I was diagnosed with ulcers at the age of 10, well before Warren's work. For 11 years I dealt with constant pain and people telling me I just needed to learn how to relax. At the age of 21, at my next twice-yearly doctor appointment, my doctor asked me if I had heard about this news. I had, and I was willing to try it out as an experimental treatment. Eight weeks later I was cured. No pain. No after effects. Robin Warren impacted my life in a very real way.
I was also diagnosed with a duodenal ulcer when I was 10. In my case, it was the late 1980's and the H. pylori cause of ulcers wasn't accepted or widely known.
I spent a week in bed in excruciating pain, throwing up blood regularly. The doctor visited a couple of times, I'm not sure what he told my mother, but it was a week before he agreed I should go to hospital.
At that stage I was severely anemic and had peritonitis. I ended up in surgery to have a third of my stomach and some of my small intestine removed. A couple of weeks in intensive care and another few weeks in the children's ward before I was strong enough to go home.
When I left, I was told that I shouldn't eat acidic or spicy foods, and that I had an ulcer because of stress. I was 10, and I can tell you, while we didn't have a whole lot, I was far from being stressed.
Nearly 40 years later that surgery still impacts on my life. I still have some digestion issues, but knowing that Warren's & Marshall's work has prevented others from repeating my experiences has been some comfort.
Good on your doctor for trying something experimental which had such a great outcome.
Counterpoint: I was diagnosed with a duodenal ulcer at 12. It was from stress.
My dad has a large amount of scar tissue in his stomach from repeated ulcers. They magically went away when the doc lit a cigarette and told him they were gonna remove part of his stomach if it happened again. Never had an ulcer after that. Instead he would break out in hives when his stress level rose.
How is that a counterpoint? You're just presenting a rare case, like Zollinger-Ellison, or some genetic or physiologic Vagal over-stimulation.
80%+ of ulcers are caused by H. Pylori infection. Next largest group is misuse of NSAIDS (also the most common causes for pediatric ulcers).
Why would a doctor not first test and treat the common things, rather than do an invasive procedure?
I got an ulcer about ten years ago, well after Warren's research, I went to a doctor and he told me that the ulcer was caused by stress. I said something like "didn't someone get a Nobel prize proving that ulcers were bacterial?" and the doctor hadn't heard that and "prescribed" me to get more rest and try and be less concerned about work.
I got a different doctor after that.
Robin Warren is someone who I respected the hell out of. It takes a lot of tenacity and determination to go against something when everyone is constantly telling you you're wrong. He will be missed.
ETA:
I should point out that I am aware that stress can aggravate and (potentially) cause some forms of ulcers, though I really wasn't terribly stressed at that point in my life, which I tried explaining to the doctor and he wouldn't hear it. My job was going fine, I didn't really have any debt, I had a decent relationship with my girlfriend (now wife), I really didn't feel stressed out at all.
Same thing happened to me about 6 years ago. Told me to relax and not eat spicy foods. Makes me wonder how long medical advancements like this take to really spread to most doctors.
For example, several years ago significant cataract improvement was achieved by applying to eyes lanasterol (chemical in your body clearing cataract naturally) with DMSO (well known widely used solvent which is used in particular to deliver various medicine through the skin, etc., and some adventurous people are also using it to for example deliver dye into eyes to change the eye color). Several other scientific teams at different places tried to reproduce the result by applying lanasterol without DMSO, and no improvement happened. They concluded that the original study effect is non-reproducible and that the application of lanasterol is non-effective. I'm not kidding - you can google these articles yourselves.
Of course, as lanosterol is how your body does it when things work ok on their own. The issue is delivery, and for unknown reason they are doing it without DMSO or anything similar. Lanosterol with its large molecular weight have no chances of making it inside on its own. The other way of course is injecting it directly into the eye, and it probably would have to be done many times, and, once injections stop, the crystalline accumulation may happen to start again (as cataracts indicate that the body probably have some issue producing and delivering lanosterol naturally), ie. cataract returning, and in this case the cataract surgery starts to look like not that bad of an approach solving the issue once and for all.
>Medicine advances so slowly.
