FROM NOVEMBER 1979 TO MAY 1982, I had the "honor" of serving time at "Evin" prison, Tehran , Iran. Evin is the historical prison which has set the pace of revolution in the country. It is composed of several "blocks." At Evin, people experienced the course, dimensions, and (as a result of the power struggle from within) the transformation of the revolution. The conditions and the emotional aspects of life there could not be compared with the experiences or settings most readers have known.
A predominantly starch diet was available. There was no shortage of medication. A critical shortage of cell space at the onset woefully deteriorated. Any professional contact had to be in the presence of the guards, who were always suspicious! I was lucky to have been able to make my observations in Block 3 when I was waiting clarification of my own situation. There I could follow-up my patients before movement became restricted and inmates were confined to their completely isolated individual or group cells.
Men and women from all walks of life, of all ages, under the prevailing uniform condition there, unfolded their particular response to different levels of stress.
Clinically diagnosed peptic ulcer disease was one major manifestation of this stress.Younger people (men much more than women) presented the typical symptoms and signs, from simple epigastric pain experienced for the first time, to recurrence and exacerbation of complaints in patients with chronic ulcer disease. Symptoms even reached the point of semi-consciousness from the intensity of pain, suggesting impending perforation; intermittent pain during the day or night; pain which limited sleep; and continuous intense fluctuation pain. Melena with anemia and hematemesis, on many occasions, supported the clinical diagnosis.
In January 1980, a chance incident forced me to treat one of the inmates , who late one night sought relief for unbearable pain, with 500 cc (two glasses) of water. His pain became less severe and then disappeared completely after 8 minutes. He was an experienced "sufferer" with a long history of repeated treatment, and found relief of pain with water a surprising but welcome experience, particularly as it permitted him to avoid any contact with the guards. He agreed to take the same amount of water every 3 hours as if he were maintaining a diet of nine "meals" a day, during his waking hours; he took three regular meals and six "water meals." The water intake was regular. Food was eaten as it arrived, to allow for the fluctuating time of arrival. The little pain he felt in between his "meals" became less severe and disappeared totally after 3 days. I told him to maintain this diet for 6 weeks. he was given no other type of medication. He had achieved a "clinical cure" with water only for the duration of his stay of a few months in the environment that had "caused" the symptomatic recurrence of an ulcer previously diagnosed by x-ray.
The result of this simple method of "treatment" seemed now too good to be abandoned or ignored. I pointed out the advantages of not depending on medication by this method, under the circumstances, especially to those who had a long history and had tried various methods of treatment with the number of medications available. Those who tried the method were satisfied. The final acceptance by everyone in Block 3 came when a man in his 20s, who had a long history of duodenal ulcer disease, developed another episode of pain at 1 P.M. His symptoms gradually worsened; antacids that he had taken and the several tablets of cimetadine he had kept against such a day did not help. By 11 P.M., he had so much pain that he had become semiconscious. Absolute relief came in 20 minutes after swallowing 500 cc water followed by another 250 cc water 15 minutes later. This total recovery was a source of amazement to me and to the young man's friends who could not believe his transformation. This simple method became the accepted standard treatment for peptic ulcer disease pain in Block 3 of Evin prison, accepted even by those who had political obsessions and personal prejudice.
The group of men in Block 3 were slowly changing because of investigation and sentencing. More and more, these men who suffered ulcer disease pain accepted this "new method" of treatment (recommended even now) now consisted of one glass of water (250cc) half an hour before meal, and an equal amount 2½ hours after each meal (i.e., 1,500 cc of water /day of 3 meals). The patients were told they could drink an extra amount if they were thirsty. The duration of treatment recommended was between 4 and 6 weeks, in keeping with the average time an actual ulcer would take to heal.
A "maintenance course" of a glass of water (250 cc) before breakfast and a similar amount 2½ hours after the three meals in "severe stress cases" proved most effective.
High urine volume and, therefore, sodium loss produced cramps in some of the first patients. As a result, extra salt intake with meals was recommended. Some of the people taking this treatment had to get up in the middle of the night to urinate. These two physiological side effects were the only observed disadvantages to this method of treatment.
