VIEWPOINT

claims and promotions are unwar- Vitamin C and the ranted. The book itself is written with the common cold fervour of a missionary, and in this cause Linus Pauling appears to take G. H. Beaton, ph.d. and S. Whalen, b.sc, Toronto that stance. The introduction de¬ scribes his earlier acceptance and per¬ Success in the search for an effective body and are required for health". sonal trial of the high-level ascorbic cure or preventive for the common This approach has great popular and, acid regimen of Dr. Irwin Stone, an cold has eluded the health profession to a degree, scientific appeal. Howev¬ industrial biochemist. His conviction in spite of extensive research and er, it cannot be assumed to be either and mission are clearly stated in the numerous trials. Today our pharma¬ effective or without potential harm; conclusion to this section: "It will cies are stocked with thousands of adequate clinical testing is still re¬ take decades to eradicate the com¬ patent medicines intended for this quired. mon cold completely, but it can, I purpose (the annual bill in the United Is Pauling's proposed regimen of believe, be controlled almost entirely States is estimated to be more than any greater value than the many nos- in the United States and some other $500 million). To the best of the trums now in use? Pauling is con- countries within a few years through writers' knowledge there is no evi¬ vinced that it is, and concludes his improvement of nutrition of the peo¬ dence that any of these preparations book with the statement "I am con- ple by an adequate intake of ascorbic will either prevent or ameliorate the vinced that the value of ascorbic acid acid. I look forward to witnessing this basic disease process. Undoubtedly should now be recognized." On the step toward a better world." some of them offer at least partial whole, his reviewers seem less con- In his book Pauling presents the relief of symptoms and are judged to vinced and have expressed or implied theoretical basis of his personal con¬ be beneficial by the consumer. How¬ opinions that Pauling's views range viction along with a discussion of ever, it is also probable that some are from near quackery to a brilliant but concepts which relate to his basic actually harmful, particularly if tak¬ speculative venture of an outstanding arguments in only a minor way but en in excess. scientist who applies the approach of which, to the casual reader, may give To this armamentarium Linus a theoretician to practical medical added credibility. In essence, Paul¬ Pauling1 urges that we add vitamin C, problems. ing's argument rests on the beliefthat to be taken in large doses as a preven¬ It is of interest that both the author some 25 million years ago man's pre- tive measure and in still larger doses and his critics seem to agree on one historic ancestors lost the enzymatic as a treatment for the cold. In support central point.at the moment there is ability to synthesize ascorbic acid at a of this he points to the benefits of no scientifically valid evidence that time when the intake of this vitamin "Orthomolecular Medicine", as de¬ Pauling's proposed prophylaxis will was close to the optimum so that its fined by him, "the preservation of work, at least to the degree that he synthesis was no longer an advantage. good health and the treatment of claims, nor is there proof that it will Since man is one of the few species disease by varying the concentrations not work. The major controversy that does lack the necessary enzyme in the human body of substances hinges on a subtle but important for synthesis, this concept has credi¬ which are normally present in the point.upon whom does the onus of bility. Assuming that man was then a proof lie, upon him who proposes a complete vegetarian, Pauling calcu- From the Department of Nutrition, School of new approach or upon the one who lates his probable vitamin C intake on Hygiene, University ofToronto, Toronto, criticizes a new theory? The bias of the basis of the composition of mod¬ Ontario. the and of many ern foods and concludes that this, the Reprint requests to: Dr. George H. Beaton, writers, perhaps Professor and Head, Department ofNutrition, medical scientists, leads them to feel optimum intake by his theory, was School of Hygiene, University ofToronto, that until the evidence is much more within the range of 2.3 to 9 g. per day Toronto 5, Ontario. substantive than at present, major (in contrast to the usually recom- C.M.A. JOURNAL/AUGUST 21, 1971/VOL. 105 355 Hasselblad. mended intake of 20 to 60 mg. per day). This would be a major overesti- mate if our ancestors at that time Some people never settle for second best. consumed significant amounts of ei¬ ther cereals or meats; it might be seriously in error ifthe foods then had a different composition from modern foods. Pauling enlists support for his theory by citing the amounts of ascor¬ bic acid synthesized by the rat. Since the rat does not require a dietary source of the vitamin, Pauling sug¬ gests that it synthesizes an optimal amount. If this amount is translated to the human on a simple weight basis, the estimate obtained is in rough accord with Pauling's predict¬ ed optimal requirement for man. On the other hand, if one attempts to translate the rat synthesis rate on the