This is one on my deepest existential fears - not just in medicine - the Ancient Greeks could have had steam turbine based ships, yet it took more than 2000 years, and i'm wondering with a tint of fear what wonderful things we're missing on and what Dark Ages we have to pass through before getting to those things (and i'm not going to see them being long gone before it). The high-tech with AI, etc. is the only area where i feel that the progress has at least some minimally reasonable speed (or at least it is hardly reasonable to ask Nature for something faster than the Moore law), and if it were in high-tech there would be already 10 start-ups funded by at least $100M each perfecting and productizing the combinations of DMSO+lanosterol and exploring the similar approaches :) Unfortunately it seems there is no money here, and the Robin Warren's discovery didn't make him a billionaire.
the bigger problem is that if society collapses again there are few easily-accessible resources anymore, particularly fuel/energy. Consider the coincidence of factors that led to the industrial age in Britain… some of those can’t be reproduced again.
Mining garbage dumps for resources could of course be a thing, but probably not abundant energy.
This time there is no plan B. We either become an interplanetary species or this planet eventually becomes our tomb. Probably a couple millennia.
well, may be civilization would be much better off if we went straight to electrified industrial society using wind and hydro energy bypassing burning of dinosauruses - windmills and watermills were known for millennia, one only had to add copper winding and some magnetic iron, the things available for the last 2000+ years.
> We either become an interplanetary species or this planet eventually becomes our tomb.
Yes, only my version of the "tomb" is that it would be our planetary scale ant city/colony as we become totally connected and our societies naturally become highly totalitarian (not necessarily due to some ideology, you'd just naturally have less and less space/resources/opportunities for your private endeavors). Some ant colonies exist uninterrupted for several thousand years, no progress, just happy busy ants doing their happy stuff. Only few of us who'd get off that planet will have a chance to continue the civilizational progress. Kind of bifurcation of our species. Interesting that Musk advances our civilization in both directions - neural implants as well as SpaceX.
How do you get the prerequisites for solar without access to large amounts of energy? Solar cells are made from silicon wafers which must be refined and doped to work. Maybe we could build windmills if we salvage copper and magnets, but refining even copper would be challenging without access to high heat fossil fuels. I guess you would have to bootstrap using charcoal, which would be very labor intensive.
Photovoltaics are not the only form of solar electricity production. Concentrated thermal solar power can easily get into the hundreds of megawatts range.
Well, you’re not going to find centuries of easily-accessible fuel by raiding gas stations. Good luck drilling natural gas two miles under the gulf with your renaissance era mineshafts.
More specifically Max Planck wrote: "A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die and a new generation grows up that is familiar with it ..."
How long medical advancements take to spread, and also how long the ineffective or outright harmful practices persist.
I guess on HN we're all relatively pro-science. But the world would be a better place if we recognised that our scientific knowledge in some areas is poorer than we like to pretend.
I started feeling that way when I worked alongside some "Evidence-Based Medicine" advocates. Years later I've landed in data science and the standards of statistical analysis and understanding I see especially in the biological sciences has only made me more sceptical.
Way back in 2007 the BMJ as part of its Clinical Evidence project published its systematic research into standards of evidence in support of common medical treatments. Some 2500 treatments were evaluated to determine whether they are supported by sufficient reliable evidence.
• 13% were found to be beneficial.
• 23% were likely to be beneficial.
• 8% were as likely to be harmful as beneficial.
• 6% were unlikely to be beneficial.
• 4% were likely to be harmful or ineffective.
• 46% were unknown whether they were efficacious or harmful.
It's quite hard to find the original Clinical Evidence project resources (might be a job for the wayback machine) but you can find it referenced all over, e.g. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2071976/ .
In the 1970s the US Office of Technology Assessment conducted a similar evaluation of medical treatments' efficacy and found that only 10% to 20% of medical treatments had evidence of efficacy. I would love to see more recent research in this vein.
There are clearly many complications and caveats around all this. Not all "common treatments" are easily studied -- the gold standard of the RCT is not always feasible or ethical. And of course absence of evidence is not evidence of absence, etc... but it sometimes feels we should be a bit more humble about even our best science.
Continuing education in medicine is a big problem. Once someone graduates med school, their knowledge mostly freezes. The good ones keep up on latest developments but some don't.