The repeated positive results even in patients with a long history of duodenal ulcer disease who responded to treatment with water, who even chose this method in preference to the standard medication methods of treatment, even when antacids, H2 blocking agents, and anticholinergics were readily available, indicated to me that we were dealing with a physiological correctable or controllable state. As a result of lucky access to printed information on peptides of the GI tract, the subsequent stage of my clinical formulations became feasible.
During the last part of confinement, I became involved at the main prison hospital which drew patients from section clinics. Many patients with hematemesis* and/or melena with low blood pressure and/or low hematocrit were seen. They were treated with blood transfusion (up to 8-10 X 250-450 cc of blood to maintain a systolic blood pressure of 90 - 100 mm mercury or a hematocrit of 30). Except for the first ill patient who was given cimetidine (4 tablets of 200 mg for 2 days only, with a supplement of a late night injection of cimetidine again only for 2 days), none of the patients received chemical medication. They were provided with a large jug of strong sugar-sweetened water, with instructions to drink a glass every hour. This period gradually increased to a glass every 1½ hours and then every 2 hours. After 36-48 hours when a feeling of "hunger" would begin, light food with water according to the foregoing schedule was the only treatment needed; i.e., once again, the clinical improvement was definite and no medicines (antacid or H2 blocking agents) were necessary to reestablish improvement. No surgery became necessary. There was no mortality from GI bleeding in these patients. No recurrence of bleeding was seen.
[NOTE: *Hematemesis or haematemesis is the vomiting of blood. The source is generally the upper gastrointestinal tract, typically above the suspensory muscle of duodenum. Patients can easily confuse it with hemoptysis (coughing up blood), although the latter is more common. Hematemesis "is always an important sign". Hematemesis indicates that the bleeding is from the upper gastrointestinal tract, usually from the esophagus, stomach, or proximal duodenum. Occasionally hemoptysis or vomiting of swallowed blood from epistaxis can be confused with hematemesis.]
[NOTE: The hematocrit, also known by several other names, is the volume percentage of red blood cells in blood. It is normally 45% for men and 40% for women. Blood is composed mainly of red blood cells and white blood cells suspended in an almost clear fluid called serum. The hematocrit test indicates the percentage of blood by volume that is composed of red blood cells. The condition called "anemia" results from having too few red blood cells.]
The authorities, who by now could not block to ignore these results any longer, conducted an unofficial trial of their own. They had a questionnaire, which I drew up, reproduced in multiple copies. In a closed "off-limits" section with 600 persons, 240 (40%) were using medication to treat their "ulcer" pain. These people filled out the form and went on the water treatment. The result was dramatic. Water treatment for peptic ulcer disease became the standard form of treatment for that institution and has survived beyond my enthusiasm and incarceration!
During the 2½ years in prison, I must have seen well over 3,000 patients with ulcer symprom. I follow-up about 600. The follow-up information from the rest came to me from their guards, from physicians in charge of other sections, and from chance meetings or messages received. The almost total lack of demand for antacid from the pharmacy during the last few months was an indicator of the success of this treatment, which had spread to all the sections. Even the prison authorities adopted this method for themselves, for they too suffered from peptic ulcer! The final recognition came when my captors, who earlier would have shot me with the least excuse, later confirmed in writing to the Medical Council, the effectiveness of this new method of treatment of peptic ulcer disease, requesting them to inform the medical profession of Iran through their journal.
The implications of this method of treatment seem important, especially the importance or usefulness of "a glass of water" as a diagnostic tool. The following points deserve emphasis:
1. Experience with thousands of patients showed that simple, clinical peptic ulcer disease complaints, the ones in whom a doctor would not suspect a complication, respond to this method of treatment. One glass of water (250 cc) relieves pain within 3 - 8 minutes. Sometimes a little more may be necessary.
2. A few cases of "appendix pain" without other clinical manifestations also responded and became pain-free. Be it from a response of the ileocoecal valve or a cutaneous representation of common thoracic nerve roots, this observation indicates that a
site of pain other than epigastric may herald a clinical picture of duodenal ulcer (d.u) disease.
