Otitis media has become the commonest pediatric diagnosis made by physicians caring for children in the United States,1 its annual budget reaching $2 billion in 1982,2 and growing ever since, with no relief in sight. After decades of punishing warfare against the resident nasopharyngeal bacteria, several medical journal articles have recently begun to admit defeat, and have questioned not only the safety and effectiveness of antibiotics and tympanostomy, but also the wisdom of prolonging the essentially military strategy based on them.3,4,5
For those pursuing more holistic approaches, the present stalemate confers both the opportunity and the obligation to come forward and present our experience to the medical community and the public at large. Nobody need just take my word for it that homeopathic remedies are inexpensive, non-toxic, and can help even the most advanced cases, or that parents, children, and their pediatricians alike will come to appreciate the non-invasive philosophy governing their use. I will feel amply rewarded if more professionals and lay people will simply try them and see for themselves.
The following cases are intended to show how the homeopathic viewpoint can assist in our practices, in both diagnosis and treatment, and also in research, both theoretical and experimental, into the etiology and pathogenesis of these increasingly common and all-but ubiquitous ailments.
The examples that I have chosen are noteworthy not for any particular skill in choosing the correct medicine, but in precisely the opposite sense, that excellent results are regularly attainable with the common remedies and case-taking methods already well-known to every serious student. Indeed, our exemplary success in using homeopathic medicines to treat these children may itself be a clue to solving the mystery of pediatric otitis media and its disturbing pre-eminence in recent times.
Case 1. C. Z., a girl of 3, had had recurrent ear infections since the age of 5 or 6 months, typically associated with colds and the production of thick, green mucus in the nose, throat, and sinuses, and treated with antibiotics each time, often for months without interruption. With no fever and perhaps a slight earache, she often became irritable and cranky as the cold ended, when her physician would make the diagnosis by otoscope. Apart from mild eczema, the child was seldom ill otherwise, and rarely had the fevers or acute illnesses to be expected at her age. A strapping 8 lb. at birth, she weighed only 16 lb. at one year, and had remained small for her age ever since. Teething was late and difficult. She had had all the usual vaccines, with no obvious reaction.
I chose Calcarea sulphurica 200, one dose, and 2 months later her mother reported “the best winter ever,” with no ear infections and two mild colds that soon cleared up with the help of Calcarea sulph. 12C. I next saw her a year later, several weeks after an episode of wheezing in the middle of a cold, for which 2 doses of Pulsatilla 30X prescribed over the phone had worked splendidly. Despite no more ear infections in all that time, she had had a fever or two, and was still plagued by quantities of thick, greenish-yellow phlegm in her nose and throat. After one dose of Sulphur 200, she never came back. When I called recently, some 5 years later, in preparation for this talk, her mother told me that she had never had another ear infection, and that there was no need to bring her back, since her general health had remained very good, and the usual remedies had proved quite effective for the typical colds, fevers, and URI’s that had developed along the way.
I want to add a few other comments about this by no means unusual case. First, as I reread it now, I doubt that either Calcarea sulph. or Sulphur was the true simillimum for this patient, since she was actually on the chilly side, and since even after the treatment she continued to produce large amounts of thick green phlegm and be subject to frequent colds. Indeed, I can’t really defend or even explain either prescription at this point. Yet her mother was more than satisfied: the ear infections disappeared, and never came back; the main constitutional issues stayed quietly in the background; and the remedies that she herself came up with continued to help without needing further assistance.
Notwithstanding all the small remedies and “cured” cases that we like to parade at our conferences, I suspect that by far the larger share of our practices and reputations are built upon stories as generic and unspectacular as this one, and am deeply grateful for a method that adds feathers to my cap even when I bumble or fall short. Second, my own experience amply confirms numerous reports in the European literature that most kids eventually outgrow their er infections anyway, if simply allowed to do so without too much allopathic interference.6
Case 2. K. G.-S., a boy of 16 months, had already had 5 ear infections and 5 rounds of
Antibiotics when I first saw him. The first episode at 6 months of age was the only
one associated with fever (T. 102.8°F.) and acute earache, both of which subsided
soon after the eardrum burst and discharged the pus that had accumulated behind it. Although he weighed 7 lb. at birth and appeared normal, he was slow to nurse, fell behind in his gross motor development, had had considerable pain and discomfort with teething, and still weighed only 20 lb. His only other complaint was a persistent diarrhea that had begun under antibiotic treatment and had since become chronic. In spite of prolonged and intense crying after the first and second DPT’s, his third DPT and MMR provoked no obvious reaction at all.
