Ava Helen’s Role in the Nephritis Story

Ava Helen Pauling serving food at the Caltech Chemistry Department picnic, 1941.

[Part 4 of 5]

“This is the record of the diet which Linus ate when he was ill with nephritis. I kept the record and noted everything that he ate. Dr. Thomas Addis of the Stanford Medical School was his physician.”

-Ava Helen Pauling

While Thomas Addis is rightfully credited with Linus Pauling’s recovery from nephritis, Addis himself preferred to place the acclaim elsewhere. Addis knew that he was not alone in his efforts to prevent the early demise of the great Linus Pauling and he recognized that he had a female cohort who was essential to Pauling’s care. Her name was Ava Helen Pauling.

Over the course of his practice, Addis relied heavily on the support of his patients’ families and was convinced that their efforts were vital to his patients’ care. In fact, Addis once said that it is the “…wives, mothers, and sisters who, with our patients are our true colleagues with whom we work and for whom we work.” Ava Helen was clearly no exception.

It did not take long for Addis to acknowledge Ava Helen as his colleague. Throughout Linus’ recovery, Ava Helen and Addis sent correspondence back and forth updating one another on Pauling’s status. Addis even signed his letters addressed to Ava Helen as “Your ever faithful collaborator, T. Addis,” and Ava Helen often referred to Pauling as “our patient” in her responses back to Addis.

Ava Helen Pauling to Thomas Addis, May 20, 1941, pg. 1

Ava Helen Pauling to Addis, pg. 2.

As soon as Pauling began the low protein, low sodium diet that Addis had prescribed, Ava Helen diligently kept a record of Pauling’s diet. This journal can now be found in the OSU Library Special Collections.

The notebook is meticulous and thorough. Occasionally, Ava Helen even includes small notes about Pauling’s health and daily activities.

Ava Helen began the record of Pauling’s diet on April 9th in 1941. In each of her entries, Ava Helen documented what and how much her husband ate, as well as the protein content (grams), the salt content (milligrams), and the calories in all that he consumed. She totaled the amounts after each meal and recorded final totals at the end of each day.  With the support of his loyal and dedicated wife, Pauling was able to stay on this strict diet for fifteen years.


The following is a brief summary of Pauling’s low protein, low sodium diet, based on Ava Helen’s record.

Each day while on his special diet, Pauling consumed between 2,000-3,000 calories (usually closer to 3,000), around 55 grams of protein, and approximately 1.2-1.6 grams of salt.

His breakfasts typically consisted of a citrus fruit or glass of fruit juice, a cereal (shredded wheat, pancakes, or crepes suzette), milk, cream, and a cup of coffee.

For lunch he generally ate various combinations of the following:  eggs, vegetables, water biscuits, apple sauce, potatoes, cheese, fruits, and vegetables.

Lunch was often followed by a chocolate bar. From April 9th-June 30th, 1941 Pauling consumed some 65 chocolate bars.

In the evenings he would dine on fruits and vegetables, cheese, water biscuits, baked potatoes, and milk.

Below is an example of a typical day on Pauling’s nephritis diet.

Meal record kept by Ava Helen Pauling for April 23, 1941.

Wednesday, April 23, 1941

Breakfast

  • 1/2 Grapefruit
  • 6 Pancakes
  • 2 Squares of Butter
  • 6 Tbs Syrup
  • 2 Tbs Cream
  • 1 Cup of Coffee

Breakfast Total: Protein 11 g; Calories 1,050; Salt 259 mg

Lunch

  • 1 1/2 Cup Eggnog
  • 1 Piece of Coconut
  • 1 Medium Orange
  • 1 Medium Pear
  • 1 Chocolate Bar

Lunch Total: Protein 20 g; Calories 858; Salt 543 mg

Dinner

  • 1 Baked Potato
  • 1 Square Butter
  • 2/3 Cup of Cabbage
  • 1 Cup of Milk
  • 1/2 Cup of Gelatin
  • 1/4 Cup Cream (30%)
  • 4 Cookies

Dinner Total: Protein 19 g; Calories 830; Salt 510 mg

Daily Total: Protein 54 g; Calories 3,020; Salt 1312 mg

It is apparent that Pauling had a sweet tooth as his dietary record is littered with notes of sugary treats such as custards with chocolate sauce, sponge cakes, meringues, ice cream, fruit tarts and pies, puddings, cookies, Coca Cola, and strawberries with cream.

This dietary record is a unique window into an important chapter of the life of Linus Pauling.

