Parveen Kumar, CBE, BSc, MD, DM (HC), FRCP, FRCP(Edin)

• Professor of Medicine & Education, Barts and The London School of Medicine and Dentistry, Queen Mary, University of London, and Honorary Consultant Physician
• Gastroenterologist, Barts and The London Hospitals NHS Trust and Homerton Hospital NHS Foundation Trust, London, UK

Geriatrics Page 265 of 385 Trauma Orthopedic Trauma Paramedic Education Standard Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression to implement a comprehensive treatment/disposition plan for an acutely injured patient treatment as prevention divalproex 250mg amex. Traction control hemorrhage by apply pressure on internal bleeding within muscles wrapped by muscle sheaths symptoms gonorrhea cheap divalproex 250 mg online. Locally increased pressure compromises local circulation and neuromuscular function 3 medications definition buy cheap divalproex 250 mg on line. Pain Management Page 270 of 385 Trauma Soft Tissue Trauma Paramedic Education Standard Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression to implement a comprehensive treatment/disposition plan for an acutely injured patient symptoms torn rotator cuff purchase 500 mg divalproex otc. Burn extends into subcutaneous tissue possibly including bone and muscle tissue h. Review percent of body surface burn estimation methods for adults, children and infants. Special management considerations Page 277 of 385 Trauma Head, Facial, Neck, and Spine Trauma Paramedic Education Standard Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression to implement a comprehensive treatment/disposition plan for an acutely injured patient. Le Fort I Fracture separates hard palate and lower maxilla from remainder of skill Page 278 of 385 b. The pressure causes the weakest area (orbital floor) to give way, causing herniation of orbital contents (inferior oblique muscle entrapment) into the maxillary sinus. Depressed skull fractures may require circumferential digital pressure to control an open skill fracture bleed 3. Not part of the cord, but a series of nerves that appears like a tail at the end of the spinal cord. Special assessment considerations (signs and symptoms are never root dependent) 1. Trauma damages a nerve, or nerve group between the ganglion and its intervention point. Cushings triad (increased blood pressure, decreased pulse and irregular respirations) 15. Pharmacological assistance Page 286 of 385 Trauma Special Considerations in Trauma Paramedic Education Standard Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression to implement a comprehensive treatment/disposition plan for an acutely injured patient. Airway, Breathing, and Circulation (improper management is the most common cause of preventable pediatric death) a. Risk is high for young and elderly, patients who can not generate heat (diseases and medications) c. Continued drops in temperature causes hypothalamic center to stimulate shriving Page 294 of 385. If cold continues, vasocontriction is lost and then vasodilation occurs with loss of core heat to the periphery f. At 85 degrees the individual become stuporous, cardiac output drops, cerebral blood flow is decreased g. If re-warming, tepid, near body heat, water immersion of extremity, usually requires 10 to 30 minutes immersion. Many toxins cause the patients cells to release bradykinins, histamines, and serotonin c. May cause head trauma, cardiac damage, burns, extremity vasospasm, paresis or parethesias. Prevention is best, many patients take acteazolamide Page 297 of 385 Trauma Multi-System Trauma Paramedic Education Standard Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression to implement a comprehensive treatment/disposition plan for an acutely injured patient. Looking a trauma scene and attempting to determine what injuries might have resulted 2. Unbelted drivers and front seat passengers suffer multi-system trauma due to multiple collisions of the body and organs c. Typically a patient considered to have multi-trauma has more than one major system or organ involved a. Multi-trauma treatment will involve a team of physicians to treat the patient such as neurosurgeons, thoracic surgeons, and orthopedic surgeons 4. Consider use of tourniquets in emergent, hostile or multiple patient situations where bleeding is considerable 3. The definitive care for multi-system trauma is surgery which can not be done in the field b. Early notification of hospital resources is essential once rapidly leaving the scene f. Changes in vital signs or assessment findings while en route are critical to report and document 7. Newly licensed paramedics who have not seen many multi-system trauma patients need to stick with the basics of life saving techniques b. Do not develop tunnel vision by focusing on patients who complain of lots of pain and are screaming for your help while other quiet patients who may be hypoxic or bleeding internally can not call out for help because of decreases in level of consciousness c. Be suspicious at trauma scenes, sometimes an obvious injury is not the critical cause one the potential for harm. Blast waves when the victim is close to the blast cause disruption of major blood vessels, rupture of major organs, and lethal cardiac disturbances b. Multi-casualty care Page 301 of 385 Special Patient Population Obstetrics Paramedic Education Standard Integrates assessment findings with principles of pathophysiology and knowledge of psychosocial needs to formulate a field impression and implement