I gave him Sulphur 10M, one dose, and one month later his mother reported that the diarrhea had worsened, becoming particularly acute the first week, but that, despite a fever of 103°F. on the third day, the highest in his life, he had had no symptoms of a cold or ear infection since. Because of the diarrhea, I gave him Calcarea carbonica 10M, one dose, and by the next visit, two months hence, he was well and had made good progress developmentally, with no sign of an ear infection, one brief cold, for which Calcarea sulph. 12C worked well, and no more diarrhea.
After that I didn’t see him again for more than a year, about 4 months after another
acute otitis episode, with fever but no earache, that was diagnosed by otoscope, and continued for a full week on antibiotics. Previously, apart from a few colds and the reappearance of diarrhea at such times, he had had no more ear infections and was continuing to develop normally. Repeating the Sulphur 10M, I never had any further news of him until I had my receptionist call recently, more than 5 years later, and learned that he had been in good health the whole time, with no ear infections and no antibiotics. After buying a kit and studying on her own, the mother had herself found Belladonna to be highly effective in the early stages of his colds and acute illnesses, and no longer needed my help.
Again not for any elegant prescribing on my part, much less from any notion that the child was “cured,” I treasure cases like this, because our work together helped his mother to take charge of his health and to perform competently in that role. When my own learned prescriptions fail, as they not infrequently do, I feel if anything even prouder when the parents themselves find the remedies that work best for their child. By far the most precious gift that homeopaths can offer the medical community is our relationships with our patients, which can continue to grow and flourish even when the simillimum proves elusive.
Case 3. J. L., a girl of 6, had had ear infections repeatedly since the age of 5 months, particularly when exposed to other kids in crowded day care or classroom settings. With little fever and no earache, the individual episodes were quite mild, with red cheeks, loss of appetite, and grumpy, cross, or irritable behavior. While vulnerable to staying up late and sudden changes of weather, she seldom ran fevers of any kind, the highest being around 102˚F. once with a “Strep throat,” yet had already taken antibiotics over two dozen times. Although vaccinated at the usual times without any obvious reaction, she developed an ear infection after her 5-year DPT booster that persisted for 4 months despite long-term maintenance on antibiotics, and had subsided only with regular chiropractic adjustments.
Two days after a single dose of Sulphur 10M, she developed a generalized rash that lasted 3 or 4 days, followed by a more “bouncy” mood and livelier energy than she had displayed in a very long time. At the time of her first follow-up, she had a mild cold, with the usual red cheeks, runny eye, temporary hearing loss, and the dreaded positive Strep culture. It required a considerable leap of faith for her mother to allow even this minor illness to run its course without antibiotics, using only Pulsatilla 30X as needed, but soon after she bought a kit of remedies and a book to learn how to use them. Two months later, her pediatrician was happy to report and even take credit for the fact that her ears were uninfected for the first time that anyone could recall.
The following winter, she was back with her usual symptoms , a low fever, and a weakly-positive Strep culture. As it subsided, I repeated the Sulphur 10M, and at her next visit the picture had changed to one of recurrent sore throats, foul breath, enlarged tonsils, dark circles under the eyes, and a loose, productive cough. This time I chose Mercurius vivus 1M, followed by the 10M one month later, with good results until yet another cold several months later, accompanied by the same swollen tonsils and loose cough as before. This time I repeated Sulphur 10M, and I never saw her again, but her mother reported a few years later that she had remained very well the whole time, with no major colds, no ear infections since the first visit, and for the first time a perfect attendance record for the school year just completed. Calling her back recently, we learned she was doing very well in high school, with no ear infections at all in the nine years since she had begun using remedies.
Once again leaving aside my rather crude prescribing in this case, I want to point out a few of the methodological issues it exemplifies, issues so obvious and so fundamental as to be readily overlooked or forgotten. First, the official policy of equating fluid behind the drum with a full-blown “ear infection” calling for antibiotic treatment ignores what every family doctor or pediatrician knows, that most colds or URI’s, especially with swelling of the tonsils and/or adenoids, can be expected to produce secondary congestion of the middle ear and some degree of temporary hearing loss as a result. The girl in this case was subject primarily to tonsillitis, and could be said to have ear infections only to the extent that the pneumatic otoscope can detect even minute amounts of fluid, and that years of war against the resident ear bacteria have culminated in this failed Vietnam-like strategy of killing everything in the vicinity.
