 hours. As my kid will tell you, I only had two, so it's not diarrhea. They're well trained. But chronic diarrhea, we define as loose or watery stools similar to constipation in at least 25% of your stools lasting for at least three weeks. Okay. That would call chronic diarrhea.

Yeah. And one of the biggest issues with diarrhea is that you're getting a lot of water loss with it. Right. Right. And diarrheal poops tend to be not only higher in water content, they also tend to be higher in protein content. And as you're losing all this water, you're also losing all those electrolytes that are with that water. So with diarrhea, you're at really high risk of dehydration and electrolyte imbalance. Protein.

Yeah, because things are just not getting digested and broken down all the way. So fats too. So fats too, depending on the type of diarrhea. It could be. It just depends on what your GI tract is able to absorb versus not. What do you mean by types of diarrhea? I mean, what is causing your diarrhea can affect the type of diarrhea that you are having? So, for example, if you have an infection that's just tearing through your GI tract so that your, say, colon just isn't really absorbing any water,

then you're just going to have really watery stools, but you're still going to probably be absorbing all those nutrients because that happens in your small intestine. Yes. Okay. On the other hand, if you have no more gallbladder, then you are leaking out bile all the time. Yeah. So you might have less ability to digest fats. So you have more fat that just made it all the way through to your colon.

And that is providing a slippery slide. Then you might have diarrhea that is more fat. fatty and is floaty fatty. But there's just, I mean, there's lots of ranges of diarrhea. Okay. And like you were talking about, there's lots of ranges of smells of diarrhea. There's some people who are like, I can smell a C-diff diarrhea versus not. So is it infectious? Is it not? Is it chronic diarrhea? Is it more of an acute diarrhea? All of them, though, can put you at risk of things like electrolyte imbalance and dehydration and all of that. Chronic diarrhea. Okay. Yeah. Yeah. And prevalence rates, when it comes to diarrhea,

I don't have like a one statistic like we do for constipation because they range hugely. Right. And we've talked so much on this podcast about acute infectious diarrhea, especially in low and middle income countries. How many kids die from diarrhea every year is in the millions? It's very depressing. But even in high-income countries, it's estimated that chronic diarrhea, the prevalence can range from like three to eight percent, which is not a small amount of people. No. So there's a lot of different things that can cause.

both constipation and diarrhea, but one that I want to kind of talk about because it can actually cause both is IBS. Yeah, okay, okay. Okay. Yeah. And again, this probably deserves its whole own episode. Oh, it does. We need to do one.

Yeah, we do. Please don't take this as a we're just going to throw this in. No, no. But I can't do a whole two episodes about poop and not talk about IBS. Of course not. Especially about problematic poops, because talk about the poster child of problematic poop. It's IBS. So IBS or irritable bowel syndrome, not the same thing, by the way, as IBD or inflammatory bowel disease, which very commonly causes diarrhea, especially bloody diarrhea, and is an autoimmune

disease and inflammatory and a huge problem. IBS is not that. It used to be like a diagnosis of exclusion, but it's not anymore. Oh, interesting. Now it's very much like you should positively diagnose this as IBS. What are the criteria? Well, they can range a little bit, but the Core criteria are recurrent cramping abdominal pain. Okay. So you get cramping pain and then changes in stool frequency or consistency. And this is where it can range. Some people have what's called IBSC, which is IBS with constipation.

Some people have IBSD, which is IBS with diarrhea. And some people have mixed. CD. CDM, we call it, though. Oh, mixed. Because you have both either constipation or diarrhea. but you're having these changes in your stool frequency, like I'm having a poop all the time all of a sudden,

or consistency where I was having like a Bristol three or four and now I'm a seven. Okay, I'm just so confused about changes in. Yeah. Because that implies a time period. Yes. This has to be for at least three months. And it has to be happening at least three, I think three times a week.

Three times a week. This is the criteria. Is the D or C? Is the changes in your stool? Yeah. So like what is. And it's associated with this cramping. So you're having this pain. And then you have either a constipated poop or a diarrheal poop or one or the other. And it's happening for three months, you said? Yeah. Yeah. Okay. And we still do not understand IBS. It's deserving of its whole own episode. But we are pretty sure that it is at least in part a disorder of the gut brain axis, which is just so interesting and fascinating to me.

No, I mean, the phrase itself is really compelling. It is. And what's underneath the surface? We don't know. Great question. Great question. But, yeah, so it's basically like your guts and your brain are not talking to each other the way that they should. Yeah.

Your neurotransmitters are probably involved serotonin. You have more of it in your gut than you're doing your brain, etc. Yep, yep, yep. But then you also see with this intestinal dismotility. So whether that is your guts are going too fast and so you're just pooping your brains out because you're not. not absorbing things because they're moving too quickly, or you're going really slow, and that's why you're constipated. And this is really interesting, visceral hypersensitivity, and that's where you get this pain.