3. Of the few patients who did not respond to this treatment, further questioning and investigation revealed other pathology. A colleague's case diagnosed a "d.u." when he adopted this method of treatment for his patients (he is conducting an open trial), developed severe "pain and signs" precipitating the need for diagnostic surgery. The condition proved to be acute cholecystitis.
4. In the majority of patients, the relief of pain was preceded by eructation of gas "indicating" that the passage of diluted acid was made possible after what may be relaxation of the pyloric sphincter.
In view of this experience, I suggest that a different interpretation of the "absolute" validity of the design and the conclusions of the "randomized clinical trials" on peptic ulcer is necessary. The water used to swallow a "pill," be it the actual medicine under test or the placebo control (up to now considered inert), has proven to have a definite (physiological) effect of its own. It is possible to theorize that water has its effect before the pharmacologic substance under study achieved optimum blood levels. My experience also suggests that the high cure rate with placebo in controlled studies reported up to now were not without a good reason. Any interpretation or comparison of medication against "placebo" should be reconsidered, due to the body's response to water as a "natural medicine," although in insufficient volume and not at the peak of secretion of acid (in d.u. patients). I think that water must be essential in maintaining homeostasis through the appropriate peptides in the region.
Acknowledgments
In this preliminary observation, the author thanks all the friends and foes who made these observations possible; the dedicated colleagues still in captivity who were of constant support and who have developed genuine belief in this method of treatment : Dr. David Fulmer of Princeton Medical Group who became a supporting voice even before seeing the author; Dr M. Litt, chairman of the Bio-Engineering Department , University of Pennsylvania, who has given the author temporary access to the facilities of the University: Dr. Mary Berwick, Bio-Medical Library, University of Pennsylvania, whose search indicates that the author must face the questions on this particular method of treatment alone; and finally Professor Iraj Zandi, University of Pennsylvavia, for his enthusiastic support.
F. Batmanghelidj, M.D.
Princeton, New Jersey
Write for reprints to: F. Batmanghelidj, M.D., P.O.Box 1512, Princeton, New Jersey 08540.
To determine how much water you need each day, divide your body weight in half. The answer is the approximate number of water ounces you should drink daily.
A predominantly starch diet was available. There was no shortage of medication. A critical shortage of cell space at the onset woefully deteriorated. Any professional contact had to be in the presence of the guards, who were always suspicious! I was lucky to have been able to make my observations in Block 3 when I was waiting clarification of my own situation. There I could follow-up my patients before movement became restricted and inmates were confined to their completely isolated individual or group cells.
Men and women from all walks of life, of all ages, under the prevailing uniform condition there, unfolded their particular response to different levels of stress.
Clinically diagnosed peptic ulcer disease was one major manifestation of this stress.Younger people (men much more than women) presented the typical symptoms and signs, from simple epigastric pain experienced for the first time, to recurrence and exacerbation of complaints in patients with chronic ulcer disease. Symptoms even reached the point of semi-consciousness from the intensity of pain, suggesting impending perforation; intermittent pain during the day or night; pain which limited sleep; and continuous intense fluctuation pain. Melena with anemia and hematemesis, on many occasions, supported the clinical diagnosis.
In January 1980, a chance incident forced me to treat one of the inmates , who late one night sought relief for unbearable pain, with 500 cc (two glasses) of water. His pain became less severe and then disappeared completely after 8 minutes. He was an experienced "sufferer" with a long history of repeated treatment, and found relief of pain with water a surprising but welcome experience, particularly as it permitted him to avoid any contact with the guards. He agreed to take the same amount of water every 3 hours as if he were maintaining a diet of nine "meals" a day, during his waking hours; he took three regular meals and six "water meals." The water intake was regular. Food was eaten as it arrived, to allow for the fluctuating time of arrival. The little pain he felt in between his "meals" became less severe and disappeared totally after 3 days. I told him to maintain this diet for 6 weeks. he was given no other type of medication. He had achieved a "clinical cure" with water only for the duration of his stay of a few months in the environment that had "caused" the symptomatic recurrence of an ulcer previously diagnosed by x-ray.