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The Methods of Thomas Addis

Portrait of Thomas Addis by Marion C. Raulston, held in the Thomas Addis Papers, Lane Medical Library Special Collections, Stanford University.

[Part 3 of 5]

[In the beginning] I was all set on measuring things and was trying to be ‘scientific.’ But anyone who has patients and patience can scarcely help coming at last to see that experiments that don’t answer questions about patients are, for the doctor, pretty irrelevant.

-Thomas Addis

The result of a lifetime of work devoted to the study of kidney disease, Thomas Addis became the first true American nephrologist. In studying the urinary contents of both healthy individuals and individuals affected with Bright’s disease, Addis was able to develop a systematic treatment plan unlike any other proposal of the time. As a clinical investigator Addis provided for his patients what most other kidney specialists at the time could not – hope and options.

Throughout his career, Addis consciously integrated his laboratory research into his clinical practice by methodically “mixing patients with rats.” In his effort to thoroughly understand the kidney and its diseases, Addis followed a group of nephritics for over thirty years while also maintaining a colony of over 1,000 rats for in vivo experimentation. Addis refused to separate his clinical work from his laboratory studies, and even went so far as to see his patients in a small cubical in the corner of his laboratory.

From his laboratory experiments and clinical experiences, Addis developed a unique method for the treatment of nephritis. Based on the physical concepts of work and healing, Addis believed that in order for the kidneys to recover, the patient must allow the organs time to rest. In pursuit of a reduced renal workload, Addis prescribed a low protein, low sodium diet for his nephritic patients. This method appeared to have worked effectively for the treatment of many (but not all) of Addis’s patients and proved to be the answer for Pauling’s ailments.

Addis’s system for treating nephritic patients relied heavily upon a series of quantitative measurements that soon became known as the “Addis count” and the “Addis urea ratio.” The “Addis count” quantitatively determined the number of red blood cells, white blood cells and casts (clumps of red and white blood cells) excreted in the urine. The “Addis urea ratio” measured the concentration of urea in the urine. These two measurements, in addition to a measurement of the total urine output, were the basis for Addis’s assessment of a patient’s progress throughout treatment. Addis believed that these measurements provided insight into both the nature and extent of the disease.

When Pauling came to Addis in 1941 for assistance with his diagnosis of Bright’s Disease, Pauling was quickly impressed by Addis’s methodology. Beyond the measurements described above, Addis qualitatively examined the cells obtained from the urine sample and identified any deformations and abnormalities that he observed.

Although Addis relied heavily on his laboratory group, he took all of the measurements and conducted the sample analyses himself, adamantly insisting that in order for the work to have meaning, the physician must be responsible for all of such analyses.  Upon gathering sufficient data, Addis used his qualitative and quantitative findings, as well as his experience with his patients, to clinically reclassify Bright’s disease and develop tailor-made treatment plans.

While Addis’s treatment offered relief to many, his findings and conclusions were often criticized by the scientific community for lacking validity. These critiques stemmed from Addis’s refusal to use controls in his clinical studies. In a note written by Pauling about Addis, Pauling proclaimed, “The trouble with Addis – no controls!” Addis firmly believed that controls in his research would be unethical. His duty, he wrote, was “to treat each patient in the way that I think will do him the most good.”

Were Addis to have incorporated controls into his clinical research, he would have been forced to split his patients into two groups. This experimental design would have left half of his patients without the treatment that he, as their physician, believed to be most effective. Addis considered such methodology to be unacceptable. As such, because Addis refused to include controls in his research, the majority of the scientific community considered there to be significant limits to Addis’s contributions.

Thomas Addis: The Man Who Saved Pauling

Thomas Addis, 1920s

[Part 2 of 5]

When Linus Pauling received his diagnosis of Bright’s disease in March of 1941, his prognosis was grim. At the time Bright’s disease was considered to be fatal and the majority of the medical community was in agreement that there was no cure or effective treatment. Fortunately for Pauling, a man by the name of Dr. Thomas Addis did not agree.

Thomas Addis, known to close friends and colleagues as Tom, was born on July 27, 1881 in Edinburgh, Scotland. After fulfilling a position as a Carnegie Research Scholar and Fellow, Addis left Europe in 1911 to pursue a career as clinical investigator at Stanford Medical School. Upon arriving in the United States, Addis devoted his life’s work to the study of kidney disease. By the time of his death at age 67, Addis’s achievements were such that some would refer to him in reverent tones. In the estimation of William Dock, an MD at the State University of New York, “As a medical scientist he was in a class by himself.”