a comprehensive treatment/disposition plan for patients with special needs. Bleeding Related to Pregnancy: pathophysiology, assessment, complications, management 1. Complications of Delivery: pathophysiology, assessment, complications, management A. Postpartum Complications: pathophysiology, assessment, complications, management 1. Post partum depression Page 306 of 385 Special Patient Population Neonatal Care Paramedic Education Standard Integrates assessment findings with principles of pathophysiology and knowledge of psychosocial needs to formulate a field impression and implement a comprehensive treatment/disposition plan for patients with special needs. Neonatal mortality risk can be determined via graphs based on birth weight and gestational age b. Resuscitation is required for about 80% of the 30,000 babies who weigh less than 1500 grams at birth 3. Complete airway obstruction a) Atelectasis b) right-to-left shunt across the foramen ovale ii. Incomplete airway obstruction a) Ball valve type obstruction b) developing pneumothorax c) chemical pneumonitis c. Transport consideration transport to a facility with special services for low birth weight newborns g. Morbidity/ mortality represent relative medical emergencies as they are usually a sign of an underlying abnormality c. Risk factors prolonged and frequent multiple seizures may result in metabolic changes and cardiopulmonary difficulties 2. Degree of myelinization will affect manner of seizure presentation/observed clinical signs 3. Term newborns will produce beads of sweat on their brow but not over the rest of their body g. Pharmacological administration of antipyretic agent is questionable in the prehospital setting d. Morbidity/ mortality infants may die of cold exposure at temperatures adults find comfortable c. Pathophysiology Increased surface-to-volume relation makes newborns extremely sensitive to environmental conditions, especially when wet after delivery a.

One commenter suggested that to counter institutional bias symptoms zoloft overdose purchase divalproex 500mg amex, which the commenter argued was on display in notorious cover-up situations at prestigious universities where employees committed sexual abuse medicine news purchase divalproex 250 mg without a prescription, the proposed rules should specifically require training on conflicts of interest caused by employees misplaced loyalty to the recipient symptoms torn meniscus effective 500 mg divalproex. Another commenter requested more information on what would constitute general bias for or against complainants or respondents under this provision treatment hyperthyroidism purchase divalproex online from canada, expressing concern that without any framework for evaluating whether a particular administrator is tainted by such bias this provision is amorphous and will add confusion and grounds for attack at smaller institutions where many student affairs administrators fill several different roles. Several commenters recommended countering inherent institutional conflicts of interest on the part of recipient employees by revising the final regulations to avoid any commingling of administrative and adjudicative roles. The same commenters recommended bolstering neutrality and independence by removing the role of counseling complainants from the office that coordinates the grievance process and requiring that investigators have some degree of institutional independence. One commenter shared an example of bias on the part of the single administrator tasked with ruling on the commenters clients appeal of a responsibility finding, where the appeal decision-maker had recently retweeted a survivor advocacy organizations tweet To survivors everywhere, we believe you, yet the recipient overruled a bias objection stating that nothing suggested that such a tweet meant the appeal decision-maker was biased against that particular respondent. This commenter proposed adding language explaining that a reasonable person standard will be applied to determine bias, along with cautionary language that a history of working or advocating on one side or another of this issue might constitute bias. One commenter asserted that Federal courts of appeal, including the Sixth Circuit, agree that being a feminist, being affiliated with a gender-studies program, or researching sexual assault 1033 does not support a reasonable inference than an individual is biased against men. Several commenters urged the Department to expand this provision to prohibit perceived conflicts of interest or the appearance of bias in line with standards that require 1033 Commenter cited: Doe v. One commenter suggested that this provision should require nondiscriminatory investigations and adjudications instead of being not biased. Unless prescription is necessary to achieve compliance with the final regulations, the Department does not wish to interfere with recipients discretion to conduct a recipients own internal, administrative affairs. The Department is also sensitive to the reality that prescriptions regarding employment relationships likely will result in many recipients being compelled to hire additional personnel in order to comply with these final regulations, and the Department wishes to prescribe only those measures necessary for compliance, without unnecessarily diverting recipients resources into hiring personnel and away from other priorities important to recipients and the students they serve. The Department acknowledges the