basis of "metabolic size", W°75, a relationship which seems more ap¬ propriate than simple weight for a number of other biological phenome¬ na, the derived estimate of human requirements is much lower than Pauling's postulated figure, albeit still higher than the usual recom¬ mended intake. Pauling infers further support for his theory from the well- accepted concept of individual varia¬ bility in biological phenomena. He suggests that in the case of ascorbic acid, man's optimal requirement may vary from 250 mg. or less to as much as 10 g. or more. Thus, the response of an individual to a given level of ascor¬ bic acid intake might vary depending upon where his own optimal require¬ ment lay. These are the arguments of a theoretician and can only be chal- lenged on a theoretical basis; it seems improbable that they will ever be proved or disproved by experimental test. It is in the area of the claimed specific effect of vitamin C on the They're aware. Involved. On the move. They From the Carl Zeiss lens through to the common cold that the controversy like to get the most out of everything they interchangeable magazines. You'll see all the this book is most heated. do. own a Hasselblad camera. want reasons for and surrounding They They performance dependability Such claims are not new. There have the superb picture quality the Hasselblad that have made Hasselblad the choice of been claims for almost all of system gives. And they don't mind paying for it. U.S. astronauts on every NASA space flight parallel If settling for second best isn't quite since 1962. For information, write to: Braun the vitamins dating from the period of your way, check in at a franchised Hasselblad Electric Canada Ltd., 3269 American Drive, their discovery and the realization by dealer and check out the Hasselblad system. Mississauga, Ontario. the medical scientist that the lack ofa necessary factor, as well as the pre¬ sence ofa noxious factor, could be the HASS£LBLAD cause ofclinical disease. In the case of ascorbic acid, the literature does con¬ tain many trials. Unfortunately many ofthe studies are poorly controlled or uncontrolled and must be discredited. A few are well controlled. But even the system here, Pauling and his critics differ on the interpretation of the data and more particularly on how it relates to his basic premise that large doses 356 C.M.A. JOURNAL/AUGUST 21, 1971/VOL. 105 (much larger than those used in the 0.58 for the experimental group-a while." From the quotation cited ear- reported trials) will eradicate or at 20% reduction. He suggests that this lier, it is apparent that Pauling thinks least greatly reduce the incidence and is a measure of severity and concludes that the success rate will be almost severity of the common cold. To ex- that ascorbic acid reduces the severity 100%. Many of his critics are a good emplify the difficulty, one study of colds. The number of complica- deal less optimistic. which has been cited and countercited tions might also be considered a In conclusion, how do we assess Dr. by Pauling and his critics2-7 is de- measure of severity, and this was Pauling's claim for the use of vitamin scribed below. reported in the original paper to be C in the prevention of colds? Unsub- In 1942 Cowan, Diehl and Baker8 somewhat higher in the experimental stantiated. Do we think that practi- reported the results of a study carried group than in the control group. tioners should advise their patients to out with students at the University of Again one might ask what the correct take the amounts of vitamin C pro- Minnesota. Over a 28-week period interpretation in the present context posed by Pauling? No. Do we think the students took either a placebo or should be. that controlled clinical trials should approximately 200 mg. of ascorbic Pauling cites from the literature a be undertaken to test his proposal? acid on a daily basis and a record was number of studies which suggest at On the basis of the arguments pre- kept of the symptoms which might be least small effects of vitamin C. As sented in the book, it is doubtful attributed to a cold. An inquiry was already noted, some of these are whether we would be in favour of such made of any history of previous colds seemingly well-designed studies sub- a course. However, when a theoreti- in the participants. The results may jected to statistical tests. More dra- cian as prominent as Linus Pauling be summarized as shown in Table I. matic claims emerge from the uncon- puts forth arguments as fervently as Pauling points out, without chal- trolled or poorly controlled studies. he does, unorthodox to the medical lenge, that the observed incidence of The latter have already been scruti- scientist as they may be, they warrant colds during the study was about 15% nized and have not swayed the general consideration. When this is coupled lower in the treated group than in the opinion of the medical profession or with a realization of the apparent controls. He claims that this differ- the nutritional scientist. In some wide acceptance and probable wide ence is statistically significant, al- cases there has been doubt about their implementation of his recommenda- though the original author suggested validity either because of poor design tions by the general public, the ques- that the