That’s “translational medicine” or “translational science” —> getting lab proven stuff to the bedside.
And yeah, it can take a while.
My dream is to a have a dumb doctor/mechanic/plumber/blah that just researches even the most basic questions unless it’s something really odd-ball and only then defaulting to their “expert opinion”.
I've thought for a long time that medicine in the AI era would end up with nurses being even more important than they are today but with doctors being drastically less so. (I know next to nothing about healthcare; this is just a guess!)
This is a problem with alot of thirdwirld surgery. If some old doctor gets to operate your appendix, he might gut you like fish,like they did back in the 80s, scar from heart to hip.not even due to missing equipment but a lack of schooling and experience on newer techniques.
I went to an ear doctor recently, who was so old that I think he graduated when I was a toddler. But when I describe my symptom he says "Well, let's also see what ChatGPT says."
So some part of new medical information might spread faster than I had thought.
* My ear problem turned out to be that my ear canal was full of wax. I guess we didn't really need ChatGPT that day.. ¯\_(ツ)_/¯
Unless things have changed fundamentally since I was in medical school (UCLA Class of 1974), a doctor's visit should start with taking a history and move on to a physical examination. I would think ChatGPT wouldn't even have been mentioned once your PE revealed a wax-filled external ear canal.
I have IBS. During my last visit, my GI doctor apropos of nothing blurted out, "you've got to get your anxiety under control!"
"What are you talking about?" I asked.
"You said the stress of getting ready to leave for the office triggers your attacks," he said.
"I work from home!!" I said. "_YOU_ posed a hypothetical and I answered with a hypothetical: that it would certainly be stressful if that happened. I also said I still have the IBS attacks when I don't have a stressful day."
In my opinion general practitioners (who are not therapists) putting their patient's issues down to "anxiety" or stress is like doctors diagnosing "hysteria" in 19th century women: it contains the in-built subtext that you're not a reliable narrator of your own symptoms, and there is no evidence you can present to disprove the accusation of "hysteria" or "anxiety".
Yeah, that's my issue; stress is a somewhat nebulous thing that's hard to directly quantify and therefore it can be a kind of "catch all" for nearly anything.
I'm not saying that stress doesn't have effects, but I think a diagnosis based on "stress" can often be reductive; who doesn't feel some stress throughout the day?
Actually, "stress" is extremely easy to measure: You have stress, you have specific hormones in your bloodstream.
Those hormones change things in your body, like redirect the blood in your body contracting or extending blood vessels.
>who doesn't feel some stress throughout the day?
It is a quantity thing, you can feel stressed during seconds, or during hours or during entire days.
For example, in a war when your family members could die at any moment, you feel stress for days. In you live in peace you just don't have an idea what that means.
I have not lived war myself but I had close contact with people in Ukraine and in the past conflicts like Congo or Central Africa Republic and other African wars.
Stress effects were obvious for people living in farms. Animals like hens can stop laying eggs or cows stop giving milk just by stress alone.
This is the poster example I use for how dramatically information can change within our lifetime. I still encounter people that are unaware that most of the "stress causes ulcers" was just wrong.
It certainly matters more in medicine, where you have very serious risk of causing people pain, but as I've gotten a bit older I've become a lot more sympathetic to people having trouble keeping up with the world sometimes.
Like, it's not a good excuse, don't get me wrong, but as much as I try, I simply cannot keep up with the entire state of the art of computer science. I wish I could, and a younger me without a family and responsibilities actually would mostly keep up with everything, but now it just feels like there's never quite enough time to learn everything I really should.
I do try and keep up, I have a million textbooks and the like, and I try and at least go through the example problems for them, but it's pretty easy to fall behind in that stuff.
While a GP should keep up to date with ulcer research, and "I'm busy!" isn't a great excuse when serious pain and/or lives are on the line, but it's something I at least understand better now.
> Like, it's not a good excuse, don't get me wrong, but as much as I try, I simply cannot keep up with the entire state of the art of computer science. I wish I could, and a younger me without a family and responsibilities actually would mostly keep up with everything, but now it just feels like there's never quite enough time to learn everything I really should.
