Tragedies, Fatal Disease, Health, and Life!
As a critical thinker, I would have ridiculed the beginning of this story, but it is a story about me — Tragedies, Fatal Disease, Health, and Life!
As a critical thinker, I would have ridiculed the beginning of this story, but it is a story about me. In 1978, I received a diagnosis that was tantamount to a death sentence. Statistically, I had about two and a half years left to live.
 | For me, there is only one life: here and now! Intellectually, I can only know or not know, but not believe. This is quite a psychological burden for a skeptical realist (critical rationalism), who does not just repress things or go on hoping. |
But such pressure can also give a person strength to reconsider all of the various connections and points of view and to use this strength and endurance to pursue a goal. See the YouTube video here.
What actually made me write about a small, yet important part of my life? I thought it might help other people who are in a similar situation to confront the problem actively and garner as much strength as possible.
First, I gathered reference books and other sources to read as much as I could about the disease and its treatment. At that time, the Internet was not even yet a dream. And computers didn’t come on the market until four years later.
There were two types of information: academic papers and well-researched technical texts and, on the other hand, personal stories that included platitudes and sometimes even charlatanism. The experts conducted studies, and the laypeople presented their unverified case histories that had had a positive outcome. Reliable facts were lacking; you could either believe or not. I couldn’t.
Should you believe me without facts? No!
Today there can be found studies that show that my path was right (doi: 10.3109/10428191003690364). Here with the link PMID 20350273 or as direct entry for Google you get a more complete text from NCBI (National Center for Biotechnology Information).
I am not selling anything. I am not promising anything. Is the motivation for this article really objective and based on good reasons?
Our lymph nodes in the head and neck and studies from the end of the 1970s
I wanted certainty and to understand what the doctors had to offer because it was my life that was on the line. That fact had become crystal clear.
It was only through asking questions and obtaining and reading medical literature that I became truly aware of my physical condition.
Doctors must have basic knowledge about hundreds of diseases. They don’t have time to delve into any one rare disease. My physician either didn’t know what the likely outcome was or didn’t want to explain it to me.
 | In the case of cancer, further clarifications are usually made as part of the process to determine the extent which the cancer has developed or spread. This is called cancer staging. You can also establish contact with professors, for example, with oncologists who specialize in cancer. But there are about two hundred different types of cancer, a number of stages, varying levels of aggressiveness, and other factors. Even the patient’s age and physical condition are important. The complexity is enormous. | |
 | In almost all such cases, these specialists receive instructions from centers that conduct research on certain diseases. These centers also search for better treatment (therapy) options based on the available “medical material” (case studies). Cancer patients are often unknowingly research subjects (test persons). Only the research team actually knows what they’re doing, but everyone else does their best. |
Doctors are people like you and I, with different personalities, and strengths and weaknesses.
1. What actually happened?
In February 1978, my former wife and I went on a ski vacation together with friends of ours, two couples who were all doctors. One of our friends was a professor of medicine. During the vacation, I noticed a swelling on my lower jaw, but didn’t “feel” any inflammation that could have caused it. I didn’t want to bother my friends with it during the vacation, so I instead made an appointment with one of these friends, my general practitioner, after the vacation.
He insisted on prescribing antibiotics because he was convinced that the condition was caused by a bacterial infection. I understand his decision as it is rarely the case that there is another reason. I had never thought of the possibility of cancer. I was generally quite healthy, apart from a few small things. Strangely however, I inwardly “knew” that my tumor was “something else.” Before the next visit three weeks later, (which included one week without antibiotics and with poor sleep), I insisted on scheduling a fine needle aspiration biopsy and histopathological evaluation (pathology, histology). I had to be a bit assertive before the doctor finally agreed to make the appointment for me.
The ENT department of the hospital considered the biopsy to be unsuccessful. Not me. The result was shocking: a malignant lymphoma. My friend and physician Hansruedi reassured me that the tissue might have suffered during the fine needle aspiration biopsy and there was therefore no reason for alarm yet. That was certainly not very professional.
After some difficulty, I finally got a surgery scheduled for 14 days later to get the lymph node (lymph gland) removed.
Histological examination. Mantle cell lymphoma (MCL) - a B-cell non-Hodgkin’s lymphoma
I wanted to have it histologically examined at several pathological institutes to make sure that the results were unambiguous. There were small differences in wording as one institution classified the disease based on WHO 1976 standards, the other as per the Kiel standard, and the third based on the Rappaport classification (United States).