Addis’s accomplishments placed him in a league of his own as a medical investigator and his persistent advocacy for his patients made him a superior clinician. This combination accounts for his recognition as a superior clinical investigator.

During his lifetime, Addis published more than 130 scientific papers. He also published two books on renal disease, The Renal Lesion in Bright’s Disease (1931) and Glomerular Nephritis: Diagnosis and Treatment (1948), both of which were well received in the medical community. Stanford University Medical professor Arthur Leonard Bloomfield would recount:

Addis’s book with Oliver on the renal lesion in Bright’s Disease is, of course, a classic, but the little volume on glomerular nephritis completed only a few months before his death seems to embody his philosophy of disease and of science in general; it will perhaps interpret the man to his followers better than anything else he has done.

Known for his unique laboratory structure, Addis strongly encouraged the collaboration of all members of his scientific team and managed his laboratory based on what he believed to be “democratic centralist principles.” Among his co-workers was Elesa, a lab dietician and Addis’s wife.

Throughout his career, Addis’s loyalty to the group as a whole never wavered. People’s World writer, Pele Edises, once requested a “profile interview” with just Addis, to which he replied, “Why can’t you just write about the lab and leave me out of it?” Addis was often described as a man of integrity and would most surely have disapproved of this blog post had his group members and their contributions not been mentioned.


Over the course of Pauling’s treatment, he and Addis became scientific colleagues and good friends. Beyond their shared professional interests, Pauling and Addis also maintained characteristically active political minds. Outspoken in his beliefs, Addis’s political affiliations led him to assume a position as the founder and chairman of the San Francisco Chapter of the Spanish Refugee Appeal. A primary activity of the Appeal was to assist the funding of a clinic in Toulouse, France, known as the Varsovie Hospital, dedicated to the care and rehabilitation of Spanish Republican refugees.

Like Pauling, Addis’s political inclinations met with significant resistance throughout his professional career. In a note that Pauling dictated in preparation for an Addis memorial, Pauling noted that Addis’s affiliation with the American Medical Association (AMA) had been turbulent throughout his lifetime due to his political allegiances. In one instance Addis raised objections to the AMA’s California Medical Association’s support of a coffee cancer cure which Addis believed to exploit individuals seeking treatment. In another incident Addis spoke out against a $25.00 contribution requested or required by the AMA to fund a fight against President Truman’s system of medical insurance.

Thomas Addis passed away on June 4, 1949, in Cedars of Lebanon Hospital in Los Angeles. His death was mourned at home and abroad – the October 1949 newsletter of the Varsovie Hospital includes this passage:

Con la muerte del Dr. Thomas Addis, los antifranquistas, los republicanos españoles, perdemos un gran amigo y un valiente luchador en defensa de nuestra causa, por la República, por la Democracia y por la Paz. [With the death of Dr. Thomas Addis, the anti-fascist Spanish republicans lost a great friend and a valiant fighter in the defense of our cause, for the Republic, for the Democracy, and for peace.]

In his honor a new laboratory was added to the out-patient clinic of the Varsovie Hospital in 1950. And long after his death, Addis’s name was used effectively to raise funds for the clinic and to provide aide to the Spanish refugees who were victims of the Franco regime. In a March 1950 letter to Ava Helen Pauling, Addis’s former secretary, in commenting on the Paulings’ political stands, noted “how happy and proud Dr. Addis would be, could he know.”

The Thomas Addis Memorial Award, 1955.

In 1955 Linus Pauling was awarded the first Thomas Addis Memorial Award by the Los Angeles Chapter of the National Nephrosis Foundation. The award would evolve into an annual honor granted in recognition of significant contributions to the study of the kidney and its diseases.

After Addis’s death, Pauling offered to write a memorial detailing Addis’s life and accomplishments. In response, the Addis family prohibited any mention of Addis’s political affiliations, for fear of their personal safety, given the nation’s current political climate. As a result Pauling and his co-author, Dr. Richard Lippman, made the executive decision to delay publication. In Lippman’s estimation, “It is impossible to characterize Dr. Addis in my opinion, without some discussion of his political ideas and his philosophy of politics and people.”

A revised version of the piece, co-authored by Pauling and Kevin Lemley, would not appear in print until 1994, the year of Pauling’s death.