This is the part of this conversation that I don't get. Yes, it is impossible for one person to contain the entire body of knowledge, which means you're not going to know some of the time, and that might be embarrassing or otherwise troublesome.
However... it should be rare that you operate in complete isolation. You should be regularly interacting with other practitioners, including people whose entry into the field is newer, and therefore should be aware of the current state of the art. There should be interactions where that information is shared, both allowing projects you work on to take advantage of advances in the state of the art even if you don't know about it, and for you to become aware of advances in the state of the art.
Oh, I absolutely do not use this to demean people that are wrong. The point is that well established and largely effective knowledge on how things work can be completely changed with most of us not realizing it. All the more reason not to get upset with someone for not being aware of some advances. This should include self.
The handful of times I've had ulcers in the past it was certainly correlated with stress. Perhaps indirectly through some other effects, but stress feels like part of the equation IME, at least for some people.
You likely have chronic heliobacter pylori infection and should really look into that. It’s a silent killer and that way beyond just ulcers since it’s a potent acetaldehyde producing microbe. Tests are often false negative because they can hide in places, eg Candida vacuoles: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8101746/
Stress can aggravate ulcers, as it can aggravate any number of underlying conditions. Similarly eating spicy food can make the symptoms of acid reflux much worse thanks to capsaicin in the refluxing acid. But in both cases the root cause is something else.
There’s an interesting level to this as there is a link between stress and ulcers. Stress reduces the mucous barrier and how quickly you heal, so reducing stress actually was helping people with ulcers. Antibiotics however where more effective in most but not all cases.
I really wasn't stressed at that time; outside of the typical annoyances of being alive, my life was going pretty ok at that point, which I tried telling the doctor and he didn't believe me. After that I went to a different doc and she gave me antibiotics and I healed after a few weeks.
I am extremely thankful that I have not had an ulcer again since then, because it was the worst thing ever.
I've always been a little annoyed about the "relax" part – of course stress exacerbates everything. We know how inflammation works globally throughout the body. Of course we would have already thought of that.
I didn’t know the wholes story but I thank Robin. As a teen, I remember the relief when the years of advice to “learn to relax” and “stop stressing out” was replaced by meds that fixed my ulcers in weeks.
I had a bleeding ulcer in high school in the 70s, so assuming it was stress, the staff at my all male Catholic HS started to treat me like a human being. It wasn't stress, but I enjoyed the change.
I believe that my ulcer was caused by daily doses of the antibiotic Tetracycline which the family Dermatologist prescribed for acne. Once I stopped taking it, my symptoms were gone.
> It defied the conventional wisdom that bacteria could not survive in the highly acidic environment of the stomach, and many scientists dismissed his reports.
There is some point in the process where those "many scientists" should have been prevented from doing any further peer reviews, at the very least. If you always say No, your opinion has no value.
I'm still waiting for a similar discovery to treat GERD. Having the condition, I've become a bit of a couch expert on GERD literature and it seems that everyone and their dog have a completely different opinion on what, in the end, causes it.
With a little bit of search, it's possible to find lots of papers that claim to solve the issue with some kind of novel treatment. Sometimes it's training the LES or other muscle (like in the article), sometimes it's correcting some sort of dysbiosis of the gut or the esophagus (see e.g. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6469450/), etc.
It's possible that they are all true, though, and GERD can either result from multiple different causes or from a sum of different causes. If that's the case, we would need better diagnostics to figure out what is causing each individuals problems in particular.
There are people with giant hiatal hernias and no GERD and there are people with bad GERD and no hiatal hernia. Hiatal hernia seems to at least make GERD worse, but is not the only factor and the causal link between hiatal hernia and GERD seems to run both ways (i.e. people with GERD also develop hiatal hernia over time instead of just hiatal hernia causing GERD).
Other possible explanations found in the literature are at least: small intestine bacterial overgrowth; dysbiosis of the esophagus; food intolerances; postural problems; incorrectly (for some reason) functioning LES (or other related) muscle etc.
It's possible that all of these contribute a little bit to GERD and whether you get problems depends in all of these factors in some non-trivial way.
This is one of those situations where the narrative is fairly simple: people believed X, it was wrong, a few iconoclasts demonstrated in a fairly convincing way that Y was indeed the case, and then over time, the story got rewritten in the literature.