Secondly, her longest period of ear involvement followed soon after a DPT booster, a connection that I have verified numberless times in my practice for a number of different vaccines, but that is rarely suspected by most doctors and parents alike, because vaccines are widely regarded as almost risk-free and indeed sacrosanct, except for a few comparatively rare life-threatening events developing within the first hours or days.7 Finally, like most of my patients with chronic otitis media, this child seldom ran fevers throughout the time she had received conventional treatment, and indeed began to do so only when her general condition improved. Useful prognostically for reassuring the family, this simple fact also carries major implications for the natural history of the disease and its evolution in recent times.
Case 4. L. P., a girl of 10 months, had already had 4 acute ear infections and received antibiotics for each one. They began at 2 months of age, when her mother was forced to wean her to go back to work, and the baby developed a rash and unusually cranky behavior on a milk-based formula. These early symptoms were all greatly intensified for a full week after her first DPT shot, followed suddenly and not long after by an acute ear infection, with a high fever and violent earache, much like all of the others.
With the help of Calcarea carbonica 1M at the outset and Chamomilla 30X as needed acutely, she did quite well, with fewer colds and none of her typical acute episodes, but mild symptoms persisted and were aggravated by teething, when the remedies had to be repeated. The following spring, 6 months later, she started all over, with 3 of her typically rip-snorting ear infections and as many rounds of antibiotics in the 3 months since her father had insisted on her long-overdue MMR vaccination. At this point I gave her Lycopodium 10M, followed by Sulphur 10M a month later, and was about to change the remedy yet again, until I learned that the parents had recently separated and were angrily vying over the child. From then on, she continued to do very well on infrequent doses of Sulphur, despite a violent bout of gastroenteritis after a DT and polio booster, and a tendency to relapse when she stayed with her father, who let her eat her fill of dairy products and took her to the pediatrician for her regular quota of antibiotics and vaccines.
I have continued to follow this child at irregular intervals for more than nine years, and although she has long since outgrown her ear infections, her underlying health issues have not changed all that much. Already evident in the acute, vigorous responses of her infancy, her basically strong constitution and immune system have matured over the years, enabling her to bounce back more quickly than ever when she does fall ill. While both allergic and mildly addicted to milk and cheese, she has continued to grow and develop relatively normally in the face of a conflicted heritage that she can not as yet understand or change.
In short, this is a child of strong vitality who exemplifies the opposite side of the same issues already discussed:
1) the innate tendency to respond acutely and vigorously to infection, and to recover
quickly from it;
2) the tendency to relapse following any vaccination, and to milk allergy which is often
associated with it; and
3) the tendency to develop the classic signs and symptoms of acute otitis media that
were the rule in the pre-vaccine and pre-antibiotic era, but have since become the exception.
With these few representative cases in mind, I will try to summarize my experience with the general phenomenon of otitis media in children, giving special emphasis to the practical issues of diagnosis, treatment, prognosis, and long-term case management.
First, as with my allopathic colleagues, middle-ear infection is one of the commonest presenting complaints of children in my practice, although I do mostly chronic work and provide well-baby and well-child visits only when the parents explicitly ask for them. In an average week, I may triage four or five acute cases over the phone, and see one new and two or three established patients with chronic or recurrent otitis that has been diagnosed and treated repeatedly or on a long-term basis with antibiotics or tympanostomy, or both.
What most of these patients have in common is the absence or relative paucity of strong symptoms, such as high fever or violent earache, that would indicate an acute, vigorous response to their illness. With a few exceptions, like the last case I presented, even when they do “flare up,” their symptoms are much more likely to be vague and nondescript in character, such as “fussy” or “cranky” behavior, whining or picking at the ear, mild hearing loss, poor appetite, and the like. In quite a few instances, there are no symptoms whatsoever, and the child behaves and functions perfectly normally, but at the well-baby visit the pediatrician detected some fluid behind the drum, signed it off as an “ear infection,” and began the cycle of antibiotic treatment that may prove quite difficult to break.