So viscera is like your guts and hypersensitive, meaning that your nerve endings are feeling more pain than they should. Interesting. So because we've talked about hypersensitivity before when. I don't remember. Endometriosis, maybe. Maybe. Yeah, yeah.

And so it's the same sort of thing. those pathways have been carved out. And so like it's like a super highway to pain. Yeah, exactly. Exactly. Exactly. But so yeah, so there's a lot, there's a lot of research being done in IBS. There are a lot of new medications, especially to treat like IBS with constipation. There's medicines that are specific for that. Same thing with IBS with diarrhea. So like there's a lot of research. But there's also a lot of people who just like suffer with either constipation or diarrhea. And they're looking for ways to manage it. And so they, turn to things like fiber or prebiotics, which are all the rage right now, which is usually

just fiber. Really? Yeah. They just market it in a weird and different way. Prebiotics. That's what they're. And then probiotics is the other one. So let's talk a little bit more about probiotics because, again, we can't talk about poop

and not talk about probiotics. Can't not. I think the last time we talked about probiotics was in our C-DIF episode. Yep. Sure. I don't remember. I believe you. Honestly, though, that was a long time.

ago that episode. And I'm not sure that we have that much more data than we did way back then. People use probiotics, and they will recommend that you take probiotics for anything from diarrhea to constipation to bloating, whether that's acute infectious diarrhea or chronic diarrhea, right? There's very little data that show that there is a benefit to probiotics depending on the certain circumstance that you're using them for. Tell me about those circumstances. Well, most of the data is on antibiotic-associated diarrhea or, like, after you use antibiotics or you're using antibiotics for something like C-diff.

And even then, the data is really, really mixed. The biggest issue is that there's huge heterogeneity in how each of these studies are conducted. And who's conducting them? Who's conducting them? Mostly it's like people who are making. supplements or yogurt or something. So there's that issue. But there's also just huge heterogeneity and like which bacterial strains are they actually using in this study? How many bacteria are you actually getting in that capsule? Well, because it's got to go through your stomach.

Exactly. It has to survive the acidic environment of your stomach. It has to make it through your small intestine to try and colonize your colonize your colonize your colon. We know now that that's like a 20 plus foot journey. So that's not necessarily easy. There's also, a huge issue with the fact that in the U.S., there's absolutely no regulation on these things. Because probiotics are regulated as supplements, see our supplement episode for so much more. Or they're sometimes classified as a food product, right, if it's like a yogurt or a yogurt drink or something like that. So we don't have really any data on how much live bacteria are even in your gummy or your capsule or your juice drink, how much of those will survive. or if that particular strain is necessarily beneficial for you in your specific clinical scenario.

I know. Honestly, it is really, it's really frustrating. Like the, I think in particular, one of my irritants is the probiotic soda. Yes. And I'm just like, it's soda. It's sugar. Yeah. What?

It's just, I mean, I'm sure there's more stuff in there, but like. Right. Some of them have prebiotics. So again, they've got like fiber or like non-dict. suggestible sugar. Okay. Great. The other issue, too, is that we have some data on a few species.

We've got some decent data on bifidobacterium that at least it's probably not harmful on a few species of lactobacillus that, again, they are good colonizers and they're not harmful. And Saccharomyces, which is actually a yeast. Right, right, right. But that's just like three and like a couple species of lactobacillus, right? So we're talking a handful of species out of the thousands that colonize our guts, like, we don't know what we're doing when it comes to probiotics.

We don't. So there are people who say, well, taking one or two species is never going to be enough. It's never going to do the thing that you needed to do. What we need is a fecal transplant, Aaron. Okay. Before we talk about fecal transplants, I do. I feel like every time we end up talking about the microbiome, we did it more recently, Aaron, and I don't remember what it was.

We're always like the hype is overrated. And the hype is not overrated for the microbiome itself. It is for our understanding of it and how we are able to manage and optimize it because we just aren't there yet. Right. Maybe we will be, but we're not there. No, not even close. But we are there with fecal transplants. Are we there with fecal transplants?

Are we? No. We're not. But fecal transplants are essentially like that is one of the answers, right? It's like, well, okay, giving someone just some lactobacillus or lactobacillus and bifidobacterium, like two little bacteria, is that going to. to change the entire architecture of their gut microbiome? Probably not, right? But hitting them with someone else's entire gut microbiome might. And that's the idea behind fecal microbiota, transplant, or FMT. This is a huge field of research. I will not do it justice. However,

the idea is basically that you take a microbial community from a healthy person's guts, someone with Bristol three or fours all the time. Beautiful poops. No bloating. Just, Exceptional. Love it all the time. And you give it to a person with some kind of gut disease. You give them some of their poop. Because in that poop, again, 50% of the biomass of their poop is bacteria. You can do this a few different ways.