But in practice it turned out to be more complicated than the narrative; X is still somewhat true and ulcers and gastric disorders are both caused by, and affected by, multiple factors. Certainly, stress can exacerbate an existing latent ulcer or gastric disorder, making many people attribute the cause to stress, but this quickly gets into "proximal causes" and "ultimate causes".
As for working with doctors who didn't get the memo, I've learned that you sort of have to sneak up new information to them without making them feel challenged by a non-expert. It's a form of social engineering.
> I've learned that you sort of have to sneak up new information to them without making them feel challenged by a non-expert
that might apply to you (depending on your background), but Warren had some serious credentials. Doctors are supposed to stay current on work like his.
I typically made a dumb reference to something I saw in the literature (JAMA, BMJ, etc) while also saying "but I guess that's just a controversial new opinion".
Basically you want to avoid directly confronting them by implying they are dumb or wrong. Instead, appeal to authority, but in a soft way, and downplay the confidence of the new result.
I had many years of being undiplomatic until I saw a video of Kevin mitnick. His normal nature was quite undiplomatic and fairly autistic, but when he did social engineering, he did an amazing job of telling people what they wanted to hear. Now, when I think something, instead of stating it in a clear and undiplomatic way, I rewrite it in a way that my mental model suggests increases the probability the listeners will change their minds and agree with me. This took a great deal of practice to be able to do in real time.
I've sometimes noticed myself giving ideas in passing during a friendly conversation where nobody is defensive, my idea is passed over initially, but some days later the person has the same idea and doesn't remember that I suggested it. This might be some kind of bias on my part though.
Point being: Offer your idea during a friendly time where it will not cause the other person to be defensive and then you have to wait. You might find that the next time you bring it up the person is more receptive.
I still remember the sound of my doctor’s voice when he looked through the endoscope as 20 yr old me laid on the table.
“Man, we find your problem”
Fortunately, the Canadian medical system knew about Dr Warren’s work and so I was properly treated with antibiotics and completely cleared up in 2 weeks, never had a recurrence.
I owe that guy a lot, I’ve heard many horror stories about ulcer treatments since then, it’s shocking this isn’t known by literally 100% of doctors (of all specialties)
I'm a fellow Canadian, and in my early 20s I realized that the normal hunger pain I was feeling... wasn't normal. Instead of pain, others experienced a different feeling that told them "I could eat right now".
After an endoscopy and a biopsy, they found that I had H. Pylori and stomach inflammation (no ulcers). After a vaccine + course of antibiotics, I stopped feeling pain whenever I was hungry and started feeling a normal appetite sensation.
I'm posting this comment in case anyone is in the same situation with hunger pain.
The vast majority of people still today directly associate any stomach pain with stress as their first thought. I would even venture to say that many doctors still inquire about stress during a consultation. Even though it is not the cause of ulcers, it is true that stress amplifies the symptoms of existing ulcers and increases stomach acid production. Personally, I find stress fascinating.
Here's a guy who had epilepsy severe enough that his parents feared to send him to college who made an enormous difference in the lives of many people.
i had h pylori and got infected twice resulting me in having chronic gastritis,daily heartburn, and esophagitis and ppi' made it worse had to eat plain foods for about approx 3 years to get better.and also drink cabbage juice daily, and eat brocolli sprouts (it kills the bacteria) you can also increase the potency of broccoli sprouts with mustard seeds. and their was another way of having to heat the broccoli sprouts but i forgot the process
My father is a GI researcher, and gave a talk on Warren and other innovators and innovations in the field (which includes endoscopy, the direct result of an innovation in computer networking, Narinder Singh Kapany's paper on fiber optic cable).
Anyway, the term that was used to describe the resistance to Warren and Marshall's resesarch was "the Acid Mafia."
Barry Marshall realized that some of the patients that Robin Warren was telling him about were his own patients. He had learned fiberoptic endoscopy, and he was performing biopsies on these same patients and knew their medical histories. So this clinical connection lit a spark, and the two of them teamed up and made a remarkable discovery. What they did was to simply correlate this finding with the presence of active chronic gastritis. They published their first paper, a brief letter to the editor in Lancet in 1983t, which described a series of their patients with active gastritis and the present of this curved bacillus in their stomachs.