difference had little practical or simply because of the difficulties of tion of trials cannot be ignored. It significance. The table reveals that if interpreting clinical trials relating to may be that there is at least marginal the histories are considered (and these such a broad syndrome as the com- benefit from supplementary ascorbic are undoubtedly less reliable than the mon cold. In other cases the magni- acid. It is also conceivable that the observations made during the study), tude of the effect did not seem to large doses of ascorbic acid so change it appears that there may have been a warrant adoption of the approach. urinary chemistry that there is poten- difference initially in the two random- Pauling argues that the consistency of tial danger in his regimen. This may ly selected groups. The final column the findings in the studies he cites be possible in patients with pre-exist- of the table suggests that both the gives them credibility. Further, he ing renal problems. Either way, bene- placebo and the treatment brought suggests that the magnitude of the fit or harm, we will not know the about remarkably similar reductions effect, even if small, is sufficient to answer without trials. What, then, of in the apparent incidence of colds in produce major economic savings if those who are now following the ad- these subjects. The difference be- this treatment were adopted. More vice given in the book? tween the 62.5 and 65.5% reduction important, Pauling postulates that if It is very unfortunate that Linus figures is appreciably less than the the relatively low levels that have Pauling chose to present his theories apparent difference in incidence been tested bring about reductions of in the form of recommendations to (13%) during the trial period. What the magnitude described, the doses he the public with as much publicity as interpretation should be placed upon proposes (1 to 2 g. per day in divided he did, before they were adequately these findings? Opinion differs. doses and 4 to 10 g. per day at the tested. He appears to have felt that On the question of the severity of onset of symptoms of a cold) would the message was so important that he the colds, Pauling notes that the au- have a much greater effect when rou- had to do so. The next step is the thors reported a reduction in the num- tinely instituted. Since this regimen responsibility of the health communi- ber of days lost from school from 1.6 has never been subjected to controlled ty. Without adequate trials we are left days per person in the control group clinical trials, the prediction can nei- with only opinions-and it must be to 1.1 days per person in the experi- ther be substantiated nor refuted. Ev- admitted that the opinion of a man mental group. Taking into account en Pauling comments: "I do not know who has won two Nobel Prizes must the different incidence of colds in the how effective this regimen really carry some weight even when his re- two groups, in a later commentary on is-whether 90 percent of all colds marks apply to a field which differs the book Pauling calculated that the can be stopped, or perhaps only 75 appreciably from his prime discipline. average number of days lost per cold percent or 50 percent. Even 25 per- was 0.73 for the control group and cent success would be well worth References 1. PAULING L: Vitamin C and the common Table I cold. San Francisco, WH Freeman, 1970 Effects of dietary supplementation with 200 mg. ascorbic 2. LEE RV: That man.... Pauling! Shaking acid up the doctors. Nut, Today 6(1): 16, 1971 Number of Incidence of colds Reduction from 3. PASSMORE R: That man.... Pauling! New Treatment subjects Previous year During study previous year nostrum. Ibid p 17 4. STARE FJ, HAYES KC: That man.... Placebo 155 5.9 ± .14 2.2 ± .08 62.5% Pauling! Not quite cricket. Ibid p 18 Vitamin C 208 5.5 ± .12 1.9 + .07 65.5% Continued on page 363 C.M.A. JOURNAL/AUGUST 21, 1971/VOL. 105 357 amazing how many of them boast of Another young woman doesn't like elderly gentleman lying quietly in "never having breakfast". In fact her shape and wants me to do her one bed, in no apparent distress. On ex- they hardly eat at all. Here, without minor favour - to transfer some fat amination he was found to have acute being asked, they give you a rapid from her thighs to her bosom or vice fulminating appendicitis with perito- account of their food schedule. They versa. I tell her that at the present nitis. triumphantly wind up by saying "You time redistribution of fat is impossi- My receptionist is authorized to can ask my husband!" The latter, ble but I am working on it. I also warn repeat anticonvulsants for the chronic unfortunately, is not immediately her not to fall victim to advertise- epileptic, oral contraceptives in cases available for information. He is ments that proclaim to be able to do where there are no problems, and spending a few well-deserved minutes this. hypnotics in the case of the addict in a nearby pub. I do not treat obesity per se unless who has been taking sleeping pills for For many years I have wasted pre- the patient has a concomitant disease years. One must be careful not to cious hours on these people which, in such as diabetes, hypertension or car- prescribe these agents over the tele- retrospect, turned out to