- Zurich called it a malignant lymphoma, a diffuse lymphoblastic lymphoma.
- Bern defined it as a malignant medium-cell lymphocytic lymphoma (partially nodular type),
- Lucerne used the term centrocytic lymphoma (ML, CC).
Today the standard international name for the disease is mantle cell lymphoma (MCL). It is a B-cell non-Hodgkin’s lymphoma.
 | Today, it is a known fact that in mantle cell lymphoma, the B-cells, (actually B-lymphocytes, a type of leukocytes or white blood cells), suffer from a reciprocal translocation of chromosomes 11 and 14, whereby cyclin D1 is more strongly expressed. It is part of our immune system, along with T-cells (T helper cells) and is formed in the bone marrow, not in the lymph glands. But if cyclin D1 undergoes this kind of malignant transformation, the lymph glands collect it and may swell up if the volume becomes too expansive. |
Excision of the lymph gland does not alter this principle. See also "Inzidenz sekundärer chromosonaler Aberrationen beim Mantelzell Lymphom (MCL) mit Translokation t(11;14)(q13;q32)" (Incidence of secondary chromosomal aberrations in the case of mantle cell lymphoma (MCL) with translocation t(11;14) (q13;q32), German only) or the full text (PDF).
Today, we also know that in all MCL cases (n = 103) examined using FISH analysis, a translocation t(11;14)(q13;q32) was detected.
This is a quote from the PDF above, dissertation written by Marie-Sandrine Sander, 2005, (Fac. of Med.), Ulm University. In 92% of patients, a secondary aberration takes place. These are subsequent chromosomal alterations (chromosomal mutation).
Further investigations revealed manifestations above and below the diaphragm, but this was not histologically proven and there were no other symptoms, such as night sweats. It was therefore assigned the status 3a. At the time, genetic examinations were not yet possible.
Today, we know that the problem is often a genetic mutation of the tumor suppressor p53 on chromosome 17p13. This can lead to the loss of the inhibitory effect on the cyclin D1/CDK4 complex (cyclin dependent kinase 4) via p21. This generally promotes cancer.
An acquaintance of mine had this procedure done in 2013/14, unfortunately without success. He was given great hope, although statistically the likelihood of a cure was very small. He was also an older man, with an increased risk.
His belief in the stem cell transplants prevented him from making a radical change to his diet as a form of adjunctive therapy (adjuvant therapy). Moreover, his doctors told him that diet would not influence his illness. He went for a few months without any findings. But after that the malignant cells began to grow again. A second attempt was made, but he died after the first cycle of treatment.
My doctor had scheduled an operation to have my spleen removed, but I canceled the appointment
Back to my case. My doctor had scheduled an operation to have my spleen removed (splenectomy), but I canceled the appointment. I was already aware of the prognosis, but my doctor hadn’t yet received the results.
Wikipedia: Although the spleen is not a vital organ, its removal can cause long-term negative effects.
But in my case, it was determined that the spleen was not necessary since it is not directly essential for survival.
The doctor also wanted me to start with chemotherapy. When I refused, he said, Erb (no longer Ernst), you had better do as I tell you.
To which I replied, Hansruedi, there’s only one thing in this world that I have to do, perhaps even before you, and that is die. That’s the only thing I have to do.
I didn’t add that a person is always responsible for their own actions.
If I had had a standard Hodgkin’s lymphoma or another type of NHL with a better prognosis, I would have followed the recommendations and undergone conventional treatment. I must emphasize this fact and warn against following my example.
Given my resolute answer, my friend and physician asked me to find another doctor. Later he heard about my radical switch to a vegan raw food diet from my wife at that time, but he never talked to me again. Not even years later, even though he knew that I had found a cure. He passed away several years ago.
That’s the situation I was in at age 41, with 5 children, and a dysfunctional family. In addition, I had a lot of stress with my companies and the construction of a new office building.
Histological results on the lymph gland that had been removed
Two of the three histological results on the lymph gland that had been removed. All three tests had very clear findings.
At first I read special literature concerning my case. I soon wondered why so many people were suffering from lifestyle diseases, sometimes even at a young age.