They went on then to make further correlations between the curved bacilli and peptic ulcers and eventually gastric cancer. This discovery was innovative and totally new. and was met with huge resistance by the medical establishment. The notion that peptic ulcer was an infectious disease met with near universal rejection. I actually remember the journal club in a Boston teaching hospital near here where this was first presented. The discovery was universally rejected by most of us in attendance. The problem was that in certain parts of the world, 80% of the population were infected. How could something that common be a cause of a disease like peptic ulcer that only occurs in, say, 1% of the population?
Barry Marshall wrote in his note cards and some of his later publication “Everyone was against me, but I knew I was right.”
So who was against him? The acid mafia, a powerful group of senior investigators who championed the idea that hydrochloric acid was the key to formation of stomach ulcers. When we were residents and fellows we had to know a lot about gastric hydrochloric acid secretion. So those who believed in the primacy of stomach acid were definitely strongly opposed to these Australian upstarts, Marshall and Warren. (https://archive.blogs.harvard.edu/lamont/2020/01/30/advances...)
Another pattern that came up in these discoveries was the doctors and researchers experimenting on themselves. For example:
In this instance the experimental subject was Barry Marshall himself. He swallowed a pure culture of Helicobacter pylori that he had isolated from one of his patients that he had previously biopsied and cured. So he knew that the strain was treatable and curable. He drank the culture of H pylori and over the next several weeks developed severe acute Helicobacter infection with nausea, vomiting, and severe dyspepsia. He stated that his halitosis was so bad, that his wife told him that he had to sleep on the couch. After the infection was established he treated himself with the anti-Helicobacter therapy and completely recovered. His experiment was soon published in the Medical Journal of Australia in 1985.
Basil Hirschowitz, the godfather of endoscopy, also followed the self-experimentation path:
Hirschowitz heard about [the fiber optic] paper from a cardiology resident who had heard about it at journal club in London. Hirschowitz flew to London, met Kapany and Hopkins in a pub, and discussed their invention. They were very encouraging to Hirschowitz and gave him a few glass fibers to take back to Ann Arbor. Hirschowitz returned to his fellowship at Michigan and built the first fiberoptic gastroscope with help from Larry Curtis and Wilbur Peters who were physicists. After a few years of trial and error, they produced the first gastroscope ... Like a lot of fellows and young researchers in science, first tested the device on himself in February 1957. He managed to control his own gag reflex, passed through his esophagus and looked around in his own stomach.
I had gastritis (duodenitis, in fact) a couple of years back, and the first thing they did was test me for H. pylori. I didn't have it. Doctor told me a vast majority of people with such issues do.
After a gastroscopy, they concluded that it was just stress and nothing else, but inflamation wouldn't heal on its own, so I got pantoprazole (PPI) and stopped ingesting potentially irritating food (caffeine, alcohol, spicy food). I also shortly changed jobs, which alleviated the stress. Mind you, I never had heartburn, just pain. My condition didn't improve for a while after that, until I stopped drinking carbonated water (the only carbonated beverage I consumed), that fixed it in less than a month. After that, I gradually weaned myself off of pantoprazol in 6 months.
There literally was no other probable cause except for stress (I was stressed, wholly self-induced), and after I switched industries and no longer felt that I'm wasting my time working for peanuts, the PPIs helped cure the symptoms.
A perhaps easier to understand explanation of this is this part of a Robert Sapolsky talk on stress, prepositioned to the bit where he talks about the interaction of stress with the bacteria [1]. The summary is that the body is good at repairing the damage the bacteria do, unless the person is under constant stress which inhibits the repair work.
What is a bit of a myth? Sounds like stress is a factor but the bacteria is a direct cause in 90 percent of cases. The myth was that stress is "the cause".
50% of people are infected with H.Pylori, so clearly the bacteria isn't a cause on its own. The myth is more that "stress doesn't cause ulcers", which many people now believe.
Burns and other life threatening conditions are the main cause. Between 60 and 100% of patients entering the ICU have stress ulcers. Chronic workplace stress, job frustration and family problems are also associated with ulcer development.