Pauling’s Battle with Glomerulonephritis

[Part 1 of 5]

On March 7, 1941, Linus Pauling stood before distinguished colleagues prepared to deliver an address in response to his receipt of the prestigious William H. Nichols Gold Medal, presented by the New York chapter of the American Chemical Society.

Before Pauling began his recitation, he spoke candidly to his audience. He thanked the award committee for his selection and expressed gratitude that the acceptance of this award had provided him with an opportunity to reconnect with old friends.

On this rare occasion, however, it was apparent to all in attendance that Pauling’s physical health was suffering. His face was bloated and he reportedly lacked the enthusiasm that he was so well known to exude. Addressing the observations of many of his peers, Pauling joked, “Several of [my old friends] said to me tonight that I appeared to be getting fat. This is not so.”

Just that morning, Pauling had awoken to find his face so bloated that his eyes were nearly swollen shut. His tongue felt enlarged and his voice was flat. Over the previous few weeks, Pauling had been experiencing noticeable swelling, weight gain, and chronic fatigue but he could not identify the cause of his ailments.

With his audience, Pauling half-heartedly pondered over the cause of his puffed-up appearance. He compared the experience to childhood memories of unfortunate encounters with poison oak.

Yesterday I must have bumped into something similar…while I was wondering what the responsible protein could have been, I decided that it was a visitation – that I was being punished for thinking wicked thoughts.

The following evening Linus and Ava Helen had dinner at Alfred Mirsky‘s residence. Pauling was examined by another guest at the dinner party, Dr. Alfred E. Cohen, a cardio specialist from the Rockefeller Medical Institute. After ruling out problems with Pauling’s heart, Dr. Cohen remained perplexed by Pauling’s condition. Nothing appeared to be wrong with the forty-year-old man other than his extreme edema. Concerned by the severity of the swelling however, Dr. Cohen recommended that Pauling come into his office the following day for a more thorough examination and lab work-up.

Adhering to the physician’s recommendation, the Paulings met Dr. Cohen in his office at the Rockefeller Medical Institute the next day. After a battery of lab tests, Pauling was diagnosed with Bright’s disease – a potentially fatal renal disease that results in the degradation of the kidneys. At the time, little was known about Bright’s disease and the majority of the medical community considered it to be a terminal condition.

After receiving this diagnosis, Pauling was fortunately referred to a leading specialist in renal diseases, Dr. Thomas Addis, head of the Clinic for Renal Disease at Stanford. Dr. Addis was a pioneer in the field of nephrology and his treatment plan, at the time, was new and revolutionary. Had Pauling not been referred to Dr. Addis’ care, the treatment he would have received elsewhere would almost surely have killed him.

Under the guidance of Dr. Addis, Pauling’s condition was effectively treated by alternative means – a low-protein, low-sodium diet – rather than the polysaccharide infusions that would have reduced his edema but done little to improve his health.  By May, Pauling reported improvements in his overall well-being and by August, the edema had completely disappeared.

Since Pauling’s time of diagnosis, Bright’s disease has been reclassified and redefined. Now it is believed that Pauling was affected by what is currently termed acute glomerulonephritis.

Acute glomerulonephritis is characterized by inflammation of the kidneys due to an immunological response. Damage to the small clusters of capillaries within the kidney, known as glomeruli, results in what can most simply be described as a “leaky kidney.” When the glomeruli are damaged, proteins leak from the bloodstream into the urine through the damaged portions of the kidney. Thus glomerulonephritis consequentially leads to excessive protein loss. Glomerulonephritis profoundly effects the body’s ability to function, because the nephritic kidneys are unable to properly filter the blood.

In his 1941 speech, Pauling had wondered aloud about a protein that was responsible for his swollen condition. The culprit protein can now perhaps be identified as albumin. As proteins leak from the bloodstream into the urine, blood proteins, called albumin, exit the bloodstream. These proteins are known to be essential in the regulation of blood osmotic pressure. Without sufficient albumin in the bloodstream, the body becomes incapable of efficiently extracting excess fluid from the body cavity. This excess fluid then remains trapped in the body and ultimately results in excessive swelling – such as the bloating that Pauling experienced in 1941.

Although the albumin did not cause Pauling’s condition, the loss of this blood protein due to the nephritis appears to have resulted in the symptoms that he was experiencing at his award ceremony. Therefore, contrary to his original speculation, it was the absence, rather than the presence, of a protein that caused his extreme fluid retention.

Over the next series of posts, we’ll explore the details of Pauling’s battle with this frightening disease, and learn more about the people and methods who saved Linus Pauling’s life.