concerns expressed both by commenters concerned that certain professional qualifications. In response to commenters concerns that the prohibition against conflicts of interest and bias is unclear, the Department revises this provision to mandate training in how to serve impartially, including by avoiding prejudgment of the facts at issue, conflicts of interest, and bias in place of the proposed language for training to protect the safety of students, ensure due process protections for all parties, and promote accountability. The Department disagrees with the commenter who suggested replacing bias in this provision with non-discrimination. As noted above, the topic of sexual harassment inherently involves issues revolving around sex and sexual dynamics such that a standard of appearance of or perceived bias might lead to conclusions that most people are biased in one direction or another by virtue of being male, being female, supporting womens rights or supporting mens rights, or having had personal, negative experiences with men or with women. The Department believes that keeping this provision focused on bias paired with an expectation of impartiality helps appropriately focus on bias that impedes impartiality. No such requirement of employee status applies to , for instance, serving as a decision-maker on a hearing panel. One commenter wondered why this provision removes vital sexual harassment training of school personnel but gave no explanation for drawing this conclusion. Some commenters urged the Department to include a definition of sex stereotypes, asserting that without clarity this provision is a legal morass exposing recipients to liability. One commenter asserted that bias lacks a definitive legal meaning and should be replaced by non-discriminatory. Other commenters requested clarity that stereotypes of men as sexually aggressive or likely to perpetrate sexual assault and references to toxic masculinity are prohibited under this provision. One commenter urged the Department to interpret this provision to require training around bias that exists against complainants and to clarify that the Start by Believing approach promoted by End Violence Against Women International should be part of these training requirements because that approach trains investigators to start by believing the survivor to avoid incorporating personal bias and victim-blaming myths that might bias the investigation against the survivor. The commenter asserted that understanding the dynamics of sexual trauma is necessary in order to treat both complainants and respondents fairly without bias. Another commenter asserted that start by believing is not appropriate for investigations but is appropriate for counseling and thus, the final regulations should require that for counseling purposes personnel must start by believing a complainant or a respondent seeking counseling. One commenter suggested this provision be modified to require training to have a working understanding of impartiality. The final regulations impose no prohibition of conflict of interest or bias for such advisors, nor any training requirement for such advisors, in order to leave recipients as much flexibility as possible to comply with the requirement to provide those advisors. The Department believes that advisors in such a role do not need to be unbiased or lack conflicts of interest precisely because the role of such advisor is to conduct cross-examination on behalf of one party, and recipients can determine to what extent a recipient wishes to provide training for advisors whom a recipient may need to provide to a party to conduct cross-examination. The Department is committed to imposing legally binding requirements by following applicable rulemaking processes. The Department appreciates the many commenters who requested a definition of sex stereotypes and asked that such a definition include, or exclude, particular generalizations and notions about women or about men. To reinforce 834 this necessity, the final regulations use must instead of may to state that training materials must not rely on sex stereotypes. Contrary to the concerns of some commenters, a prohibition against reliance on sex stereotypes does not forbid training content that references evidence-based information or peer reviewed scientific research into sexual violence dynamics, including the impact of trauma on sexual assault victims. The Department is not proactively scouring recipients curricula to spot instances of sex stereotyping; rather, the Department is 835 placing reasonable conditions on materials specifically used by recipients to carry out recipients obligations under these final regulations. At least one commenter urged the 1043 Department to adopt the training language from the withdrawn 2014 Q&A. One commenter suggested the Department create an aspirational list of training components. Thus, the Department declines to expand this provision to mandate that training address the topics suggested by commenters. The Departments intent with respect to this provision is to provide flexibility for each recipient to design or select training components that best serve the recipients unique needs and educational environment, while prescribing those training topics necessary for a recipient to comply with these final regulations. One commenter believed that using impartial instead of trauma informed is offensive to rape victims, for whom trauma necessitates a cognitive interview that takes the