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What were we doing wrong? A sick animal in the wild would quickly fall prey to its predators, if it were to get sick. Cancer does of course occur in nature as well, and the causes for it are known: the wrong habitat and stress.
Initially, I was also unaware of the many bovine "growthhormones" found in milk and dairy products consisting of a structure that is 70% the same as the "growthhormones" in humans. See the book review on "Milk Better Not"!
Multizentrische Therapiestudie - "Festlegung der optimalen Behandlungsstrategie für das fortgeschrittene centrocysche Lymphom"
I decided to eat vegan because I suspected that animal proteins probably promoted cancer. We can live well on vegetable protein alone and do not need animal protein. See also the book review on "The China Study" or the book itself.
That’s how you are supposed to defeat cancer? It may sound quite naive, I know. To help get me started, I spent a few weeks in the Bircher-Benner clinic in Zurich.
Ca-Kost (Ca food, Ca = cancer)
But to my surprise they had stopped serving raw food some time ago and instead were serving what they called Ca-Kost (Ca food, Ca = cancer), which was vegetarian, but not vegan, and it was also cooked. I refused it right from the start and asked to speak with the chef. Thankfully, his answer to my request for raw vegan food was, “Yes, of course.”
As I described in the book review on "The China Study" by T. Colin Campbell in a comment box near the end, I was very surprised that the chef welcomed my request to receive only vegan raw food despite the fact that this would mean overtime for him. I wrote the following there:
He actually invited me to his home and introduced me to his family. I found out that they had changed to a vegan raw food diet five years before because his wife had suffered from malignant melanoma with numerous metastases. She seemed to be in her mid-twenties. Cancer at this stage almost always ends in death within a few months. But she had cured herself by making the radical and permanent change to an exclusively vegan raw food diet.
Later, I met a 35-year-old Austrian, who had also cured himself from cancer. At least, the doctors couldn’t find any signs of the cancer in his blood. But after he had just barely recovered, he reverted back to his previous eating habits and died a little over a year later, just as I had expected. The same type of cancer had come back.
Several years later I heard that that the chef’s wife had stayed healthy.
I had heard a few other such stories with positive outcomes. Unfortunately, conventional medicine wasn’t interested in any of these cases and their extraordinary recoveries.
At least retrospectively, these should be examined even more closely than conventional healing methods and their possible causes identified in order to obtain patterns. Otherwise, conventional medicine can always hide behind the “fact” that there are no statistics, simple as that.
At the time, conventional medicine believed that it would be impossible to maintain a vegan raw food diet in the long term. This was despite the fact that many strict followers of the Jain religion had practiced it for the last 2'500 years. ... This is why I no longer wanted to focus on the subject and chose instead three books on a different topic. I didn’t want to keep kidding myself.
At times, I felt like a lone wolf (Steppenwolf)
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I was, however, able to focus on just ONE disease, a luxury that doctors can’t afford.
As you know from the article on Erb Muesli, I kept to a strict raw food diet for seven years. You can also read there why I changed my diet.
This radical change freed me of chronic inflammation of the sinuses and hemorrhoids as well
In my late teens, I started to suffer from chronic inflammation of the sinuses (sinusitis). This affected primarily the two maxillary sinuses. At night, I usually needed a cortisone nasal spray to get my nose somewhat cleared. Even during vacations, the nasal spray was my constant companion.
I often had to get the pus removed by an ENT specialist, which he did by jabbing through the nasal bone into the sinus cavity and flushing it out. At the time, I didn’t know about the kind of nasal irrigation described in this link. The “prick” was uncomfortable, but did not cause pain. It made the situation better for a certain length of time. Steam inhalation and infrared treatments didn’t help much either. I probably had an empyema.
The hemorrhoids that I had suddenly got at age 21, which were constantly bleeding and needed repeat treatments, also disappeared completely. I was also able to dispose of the suppositories the doctor had prescribed me.
Here is a brief summary of what happened next. When I started to eat cooked food again because of my former wife, Margot from Germany, whom I had met in Tenerife, I again experienced health problems. I had digestive problems and was very fatigued. After a year, I had a medical examination done in Switzerland. Luckily, they didn’t find anything, except for a lactose intolerance.
Interestingly, in our family we had to drink almost a liter of milk every day when we were children and adolescents. I acquired a lactose intolerance as a result of seven years of not consuming milk and dairy products. Nature can turn off our ability to digest dairy products, if we don’t consume any for many years — even in lactose-tolerant people.