Similarly, although the symptoms often recede to some extent during conventional treatment, relapse is common afterwards, and even when the child appears clinically well, the presence of fluid is generally interpreted as a persistence of the infection, or in any case as a mandate for continuation of antimicrobial therapy. In this way, a child who may never have been that sick also never gets entirely well, and continues to relapse until the pediatrician recommends maintenance doses of antibiotics for months at a time, or indefinitely, as well as surgical insertion of tubes and artificial drainage if the condition persists despite these measures, as indeed it often does. In short, the most striking and disturbing features that such cases have in common is simply their chronicity, their tendency to develop smoldering or persistent responses to illness, to relapse more and more easily, and their failure to heal or resolve themselves in a clearcut or timely fashion.
In treating such a case, the physician needs only to break this cycle of chronicity, which is accomplished fairly easily if the parents are willing to co-operate. But here too lies the major obstacle, our own cultural belief and professional indoctrination that reduces the art of diagnosis to the specialized detection of abnormalities and the goal of treatment to the killing or decimation of our resident bacteria. Even more than finding the correct remedy, the most difficult and important requirement for success in treating these kids lies in re-educating the parents and developing an alternative model that works and makes sense for them.
First, I try to redefine the nature of the illness and the best way to detect and diagnose it, beginning with some basic anatomy of the ear, nose, and throat, and the typical clinical and pathological features of a URI with ear involvement (congestion, earache, etc.), contrasting it with that of full-blown acute otitis media. Always my emphasis is focused on the signs and symptoms that they are already well aware of, that is, how the child feels and functions, or what we homeopaths like to call “the totality of symptoms.”
If we’ve made a good connection and feel pretty much “in synch” so far, I may go a step further and propose that we not look in the ear just yet, unless the clinical picture is especially intense, or hasn’t resolved after giving remedies, or either of us is so panicked that we just have to know. Since almost any URI can produce detectable fluid congestion behind the drum, and it is not necessary or even desirable to treat the illness all the way to the end, the totality of symptoms is what best defines the illness, and what we can see through the otoscope adds really useful information only in the rarest and most difficult cases.
If there is significant ear involvement, I like to reassure parents that giving antibiotics is no more effective than placebo,8,9,10 and that in fact it produces more frequent relapses than giving analgesics and simply allowing the children to recover on their own.11 Only at that point will I add the punch line, that homeopathic remedies are wonderfully effective, both as needed for the acute episodes, and “constitutionally,” to prevent them or minimize their number and severity.
Finally, I will take a careful vaccine history and look for any other underlying chronic or constitutional influences that may contribute to the problem, such as a difficult pregnancy, traumatic birth, or other established illness, food allergy, emotional upset, and the like. Quite often, the first episode can be traced to shortly after the time of a DPT, MMR, or some other vaccination, even when no acute or obvious reaction was noted at the time,12 or the old pattern of chronic or recurrent otitis is reactivated by a booster after a long period of remission.13 Quite often a relapse following this or that booster after a long period of good health is what first convinces the parent of the connection, which has also been independently corroborated by the curative effect of homeopathic nosodes prepared from the vaccine or natural disease in such cases.14 Citing these experiences, I will ask the parents not to vaccinate the child at least until the condition has been resolved, and refer them to my various writings on the subject for further study.
While they are by no means the only important factor in the background of such cases, and I have certainly seen my share of chronic otitis even in unvaccinated kids, vaccines stand alone in being legally mandatory for every child, and in being regarded as so uniformly safe and beneficial that the mere possibility of chronic, long-term sequelæ is seldom if ever taken seriously.15
With this important preparatory work done, I am ready to proceed with homeopathic remedies. The guidelines I follow and the remedies I use are no different from the ones that we use in general pediatric practice, and I see no need to elaborate on them here. If the child is not acutely ill at the time of the first visit, I usually begin with a single dose of the indicated preventive or “constitutional” remedy in perhaps a 200 potency, often a typical polychrest, such as one of the Calcareas or Kali salts, or Sulphur, or sometimes with a so-called “acute” remedy like Aconite, Belladonna, or Chamomilla if it is indicated for the acute episode but clearly discernible in the chronic pattern as well.
I also find it very helpful to suggest the 12C or 30X of a remedy to have on hand for acute flare-ups, often the same one as the 200, or perhaps another complementary to it, and to see the child or at least coach the parents through the episode with words of encouragement, changing the remedy if necessary. Once remedies have helped them through an acute episode without antibiotics, the remainder of the treatment is apt to proceed quite smoothly. If the child has never had a fever or responded acutely or intensely before, it is prudent and even reassuring to prepare the family for such an eventuality beforehand.