effects of trauma into account, while another commenter believed training must require trauma-informed best practices. A few commenters believed that the provision should address the use of trauma-informed theories by cautioning against misuse of victim-centered approaches for any purpose other than interviewing or counseling; these commenters distinguished between remaining impartial, one the one hand, while still using trauma-informed methods when questioning a complainant so that the investigator does not expect a trauma victim to provide details in chronological order, on the other hand. Several commenters asserted that trauma informed and believe-the-victim approaches must be prohibited in the interview process because 840 those approaches compromise objectivity, create presumptions of guilt, and result in exclusion of relevant (often exculpatory) evidence. One commenter stated that 1044 several states including New York, California, and Illinois mandate trauma-informed training for campus officials who respond to sexual assault and asserted that the proposed rules are unclear about whether the Departments position is that trauma-informed practices constitute a 1045 form of sex discrimination, thus inviting further litigation on this issue. Discussion: the Department understands from personal anecdotes and research studies that sexual violence is a traumatic experience for survivors. The Department is aware that the neurobiology of trauma and the impact of trauma on a survivors neurobiological functioning is a developing field of study with application to the way in which investigators of sexual violence offenses interact with victims in criminal justice systems and campus sexual misconduct proceedings. The Department appreciates the views of commenters urging that trauma-informed practices be mandatory, and those urging that such practices be forbidden, and the commenters noting that trauma-informed practices are required in some States, and noting there is a difference between applying such practices in different contexts. Nolan, Fair, Equitable Trauma-Informed Investigation Training (Holland & Knight updated July 19, 2019). Recipients have flexibility to choose how to meet those requirements in a way that best serves the needs, and reflects the values, of a recipients community including selecting best practices that exceed (though must be consistent with) the legal requirements imposed by these final regulations. Comments: One commenter suggested expanding the persons who must be trained to include counselors, diversity and inclusion departments, deans of students, ombudspersons, and restorative justice committees. Nolan, Fair, Equitable Trauma-Informed Investigation Training 14-15 (Holland & Knight updated July 19, 2019) (concluding that All parties can benefit if trauma-informed training is provided in a manner that is fair, equitable, nuanced, and adapted appropriately to the context of college and university investigations and disciplinary proceedings, and that does not rely on sex stereotypes. The use of trauma informed approaches to evaluating evidence can lead adjudicators to overlook significant inconsistencies on the part of complainants in a manner that is incompatible with due process protections for the respondent.

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The emotional disturbance may then lead to the conclusion by the doctor as well as by the patients friends that the whole episode is a sign of neurosis or an anxiety reaction symptoms influenza order 250mg divalproex free shipping. The same is true of the aviator who has had an exceptional disorientation episode medications ritalin order divalproex 250mg with amex. Whatever the actual cause of the disorientation symptoms intestinal blockage buy divalproex 250 mg without a prescription, the emotional overlay that is likely to result from the episode must be dealt with medications 5 rights discount 250 mg divalproex overnight delivery. In handling such cases, it is important for the doctor to show that he is interested. This will or dinarily be accomplished in the process of taking a history of the incident and relevant background material. It is first necessary to establish clearly whether or not the occurrence of disorientation in a pilot is due to a natural response to an unusual flight condition. The absence of similar reports by others in the aircraft does not by itself constitute evidence of an abnormal reaction from the pilot. In attempting to relate disorientation to flight conditions, items in the check lists should be con sidered. When it appears that disorientation is attributable to normal reactions to either aircraft 3-46 Vestibular Function or flight conditions, then reassurance that the reaction was normal, possibly including discussion with other pilots, may be sufficient to allay anxiety. If concern persists, then a period of dual flight may serve to restore confidence, but it may be necessary to seek the help of a specialist (cf. There is some evidence that acquired fear of some aspect of flying in a previously confident aviator is amenable to treatment with a fairly high probability of success (Goomey, 1973; OConnor, Lister & Rollins, 1973). Organic causes of disorientation are discussed in Chapter 8 on Otorhinolaryngology. Visual suppression of inappropriate eye movements induced by vestibular stimulation. Workshop of the European Brain and Behavior Society: Vestibular Function and Behavior, Pavia, Italy, April 25-26, 