About my family
One more thing about my family: I was the oldest of seven children.
The youngest of the seven, my brother Werner, died when he was 26. I only knew that he had health problems, as I was ten years older and had almost no contact with him.
Three of my other siblings died from cancer at a young age.
My youngest sister, Margrith (21.2.1945–15.4.1994) died of lung cancer before she reached the age of 50, even though she didn’t smoke.
Our uncle Armin Fritz passed away when he was 54. My brother Kurt died early because of a brain tumor.
My mother, however, was lucky. She had another solid type of brain tumor, which was able to be removed surgically.
My sister Annelies (Teddy) died of breast cancer.
Margot was diagnosed with breast cancer in Australia, where we had wanted to move to in 1990. The cancer was immediately treated with surgery and then chemotherapy. She was given an average of about five years to live. We got married then so that our two children could also have Swiss citizenship.
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Commercial production of banans and my own bees
 | The original vineyard with a house over 200 years old and 3,500 square meters of terrain required a lot of work in terms of irrigation and renovation. I had purchased it from a German couple, Fritz and Gerda Langner, who had been using it for organic farming. The finca (farm) served mainly as an experimental garden because the elevation (300 meters above sea level) was too high for the successful commercial production of bananas. |
Bananas can grow there, but the yield is not high enough. However, I was able to grow about 50 different types of fruit as part of my efforts. There was a lot to learn. In particular, having my own bees was an interesting challenge. I never fed them sugar as it was unnecessary in that climate.
Decades later, I was able to attend Mr. Langner’s 100th birthday celebration. It was held in Küssnacht, Switzerland, in February 2009.
2. What family tragedies can cause
In the 1990s, we were living in Rigi-Kaltbad, at 1'500 meters above sea level. Margot finally decided that she wanted to switch to a raw food diet and she did this to a great extent, but she needed her daily coffee. However, this beverage is filled with Maillard molecules.
In 1997, Margot fell in love with a younger man (12 years younger) and left us. She later found out that this man was already living with another woman who was about her age. Put to the test, the man decided to end the relationship with Margot. I don’t know if she was still on a raw food diet or not because she had moved to live with her mother in Bavaria, Germany. However, after this emotional turmoil she developed metastases and passed away in 1999. Organization Exit (Swiss association that assists people who have terminal illnesses) provided us with assistance during this time.
In 1998, I moved to Lucerne with our two children. We formed a patchwork family there with Kathrin (my current wife) and her children. Her children had lost their father, and mine their mother. As the children had been through a traumatic ordeal, these were very difficult times for all of us.
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In 1997 and 1998, I was suffering from severe back pain, even at night. If I stretched out my arms out in front of me, I couldn’t even hold a heavier book. This condition was certainly a result of the emotional stress I had been through, and it gradually disappeared.
However, a few years later I had to see a urologist, and the results of the examination showed that I had a serious prostate problem. I had a PSA (prostate specific antigen) of 18.4 and free PSA of 0.79, in other words a free: total PSA ratio of 0.04!
A later examination showed that I also had a papillary tumor in my bladder (transitional cell carcinoma, urothelial papilloma).
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3. A new beginning with raw food
To avoid this prostatectomy, I wanted to go back to a one hundred percent vegan raw food diet. I asked Kathrin if she wanted to change her diet with me and she agreed. If it weren’t for my previous experiences, I would have had the operation. As my situation was special, I can’t recommend my approach to others.
The removal of her uterus (hysterectomy only) about two years before had not alleviated the endometriosis.
Endometriosis
This was because the endometriosis tissue, which had already grown in the intestine, caused periodic intestinal bleeding and severe abdominal pain. But the extreme change in diet ended up curing this condition several years before Kathrin entered menopause.
The severe pain and bleeding during her menstrual cycle subsided after a few cycles. And after about 18 months, all of the pain was gone.
Wikipedia: Endometriosis may spread to the vaginal wall or the intestines. However, endometriosis has rarely been found in the lungs and brain. Endometriosis can be a cause of infertility in women...
Wikipedia (May 2015) includes the following information about endometriosis: Since the cause of the development of endometriosis has not yet been clarified, causal treatment or prevention are impossible at this time.