The result of this simple method of "treatment" seemed now too good to be abandoned or ignored. I pointed out the advantages of not depending on medication by this method, under the circumstances, especially to those who had a long history and had tried various methods of treatment with the number of medications available. Those who tried the method were satisfied. The final acceptance by everyone in Block 3 came when a man in his 20s, who had a long history of duodenal ulcer disease, developed another episode of pain at 1 P.M. His symptoms gradually worsened; antacids that he had taken and the several tablets of cimetadine he had kept against such a day did not help. By 11 P.M., he had so much pain that he had become semiconscious. Absolute relief came in 20 minutes after swallowing 500 cc water followed by another 250 cc water 15 minutes later. This total recovery was a source of amazement to me and to the young man's friends who could not believe his transformation. This simple method became the accepted standard treatment for peptic ulcer disease pain in Block 3 of Evin prison, accepted even by those who had political obsessions and personal prejudice.
The group of men in Block 3 were slowly changing because of investigation and sentencing. More and more, these men who suffered ulcer disease pain accepted this "new method" of treatment (recommended even now) now consisted of one glass of water (250cc) half an hour before meal, and an equal amount 2½ hours after each meal (i.e., 1,500 cc of water /day of 3 meals). The patients were told they could drink an extra amount if they were thirsty. The duration of treatment recommended was between 4 and 6 weeks, in keeping with the average time an actual ulcer would take to heal.
A "maintenance course" of a glass of water (250 cc) before breakfast and a similar amount 2½ hours after the three meals in "severe stress cases" proved most effective.
High urine volume and, therefore, sodium loss produced cramps in some of the first patients. As a result, extra salt intake with meals was recommended. Some of the people taking this treatment had to get up in the middle of the night to urinate. These two physiological side effects were the only observed disadvantages to this method of treatment.
The repeated positive results even in patients with a long history of duodenal ulcer disease who responded to treatment with water, who even chose this method in preference to the standard medication methods of treatment, even when antacids, H2 blocking agents, and anticholinergics were readily available, indicated to me that we were dealing with a physiological correctable or controllable state. As a result of lucky access to printed information on peptides of the GI tract, the subsequent stage of my clinical formulations became feasible.
During the last part of confinement, I became involved at the main prison hospital which drew patients from section clinics. Many patients with hematemesis* and/or melena with low blood pressure and/or low hematocrit were seen. They were treated with blood transfusion (up to 8-10 X 250-450 cc of blood to maintain a systolic blood pressure of 90 - 100 mm mercury or a hematocrit of 30). Except for the first ill patient who was given cimetidine (4 tablets of 200 mg for 2 days only, with a supplement of a late night injection of cimetidine again only for 2 days), none of the patients received chemical medication. They were provided with a large jug of strong sugar-sweetened water, with instructions to drink a glass every hour. This period gradually increased to a glass every 1½ hours and then every 2 hours. After 36-48 hours when a feeling of "hunger" would begin, light food with water according to the foregoing schedule was the only treatment needed; i.e., once again, the clinical improvement was definite and no medicines (antacid or H2 blocking agents) were necessary to reestablish improvement. No surgery became necessary. There was no mortality from GI bleeding in these patients. No recurrence of bleeding was seen.
[NOTE: *Hematemesis or haematemesis is the vomiting of blood. The source is generally the upper gastrointestinal tract, typically above the suspensory muscle of duodenum. Patients can easily confuse it with hemoptysis (coughing up blood), although the latter is more common. Hematemesis "is always an important sign". Hematemesis indicates that the bleeding is from the upper gastrointestinal tract, usually from the esophagus, stomach, or proximal duodenum. Occasionally hemoptysis or vomiting of swallowed blood from epistaxis can be confused with hematemesis.]
[NOTE: The hematocrit, also known by several other names, is the volume percentage of red blood cells in blood. It is normally 45% for men and 40% for women. Blood is composed mainly of red blood cells and white blood cells suspended in an almost clear fluid called serum. The hematocrit test indicates the percentage of blood by volume that is composed of red blood cells. The condition called "anemia" results from having too few red blood cells.]