be an exer- diovascular disease, etc. phone in the case of patients whom cise in futility. Nowadays I am quite you have only seen once. abrupt with them. I tell them I am not The remote-control patient very good in this field. They will If the members of the legal profession The affluent patient receive no benefit from coming to me knew the amount of work done by the In contrast to the poor and humble, with this problem, and my reputation average G.P. over the telephone, they we have the rich and the V.I.P. My as a non-producer (or reducer) will would express shocked disbelief. This remarks about this type will not be get a black mark. I highly recom- work, of course, is gratis. For a law- complimentary. There was a time in mend the Weight Watchers club - yer it would amount to a sizable the memory of the older physician group therapy succeeds where an in- income. when, if a doctor had several rich dividual therapist fails. The true remote-control patient is patients in his practice, he was envied I cannot understand why persons a person you seldom see in your of- by his colleagues. It was felt that here who took 10 years to put on 50 pounds fice. You treat him for a cold he at least the practitioner had a chance should expect to lose it all in two cannot shake. (In my practice I have a to get paid for his services. Nowa- months; they should allow a compa- large number of poor shakers.) Or for days, with universal prepaid medical rable period to take it off. Incidental- insomnia, sunburn, etc. Occasionally plans, the rich literally get into the ly, when they say they are not "eat- a person will call for a repeat pre- "Act". However, because of their ing" too much, they may be telling the scription for a pill I gave him 10 years standing in the community and their truth. The word "eating" connotes ago. He does not remember the name, self-esteem, they attribute to them- the need for teeth, knife and fork, etc. but it tasted like peppermint, and it selves a superior role. When they There is an instinctive feeling that was mauve in colour. (I am colour- honour you by consulting you it is to drinking is harmless, and these people blind.) His record was put away a get referred to the "best specialists". have also been brain-washed into be- long time ago and it would be time- They expect special appointment lieving that fruit juices are "good for consuming to resurrect it. What does times, since they cannot imagine you". In the course of examining a one do? Admit defeat, confess that themselves waiting alongside preg- young man with an acute abdomen, I your memory is indeed slipping, and nant women or howling youngsters. questioned him regarding his food that you have no idea what the par- For that matter, neither can you. intake that day. His reply was: "I ticular pill was. You subtly hint that They often put the onus on you by didn't have a thing to eat all day. All I perhaps after 10 years it might be wise saying "Call me when you are not had was four milk shakes." for him to consult a doctor. And in busy." They take a dim view, howev- Generally speaking, these patients order not to appear to be soliciting for er, of extra billing. Such a patient know more about calories than you business, I tell him I am booked solid must be classified as a liability rather do. Furthermore, each individual for months. than an asset. However, if you belong knows where his weakness lies (e.g. I don't know how to stop the prac- to the same golf club, mix with him chocolate, ice cream, beer) and there- tice of remote control, because there socially, or if you are married to his fore can help himself more than you is a real risk in making a diagnosis daughter, the above considerations can. over the telephone. A great deal de- do not apply. Then there is the young woman pends on the communicative capacity H. J. Skully who has an obsession about weight. of your informant. A case that hap- She is perhaps 10 to 15 pounds above pened in my practice recently is worth normal. She claims she feels "fat". relating. A young woman was in the She utters the word "fat" with dis- office for a routine check-up. On gust. When asked to demonstrate her leaving, she casually asked me if I "fat", she points to a "spare tire" would mind stopping to see her father Continuedfrom page 357 around her abdomen and to her hips. on my way home from the office Tell such a person that it is not wise to 5. ENLOE CF: That man.... Pauling! The because he had mild abdominal pains. virtue of theory. Ibid p21 drive without a "spare tire". As far as The request was so lukewarm that my 6. PAULING L: That man.... Pauling! Dr. her hips are concerned, you point out reaction was similarly lukewarm. I Pauling responds. Nutr Today 6(2): 21, that nature endowed woman with went home to dinner, not making the 1971 curves, which are basic and not un- requested call. During dinner the 7. BUTTERWORTH CE: That man .... Paul- wife ing! Dr. Butterworth comments. Ibid p24 desirable. To convert this person into telephoned to say that she was some- 8. COWAN DW, DIEHL HS, BAKER AB: Vita- a "Twiggy" would be foolish and not what worried about her husband. mins for prevention of colds. JAMA 120: medically sound. When I arrived at the house I saw this 1268-1271, 1942 C.M.A. JOURNAL/AUGUST 21, 1971/VOL. 105 363