By no means grounds for discouragement, relapses many months or even years later are even simpler to treat, since the precipitating factors will be much more obvious after a period of good health, and the remedies that worked well before will most likely perform even better the next time, as the children often know by asking for it themselves. This uncanny ordering and clarification of the case over time is the predictable legacy of effective treatment, and the awe and wonder that they inspire in doctors, patients, and family members are among the most treasured perks and lasting rewards of every homeopathic practice.
What is most mysterious and problematic about ear infections in children is therefore not in the manner of their treatment, which is not especially difficult, and typically involves the same remedies as are indicated for many other chronic ailments, but rather, as we have seen, in the nature, causes, and effects of that chronicity itself.
When I was a medical student in New York City in the early 1960’s, otitis media was pre-eminently an acute disease, often presenting in the Emergency Room with a high fever and a piercing scream, both of which ended abruptly as soon as the eardrum burst and discharged its purulent contents. While certainly not a pleasant experience for doctor or patient, it seldom lasted very long, indeed had often taken care of itself before we had the chance to interfere with it, and was unlikely to come back for a long time to come. In short, it closely resembles the type of acute flare-up which, when I see it in one of my patients today, I have learned to interpret as a favorable prognostic sign.
When I moved to Boston in 1982, stopped doing births and primary care, and limited my practice to classical homeopathy, I started to see large numbers of chronic otitis patients such as I have just described. Why the occasional acute ear infection I knew in medical school had mushroomed into a chronic disease of epic proportions was also precisely the question with which I began this article. Both my clinical experience and the research I have conducted to support it have amply confirmed my intuitive sense that the modern pandemic of chronic otitis media is largely attributed to two cruel, fanatical, and ultimately self-defeating wars that carry on the same militaristic philosophy:
1) the war on the nasopharyngeal bacteria, fought with antibiotics, tympanostomy tubes, and the systematic cultivation of fear of communicable disease; and
2) the vaccination of entire populations against a growing list of acute diseases, more
or less on principle, with no end in sight, and no inclination to consider the possible
long-term consequences of doing so.
Based on Koch’s postulates and their considerable predictive value, the war on our own resident bacterial flora is undesirable, to begin with, and in fact unwinnable, even in thought. It is unwinnable, in the first place, because as this planet’s most basic life forms, bacteria can reproduce themselves in an average of six hours, and through natural selection rapidly become resistant to even the most lethal antibiotics. In clinical medicine, some important examples include nosocomial or hospital-borne outbreaks of resistant Staphylococci and E. coli, and the emergence of infections with new, mutant organisms such as Mycoplasma, and PPLO, which lack cell walls, obvious adaptations to penicillin-rich environments. In a recent Newsweek article, the propagation of resistant strains made hospitals into veritable centers of germ warfare, from which virulent organisms are widely disseminated out into a general population more or less powerless to stop them.16
In the case of childhood ear infections, resistant strains have similarly been implicated in the weakened primary immune responses and high relapse rates associated with antibiotic treatment. 17 Other common sequelæ include superinfection with yeasts and other common fungi, as well as the food and environmental allergies that often accompany them.
Other studies of the fluid isolated from kids’ infected ears have shown that the predominant organisms are simply the common pathogens of the tonsils and nasopharynx, such as the “pneumococcus,” or Streptococcus pneumoniæ, ß-hemolytic Streptococcus (Group A), the main culprit of “Strep throats,” Hemophilus influenzæ type B (HiB), and Staphylococcus aureus, all of which are commonly found in healthy throats as well.18 Indeed, in 20% of the children with acute otitis media, and 80% of those with the chronic serous variety that is now most prevalent, the effusions are sterile and no longer contain any organisms whatsoever.19,20 In other words, once the resident bacteria are destroyed, the common result is “glue ear,” an important cause of chronic and sometimes permanent deafness. Thus even more injurious than the drugs themselves is the fanatical strategy of attacking and killing everything in sight that makes such imagery seem attractive.