The authorities, who by now could not block to ignore these results any longer, conducted an unofficial trial of their own. They had a questionnaire, which I drew up, reproduced in multiple copies. In a closed "off-limits" section with 600 persons, 240 (40%) were using medication to treat their "ulcer" pain. These people filled out the form and went on the water treatment. The result was dramatic. Water treatment for peptic ulcer disease became the standard form of treatment for that institution and has survived beyond my enthusiasm and incarceration!
During the 2½ years in prison, I must have seen well over 3,000 patients with ulcer symprom. I follow-up about 600. The follow-up information from the rest came to me from their guards, from physicians in charge of other sections, and from chance meetings or messages received. The almost total lack of demand for antacid from the pharmacy during the last few months was an indicator of the success of this treatment, which had spread to all the sections. Even the prison authorities adopted this method for themselves, for they too suffered from peptic ulcer! The final recognition came when my captors, who earlier would have shot me with the least excuse, later confirmed in writing to the Medical Council, the effectiveness of this new method of treatment of peptic ulcer disease, requesting them to inform the medical profession of Iran through their journal.
The implications of this method of treatment seem important, especially the importance or usefulness of "a glass of water" as a diagnostic tool. The following points deserve emphasis:
1. Experience with thousands of patients showed that simple, clinical peptic ulcer disease complaints, the ones in whom a doctor would not suspect a complication, respond to this method of treatment. One glass of water (250 cc) relieves pain within 3 - 8 minutes. Sometimes a little more may be necessary.
2. A few cases of "appendix pain" without other clinical manifestations also responded and became pain-free. Be it from a response of the ileocoecal valve or a cutaneous representation of common thoracic nerve roots, this observation indicates that a
site of pain other than epigastric may herald a clinical picture of duodenal ulcer (d.u) disease.
3. Of the few patients who did not respond to this treatment, further questioning and investigation revealed other pathology. A colleague's case diagnosed a "d.u." when he adopted this method of treatment for his patients (he is conducting an open trial), developed severe "pain and signs" precipitating the need for diagnostic surgery. The condition proved to be acute cholecystitis.
4. In the majority of patients, the relief of pain was preceded by eructation of gas "indicating" that the passage of diluted acid was made possible after what may be relaxation of the pyloric sphincter.
In view of this experience, I suggest that a different interpretation of the "absolute" validity of the design and the conclusions of the "randomized clinical trials" on peptic ulcer is necessary. The water used to swallow a "pill," be it the actual medicine under test or the placebo control (up to now considered inert), has proven to have a definite (physiological) effect of its own. It is possible to theorize that water has its effect before the pharmacologic substance under study achieved optimum blood levels. My experience also suggests that the high cure rate with placebo in controlled studies reported up to now were not without a good reason. Any interpretation or comparison of medication against "placebo" should be reconsidered, due to the body's response to water as a "natural medicine," although in insufficient volume and not at the peak of secretion of acid (in d.u. patients). I think that water must be essential in maintaining homeostasis through the appropriate peptides in the region.
Acknowledgments
In this preliminary observation, the author thanks all the friends and foes who made these observations possible; the dedicated colleagues still in captivity who were of constant support and who have developed genuine belief in this method of treatment : Dr. David Fulmer of Princeton Medical Group who became a supporting voice even before seeing the author; Dr M. Litt, chairman of the Bio-Engineering Department , University of Pennsylvania, who has given the author temporary access to the facilities of the University: Dr. Mary Berwick, Bio-Medical Library, University of Pennsylvania, whose search indicates that the author must face the questions on this particular method of treatment alone; and finally Professor Iraj Zandi, University of Pennsylvavia, for his enthusiastic support.
F. Batmanghelidj, M.D.
Princeton, New Jersey
Write for reprints to: F. Batmanghelidj, M.D., P.O.Box 1512, Princeton, New Jersey 08540.
To determine how much water you need each day, divide your body weight in half. The answer is the approximate number of water ounces you should drink daily.
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