1974. Proceedings of the 18th International Congress of Aviation and Space Medicine, Amsterdam, 1969. Comparison of tracking task performance and nystagmus during sinusodial oscillation in yaw and pitch. The perception of body orientation relative to a rotating linear acceleration vector. Differential effects of central versus peripheral vision on egocentric and exocentric motion perception. Archiv fuer Physchiatrie und Nervenkrankheiten (West Germany), 1971, 214, 365-389. Effects of angular acceleration on man, thresholds for the perception of rotation, and the oculogyral illusion. Visual input improves the speedometer function of the vestibular nuclei in goldfish. Physiology of peripheral neurons innervating otolith organs of the squirrel monkey. Response to static tilts of peripheral neurons in nervating otolith organs of the squirrel monkey. Observations on perceived changes in aircraft attitude attending head movements made in a 2-g bank and turn. Perception of the horizontal or vertical with the head upright, on the side, and 3-48 Vestibular Function inverted under static conditions, and during exposure to centripetal force. The validity of the oculogravic illusion as a specific indicator of otolith function. Vestibular nucleus units in alert monkeys are also influenced by mov ing visual fields, Brain Research, 1974, 71, 144-149. Receptive fields of units in the visual cortex of the cat in the presence and absence of bodily tilt. Response of flocculus Purkinje cells to adequate vestibular stimulation in the alert monkey: Fixation versus compensatory eye movements. Theoretical man-machine interactions which might lead to loss of air craft control. Psychophysiological and environmental factors affecting disorientation in naval aircraft accidents. Effect of vestibular Coriolis reaction on respiration and blood-flow changes in man. The effects of semicircular canal stimulation during tilting on the 3-50 Vestibular Function subsequent perception of the visual vertical. Role of the vestibular apparatus in the perception of motion on the parallel swing. Much information has been realized since the onset of manned space flight some three decades ago. Rather, it should serve to acquaint operational physicians with characteristics unique to manned space flight. Manned Space Flight Programs for the 1990s A new vista in manned space flight was reached on 12 April 1981 when the Space Shuttle made its maiden voyage. As conditions associated with space travel cannot be duplicated anywhere else on Earth, plans are underway to build and operate a manned space station early in the next decade. Other plans in the next two decades entail interplanetary travel, potentially years in duration. Therefore, it behooves all personnel associated with or interested in aerospace medicine to acquaint themselves with these programs and the unique biomedical problems associated with microgravitational states. Naval Flight Surgeons Manual Medical Standards for Shuttle Astronauts As mission requirements change, so to do the physiological requirements associated with them. Class 1 (pilot) astronauts, Class 2 (mission specialist) astronauts, and Class 3 (payload specialist) astronauts require selec tion and annual medical recertification. Class 4 space flight participants must be selected and pass medical certification germane to individual mission requirements. Physiological Considerations in Space Flight the Neurovestibular System Some 40 to 50 percent of those who travel in space for any length of time can be expected to ex perience some form of space motion sickness. It is generally felt to be caused by the lack of gravitational effect on the otolith organ and the semicircular canals. More centralized symptoms include anorexia, lethargy, malaise, headache, confusion, spatial disorientation, anxiety, and depression. Postflight vestibular symptoms last up to a week, depen ding upon the length of time spent in space. Standard autogenic biofeedback techniques such as those currently employed by the Navy and Air Force to desensitize susceptible aircrew members suffering from air sickness have proven ef fective in reducing the incidence and severity of the symptoms. Therefore, if one drug or drug combination doesnt work, the flight surgeon should try others until a suitable combination is found. The major sources for the fluid shifted cephalad comes from the lower extremities and the pelvis. Symptomatology experienced after the shift in fluids includes a feeling of nasal stuffiness, a full feeling in the head, and facial edema. With longer missions, several fluid shifts from cephalad to caudad and vice versa can be expected. These fluid shifts are also accompanied by orthostatic intolerance during the first week of space flight. However, it has been noted that having the astronauts drink 1 liter of normal saline im mediately prior to initiation of the landing sequence has reduced the severity of postflight syn cope. Cardiovascular parameters on electrocardiograms, echocardiograms, and vectorcardiograms undergo changes throughout space flight. The exact extent to which dysrhythmia can be attributed to space flight remains under investigation. No fatal dysrhythmias or cir culatory collapse have been reported in relation to these dysrhythmias. While the rate of loss is slow at first (around 140 mg per day), by 84 days into flight it ap proaches 300 mg per day. Time taken to remodel lost bone mass parallels the time spent in space during which it was lost.