A further application of the same military strategy has been the development of the pneumatic otoscope, its tight seal permitting the detection of even minute amounts of fluid and thus facilitating both early diagnosis and even more minute surveillance. Yet diagnosing more infection has only unleashed still more firepower, with the same ruinous results as described above. With tympanostomy, the war against otitis media attains its final dead end, looking like an obvious practical solution to the mechanical problem, yet itself recently found to be a major cause of otosclerosis and permanent hearing loss, ironically the same spectre used to browbeat reluctant parents into accepting it in the first place.21 Even more ironic is the fact that such ear tubes merely substitute a fixed, artificial conduit for the natural process of perforation and drainage that the acutely infected ear heals so well by itself and with so few complications.
In any case, it makes no sense to search out and destroy the mostly friendly bacteria that have already established residence in our bodies and police them so effectively for our benefit, or to suppose that monkeying around with them could ever produce anything but more war, more devastation, and the emergence of still other and for the most part more hostile types of bacteria capable of surviving it.
As for vaccine-related illness, comparatively little of my experience is of the kind that Harris Coulter and Barbara Fisher described in their book, Shot in the Dark,22 which like most of the anti-vaccination literature is limited to what appear to be specific effects of specific vaccines, in their case, different types of encephalopathy or brain damage from the DPT. While such reactions are likely to be the most dramatic and severe, as well as those for which the corresponding homeopathic nosodes would probably be most useful, most of my own clinical experience has to do with subtler, more generic reactions of what I would describe as a non-specific type. By that I mean that they appear to represent exacerbations of a pre-existing chronic state, as is evident from the fact that they appear more or less the same in a given individual, regardless of which vaccine is given, and are benefited by the same group of remedies that we already use for the general population, whether vaccinated or not. While such reactions are rather more difficult to recognize and verify, they are also much more common and, I suspect, considerably more important.
In particular, two of the four cases I presented exhibited prolonged, severe relapses of their chronic state after a vaccination; one patient suffered almost identical relapses after two different vaccines; and all four first developed their chief complaint during their first dose of the DPT series. In no case were their responses acute or obvious enough to be identified as a repeatable symptom of that particular vaccine. Indeed, all that was repeatable in all cases, and with all the vaccines, was simply the chronicity of the responses, the fact that they occurred more frequently, persisted for longer periods of time, and showed less of a tendency to resolve themselves spontaneously.
It is precisely this congruence between vaccine-related responses and the original illnesses that they make worse, that suggests how vaccines act nonspecifically on the immune system as a whole, and so implicated vaccines in the still more basic riddle of chronicity itself. As biotech firms are busily cranking out new genetically-engineered vaccines almost as fast as they can identify possible organisms to attack, the all-out war against identifiable acute diseases has already added to the pre-existing chronic disease burden a full complement of new DNA- and RNA-like fragments looking for chromosomes to recombine with, and thus inadvertently to engender new diseases of which as yet we know nothing. In short, I’m afraid that doctors, like politicians, are here to stay.
1. Koch, H., Office Visits to Pediatricians, National Center for Health Statistics, Washington,
2. Bluestone, C., “Otitis Media in Children,” New England Journal of Medicine 306:1399,
10 June 1982.
3. Cantekin, E., et al., “Antimicrobial Therapy for Otitis Media with Effusion,” Journal of the
AMA 266:3309, 18 December 1991.
4. Frenkel, M., “Acute Otitis Media: Does Therapy Alter Its Course?” Postgraduate Medicine
82:83, October 1987.
5. Family Practice News, 15 December 1990.
6. Van Buchem, F., et al., “Therapy of Acute Otitis Media,” Lancet 2:883, 1981.
7. Moskowitz, R., “The Case Against Immunizations,” Journal of the American Institute of
Homeopathy 76:7, March 1983.
8. Cantekin, op. cit.
9. Van Buchem, op. cit.
10. Townsend, E., “Otitis Media in Pediatric Practice,” New York State Journal of Medicine
64:1591, June 1964.
11. Cantekin, op. cit.
12. Moskowitz, R., “Vaccination: A Sacrament of Modern Medicine,” Journal of the AIH 84:96,
16. “The End of Antibiotics,” Newsweek, 28 March 1994.
17. Cantekin, op. cit.
18. Bluestone, op. cit.
20. Cantekin, op. cit.
21. Family Practice News, op. cit.
22. Coulter, H., and Fisher, B. L., DPT: A Shot in the Dark, Avery, Garden City, NY, 1991.