You can instill the poop into somebody via colonoscopy from the bottom or an NG tube from the top because you wouldn't want to just eat it because that's gross. But you could make it into pellets. Yeah. And then you could take it as a capsule. You can freeze dry them or you can. freeze them either way. And there is so much research being done on this. It is used clinically already, but only in one scenario so far outside of the research sphere as of recording. So there is a FDA-approved treatment here in the U.S. for recurrent C-DIF infection that is

an FMT. There's two approved products. One of them is given via an enema suspension. Right. And the other one is oral capsules, which is just really exciting because that's so much more palatable to people. Yeah. And also, like, lower barrier to entry because you don't have to go into the office, you don't have to do it in clinic, etc. You could just pop it in your mouth. Yeah, pop it in. Yeah.

So it's a very exciting area of research. But that's all that I really have about it because there's a lot of people who are wanting to use it for treatment of IBD. There's some really promising research in that area. There's some promising research on it for IBS even, which I think is very exciting. But that's all that I really have about that. I mean, we could do a whole, another whole. I know that in our C-Diff episode, we did like a big segment on FMTs. Shout out to Dr. Imajdi Osmond, who we had on the pod.

Great. But I think that we could do a whole update episode on it because I also want to know, like, okay, people who got a fecal transplant five years ago. How are they doing now? What are their poop like today? Do they have the same microbes that they were, you know, laced with in that first FMT? Certainly not. I would think that there's some turnover. Oh, I'm sure there's turnover.

But I mean, like, how much does the community? Yeah. Oh, it's so interesting, Erin. I know. There's just so much, I think, about our guts and our poop that is exciting. I know. But it's very true. And I feel like it has been a field of, like, taboo to talk about or to be excited about or be

like it's really interesting or anything like that. And so it's discouraged interest in this really promising field. Right. But it's also awesome. Yeah. I love it. That's pretty much the end of what I got, Erin. Poop is gross.

It is awesome. We love it. We love it. There's more to it. And we'll wash our hands after we poop. And we will certainly do that. Oh, should we tell the people where they can read more about fun poop stuff? Fun poop stuff.

There is so much more when it comes to, A, the history of sewers, and B, what people are doing about solving the poop problem. I'm excited about that. So there's a book by Lena Zeldovich, who if I interviewed for a book club episode earlier this year for about phage therapy. Yeah. But her earlier book is called The Other Dark Matter, the science and business of turning waste into wealth and health. I love that. Really fascinating. Then by Stephen Halliday, the Great Stink of London, Sir Joseph Basilgett and the cleansing of the Victoria Metropolis. And then another book by him as well. But it's like an illustrated coffee table book for sewers.

And it's called an underground guide to sewers or down through and out in Paris, London, New York. I love that. And it's here. It is honestly beautiful and really fun. And I loved it. Yeah. It was great. I also actually had a book for this one.

I never have books. But I did enjoy it by Dr. Fong. It's called Constipation Nation, which is such a good title. I really did enjoy that book. I rarely read entire books and I actually read that whole entire thing. So that's how you know it was good. And there's like a lot more detail on constipation. I think there's even like treat your constipation smoothies at the end, which is hilarious to me.

But then I also love, oh, this is where I have the citation for the paper. We actually mentioned the last episode about how it takes only 12 seconds to poop. Because I didn't even get into like, we spend so much time on the toilet. I mean, and that's related to hemorrhoids and that's related to. There was a 20-25 paper that was like, if you spend time on the phone, you're at higher risk of hemorrhoids, and I was like, there's so much to this. Let's keep going. You're going to do a hemorrhoid episode. Anyways, that paper was from 2017. It was called the hydrodynamics of defecation, published in soft matter.

Soft matter. And then I've got several papers on like the global prevalence of constipation, on FMT. I also have some more data on, because we didn't get deep into this, but on colon cancer rates. And we're going to talk more about colon cancer later this season. So you can find all of it on our website, this podcast, wakilia.com, under the episodes tab. You can. Thank you to Bloodmobile for providing the music for this episode and all of our episodes. Thank you to everyone here at the exactly right studios. Yes, thank you, thank you. And Tom and Leana and Brent and Pete and everyone who's involved in making this podcast possible. Heck yeah. A big thank you to our listeners who listen or watch or read the transcripts even anyone, you know, who somehow enjoys or, you know, just partakes in this podcast.

You don't even have to enjoy it. Thank you. Thank you. You've helped us out. As always, thank you. Also, to our patrons, your support really, really does mean the world to us. So we really appreciate it. Yes, thank you.

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