Actual personal experiences, such as what I described above, do not get used by conventional medicine.
In my case, my back problems disappeared, but I do not ascribe that to the raw food diet. I believe that these disappeared as I was able to finally mentally process the difficult events that had occurred. Even during the years where I didn’t eat a completely raw food diet, I always ate a raw breakfast with my Erb Muesli. Sometimes, we also ate other meals raw. We always ate a lot of fruit, and we never had any meat. However, I loved and ate plenty of soft cheese or, for example, Rösti mit Käse
(fried grated potatoes with cheese). After moving to Lucerne, in 1998, we continued to eat that way because the kids loved it.
Are hip or knee problems really necessary? Or are they actually preventable and even reversible?
When I met Kathrin, we would go hiking in the mountains, and she could barely walk 300 meters downhill without her knees becoming very painful — and that at the age of 40.
As I know other people who have reversed this type of arthrosis simply by cutting milk and dairy products from their diet, I would highly recommend taking this step. You should at least try it for a period of three months before looking into other options.
Shortly thereafter, we were able to hike for 11 hours straight without any problems. In 2003, for example, we hiked from Ferden in the Canton of Valais over the Lotschen Pass via Kanderfirn, through Gastern valley up to the town of Kandersteg — and all that without an overnight stay.
Then we went spent several days hiking from Meggen to Montreux. We went through Rigi-Kaltbad, from Scheidegg to Brunnen, then over the Surenen Pass to Engelberg, and over the Joch Pass to Engstlenalp, Planplatten, and Meiringen. Next we generally followed the “back alley” route and went from Barentreck to Rosenlaui, Grosse Scheidegg, Grindelwald, Kleine Scheidegg, Wengen, Mürren, Sefinefurgge, Griesalp, Hohturli, and Kandersteg. And then we continued on via Bunderchrinde to Adelboden, over Hahnenmoos Pass, to Lenk, and from Tritlisbergpass to Gstaad, then to Saanen, and Chateau-d’Oex, and Montbovon on the Rochers de Naye Montreux. But it wasn’t at all a forced hike as we had a few overnight stays.
I started jogging at age 78 and after three and a half months, I ran a half marathon, which is 13.1 miles or 21.1 km, in (a rather slow) 2:36 hrs. Late, but still a good change to the many and unhealthy hours I usually spent at the computer. Photos taken by Sandra Marchesi, a gift from Frank to me. Snapshot was taken as we were eating ... sorry ...
4. Something that does not want to go away
I am lucky in that I can usually get along with a shorter amount of sleep. However, every now and again I have some difficulties.
They began suddenly and strongly, but lessened considerably after a few months. The onset of the disease, which had been dormant for many years, began much like Parkinson’s disease. Before the symptoms appeared, I had eaten only cooked food for six weeks.
The first sign that something was wrong was that I began to have strong tremors in my left hand. If I had held a glass in my hand, I would have spilled the contents immediately. The reaction pattern of borrelia in the IgG Western blot showed that I must have had an infection several years ago.
Lyme disease
In 1990, we lived with a family of friends in Sidney in a forest cabin by a creek.
The woman suffered from neuroborreliosis, and her husband got it later as well. They both passed away early. We had both also visited Fiji. This disease manifests differently in Switzerland than in those two countries. Wikipedia does not show Lyme disease on the map for Australia or Fiji. But it was clear that I didn’t get infected from a human.
After the first attack in 2003, I alternately had weeks and months of headaches (morning only), speech difficulties (near semantic paraphasia), thought disorders in the form of inhibition of thought, and restless legs syndrome (RLS).
Luckily the symptoms never happened all at once, but instead I usually only had one or two at a time. Oddly enough ever since then, I have also had swelling in my legs. This is despite the fact that my veins and heart are in excellent condition. I wear long, narrow runners socks, and they help to keep the swelling in my lower legs and feet at bay.
These symptoms come back every now and then and then stay for weeks or even months. The sleep disturbances I experience can be very exhausting. I wouldn’t want to know how this disease would have progressed if I weren’t eating a vegan raw food diet. If you read the information in the link above, you will learn that antibiotics only make a difference in the first few weeks.
After that, you are pretty much powerless in terms of ridding yourself of the disease. I have not heard of any successes with subsequent venous administration of antibiotics that can overcome the brain barrier. The treatment is also extremely expensive. However, there are books about successful holistic healing methods.