If the start of this regimen is delayed and it is instituted only after the virus has spread throughout the body medications multiple sclerosis quality divalproex 250 mg, the results may not be so dramatic medicine 54 543 discount divalproex online american express, but ascorbic acid will nevertheless be of great benefit treatment quadratus lumborum buy divalproex 250mg free shipping. Continued dosages at one or two-hour intervals will shorten the duration of the attack medications during breastfeeding purchase divalproex, often to a day. The great advantage of this common cold therapy is that it utilizes a normal body constituent rather than some foreign toxic material. This regime should be the subject of large scale, long-range clinical studies in order to establish its efficacy and safety, and to provide the data required by medicine for any new suggested therapy. As a result of his successful personal experience and other work, he published in 1970 the book (18) Vitamin C and the Common Cold. This volume, the first published book in the new fields of megascorbic prophylaxis and megascorbic therapy, gives a more detailed and practical account of the use of ascorbic acid for this condition than is possible in the space of this short chapter. With the publication of this book, there was a rash of unjustified criticism heaped upon Dr. Up to the date of the publication of this book, the author is not aware of any clinical tests planned or started that follow the suggested regimen of: 1. Three groups are generally recognized: the viral diseases, the bacterial infections, and the diseases caused by more advanced types of parasitic agents. It so happens that this classification also denotes the relative size and complexity of the infectious agents. The viruses are the simplest and most primitive forms; in fact,they are sort of transitional substances between living and nonliving matter. They cause a wide variety of diseases such as poliomyelitis, measles, smallpox, chicken pox, influenza, "shingles," mumps, and rabies. The common cold, discussed in the previous chapter, is a virus disease, although various bacteria generally infect the weakened tissues as secondary invaders. When a virus infects a mammal and gains a foothold in the mammalian body, the mammal reacts by showing the symptoms of the disease and at the same time organizes its own biochemical defenses against the virus. In nearly all mammals,this biochemical defensive reaction is at least twofold: the victim starts to product antibodies against the virus and also increases the rate of ascorbic acid synthesis in its liver. This is the normal mammalian reaction to the disease process, except in those species, like man, that cannot manufacture their own ascorbic acid. Let us see what a review of the medical literature reveals about megascorbic therapy and viral disease: 71 Poliomyelitis the application of ascorbic acid in the treatment of poliomyelitis is an incredible story of high hopes that end in disappointment, of blunders and lack of insight,of misguided labors and erroneous hypothesis. And then, when a worker finally seemed to be on the right path and had demonstrated success, hardly anyone believed his results, which were systematically ignored. Within two years after the discovery of ascorbic acid, Jungeblut (1) showed that ascorbic acid would inactivate the virus of poliomyelitis. This was followed, in 1936-1937, in rapid succession by other workers showing similar inactivation of other viruses: by Holden et al. Thus, at this early date it was established that ascorbic acid had the potential of being a wide spectrum antiviral agent. Here was a new "magic bullet" that was effective against a wide variety of viruses and was known to be completely harmless. Materials with such exciting properties do not happen often and a tremendous amount of research time should have been expended in tracking it down in minute detail, but let us see what happened. The reader should realize that this work was being carried out in the pre Salk days. Then, all a doctor could do in a polio case was apply symptomatic relief and hope for the best. An epidemic could run its course without much interference from medicine and an effective, harmless virucide would have been a priceless commodity. Jungblut (8) continued his work and published a series of papers from 1936 to 1939 in which he showed that the administration of ascorbic acid to monkeys infected with poliomyelitis produced a distinct reduction in the severity of the disease and enhanced their resistance to it. In further efforts to explain their variable clinical results, both scientists got bogged down chasing the