Borreliosis manifests quite differently for each person. You never know what would happen if... I included information about this disease so that you can see that raw food isn’t a panacea. I also cannot say whether the course of the disease would have been more serious if I had been on a regular diet. I still hope that over time more will be learned about this disease. You can also see this scientific report for more information.
Another disease caused by borrelia is relapsing fever, specifically tick relapsing fever.
5. The papillary tumor in my bladder
As mentioned above, a papillary tumor was discovered in my bladder. I have good current results (July 15, 2015), which you can view below (the last two of the five documents). I would like to emphasize that Professor Dr. med. Hansjörg Danuser is completely right in recommending an endoscopy that would include what is called a transurethral bladder resection (TURB). He was very kind and is also an excellent physician. I can’t and don’t want to recommend my personal path to anyone.
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6. What kind of strength do you need to get cured?
It wasn’t until a few years after the onset of my illness that I discovered other things besides a vegan raw food diet that could have helped me recover. I read a lot in Tenerife, including books written by Carlos Castaneda, who was essentially also searching for answers. Based on the volume of reading material I’d gone through, there was not much left to learn from him — and yet I found something rather important in the following statement made by Don Juan Matus as a Nagual in the "Second Ring of Power":
All you have to do is remind her that she’s an incurable patient. Since she’s a terminal case, she has power. She has nothing to lose anymore. She’s lost everything already. When you have nothing to lose, you become courageous. We are only timid when there is something we can still cling to.
This realization came too late for me because I had already been down this path. And I wasn’t a supporter of the New Age Movement. Quite to the contrary, I am a realist and as such an agnostic (agnosticism in the sense of Thomas Henry Huxley). But as a realist, who is still seeking answers, it would be a mistake not to stay open for new ideas and views.
Books that were very important for me
Some books that were very important for me included, for example, "Siddhartha" by Hermann Hesse and before that "Steppenwolf" and "Demian" (by Emil Sinclair, pseudonym). Of course I would not have identified with the character Govinda in "Siddhartha".
However, Hermann Hesse was too much of an idealist for me. But realism without ideals is as bad as idealism. This statement in itself is hard to understand if you don’t understand the huge difference between “having an ideal” and idealism. The idealism condemned here doesn’t have anything to do with German Idealism.
When I read "Demian", I realized that I had reached a high degree of individuation early in my youth and was lucky enough to be able to continue to grow and develop, unlike my father. But I admire him for other reasons.
Realism and acting quite the opposite as the lemmings in the Walt Disney story "White Wilderness" (1958), allowed me to seek the truth about my illness, suffer from it, and as a result of psychological reasons lose a few pounds, even though I didn’t have many pounds to lose.
It was the fear of death (rational) rather than death anxiety that gave me the strength to follow my own path. But I also knew that I couldn’t just grasp at one of the many straws. But most people do just that again and again. ... The expression “grasp at straws” most likely comes from Lucilio Vanini (1585–1619), whose tongue was pulled out with pliers by servants of the church. He was later burned at the stake.
I made this decision based on the knowledge that there must have been a decisive change in the body as our body was actually built to consume raw food. To start out strong, I did a juice fast for the first 10 days that consisted of only raw vegetable juice and water.
There are several books on this subject, if you are interested. I would recommend "Überleben im Stress - Autogenes Training - Der Weg zur Entspannung - Gesundheit - Leistungssteigerung" (Surviving in stress — autogenic training — the path to relaxation, health, and better performance, 1977) written by Dr. med. Hannes Lindemann.
You can purchase this book for almost nothing (German only), and it works well for self-study. The actual developer of autogenic training Dr. med. Johannes Heinrich Schultz was unfortunately not an outstanding member of society.
This method probably also helped provide me with the necessary strength. The real and necessary fear of death still occupied me for several years.
I do not consider the neuroborreliosis and papilloma in my bladder to be predators that I must combat with all means possible. I lack the necessary fear of death, and it is an intentional self-experiment.
Since I consume primarily vegan raw food, my body gets what it needs to maintain optimum health. This is another reason why I lack fear. But if I had to battle deep emotional stress, I would choose to have surgery (transurethral resection, TURB) for the bladder ulcer or cancer (bladder cancer). I do, of course, have this condition examined regularly by a physician.
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