technical details of the tests. It may be easy for us to look back now and say that the size and the frequency of the dosages were insufficient to maintain high levels of ascorbic acid in the blood during the incubation of the disease. The upshot was that the negative findings of Sabin effectively stifled further research in this field for a decade. Klenner (10) described his successful treatment of poliomyelitis, as well as a variety of many other viral infections, using ascorbic acid. He gave the rationale for his treatment, his technique in detail, and his dramatic case histories. Klenner realized that the secret was in the massive doses he employed, and he tried to impart this 72 knowledge to an unbelieving profession. He records one successful case history after another in these papers, as well as in his 1953 report. His results indeed proved that ascorbic acid was a harmless and effective wide spectrum virucidal agent. If high blood and tissue levels of ascorbic acid are continuously maintained, an extremely unfavorable environment for viral growth and reproduction is created in the human body, Two other papers appeared in 1952, in which ascorbic acid was used in the therapy of poliomyelitis at daily doses below those recommended by Klenner. Gsell and Kalt (11), using 5 to 25 grams per day, reported that there were no definite effects on the course of the disease. Besides using lower dosages, they also started this treatment on the majority of their patients only after they had had the disease for at least four days. Baur (12), using 10 to 20 grams per day, was able to report beneficial results in shortening the fever and convalescent time. Over the years, the emphasis of medical research on poliomyelitis has shifted toward the development of vaccines. But a polio vaccine is only effective against the polio virus and has no action on the viruses of other diseases. Millions of dollars of research money have been spent in unsuccessful attempts to find a nontoxic, effective virucide and all sorts of exotic chemicals have been tried. All the while, harmless, inexpensive, and nontoxic ascorbic acid has been within easy reach of this investigators. Hepatitis Soon after the discovery of ascorbic acid, Bessey and coworkers (14), in 1933,showed that guinea pigs derived of ascorbic acid developed a fatty degeneration of the liver. Ten years later, Russell and Calloway (15) also showed pathologic changes in the livers of guinea pigs with scurvy. Willis (16), in 1957, further investigated and extended these earlier observations and demonstrated the vital importance of ascorbic acid in maintaining healthy liver tissue free of cirrhotic, degenerative changes. Ascorbic acid should, therefore, be twice as sound for use in the treatment of the viral liver disease, viral hepatitis. When used at the necessary high dosages it should inactivate the hepatitis virus and it should also act on the liver tissue to prevent degenerative changes. In 1954, Bauer and Staub (17) observed good results in the treatment of viral hepatitis with the use of 10 grams of ascorbic acid per day. It accelerated the disappearance of the symptoms of the disease and shortened the duration of the illness. Twenty years later in Germany, Kirchmair (19) used 10 grams of ascorbic acid daily for five days on sixty-three children with hepatitis and found marked improvement, weight gain and good appetite in the first few days, rapid disappearance of jaundice and half the hospitalization time. The swelling of the liver, which normally took 30 days to subside, only took nine days with ascorbic acid. In 1960, Calleja and Brooks (20) reported successful treatment with 5 grams of ascorbic acid a day for twenty-four days in a refractory case of hepatitis that did not respond to other medication. Dalton (22), in 1962, also reported dramatic and rapid recovery of a case of hepatitis. In these clinical reports on hepatitis, the doses of ascorbic acid were below the range postulated by Klenner and also below the quantity considered necessary by the genetic disease concepts. The provocative clinical results reported in the medical literature have not been extended or explored. Further intensive clinical research is needed on the use of ascorbic acid at the proper high-dosage rate for the control of this serious liver disease and also for the prevention and therapy of the degenerative,cirrhotic liver changes that occur, for instance, from the excessive use of alcohol. It is tragic that organizations concerned with alcoholism have not picked up these exciting leads for further exploration to prevent the degenerative 74 liver changes which cause such misery and death to so many.