Critical Overview of Homeopathy:Annals of Internal Medicine



Series Editors: David M. Eisenberg, MD, and Ted J. Kaptchuk, OMD

A Critical Overview of Homeopathy

Wayne B. Jonas, MD; Ted J. Kaptchuk, OMD; and Klaus Linde, MD

Homeopathy is a 200-year-old therapeutic system that uses small doses of various substances to stimulate autoregulatory and self-healing processes. Homeopathy selects substances by matching a patient’s symptoms with symptoms produced by these substances in healthy individuals.

Medicines are prepared by serial dilution and shaking, which proponents claim imprints information into water. Although many conventional physicians find such notions implausible, homeopathy had a prominent place in 19th-century health care and has recently undergone a worldwide revival.

In the United States, patients who seek homeopathic care are more affluent and younger and more often seek treatment for subjective symptoms than those who seek conventional care. Homeopathic remedies were allowed by the 1939 Pure Food and Drug Act and are available over the counter.

Some data—both from randomized, controlled trials and laboratory research—show effects from homeopathic remedies that contradict the contemporary rational basis of medicine. Three independent systematic reviews of placebo-controlled trials on homeopathy reported that its effects seem to be more than placebo, and one review found its effects consistent with placebo.

There is also evidence from randomized, controlled trials that homeopathy may be effective for the treatment of influenza, allergies, postoperative ileus, and childhood diarrhea. Evidence suggests that homeopathy is ineffective for migraine, delayed-onset muscle soreness, and influenza prevention.

There is a lack of conclusive evidence on the effectiveness of homeopathy for most conditions. Homeopathy deserves an open-minded opportunity to demonstrate its value by using evidence-based principles, but it should not be substituted for proven therapies.

The increasing use and reported success of homeopathy worldwide suggest that we should take a serious look at it. This article describes the history and principles of homeopathy, its practice patterns, and current research.

The Origin and Principles of Homeopathy

The "Principle of Similars"

A German physician, Samuel Christian Hahnemann (1755–1843), developed homeopathy at the end of the 18th century (1). As the story goes, Hahnemann was translating an herbal text from English to German when he found that Cinchona bark (China officalis) cured malaria because it was bitter. He thought this explanation was preposterous and took repeated doses of Cinchona to personally determine its effects, which appeared remarkably similar to the symptoms of malaria. Hahnemann hypothesized that one may select therapies on the basis of how closely a patient’s toxicologic symptoms matched the symptoms of the patient’s disease.

He called this the "Principle of Similars." He subsequently gave repeated doses of many common remedies to healthy volunteers and carefully recorded the symptoms they produced. This procedure is called a "proving" or, in modern homeopathy, a "human pathogenic trial." Hahnemann then attempted to select his treatments for sick patients by matching these drug symptom pictures to symptoms in sick patients (2).

The Minimum Dose and Avagadro’s Number

The second and most controversial tenet in homeopathy is that remedies retain biological activity if they are diluted in a series (usually in a 1:10 or 1:100 diluent–volume ratio) and agitated or shaken between each dilution. Hahnemann began this process to reduce toxicity, but later he claimed that this "potenization" process extracted the "vital" or "spirit-like" nature of these substances (2).

The limit of molecular dilution (Avagadro’s number) was not discovered until the later part of Hahnemann’s life; by then homeopaths all over the world were reporting that even very high potencies (dilutions lower than Avagadro’s number) produced clinical effects.

The implausibility of such claims has led many to dismiss any evidence of homeopathy’s effectiveness as artifact or delusion (3).

Holism and the Totality of Symptoms

The third principle in homeopathy is that remedies are most effective when they are selected on the "total" characteristic set of symptoms, not just those of the disease (4).

For example, a homeopath would treat a patient with a cold whose primary symptoms are lacrimation, stinging and irritation of the eyes, and thin, clear nasal discharge with a potency prepared from onion extracts (Allium cepa) because these symptoms mimic those produced by onions.

However, another patient with a cold might have thick, yellow nasal discharge, have lost all thirst, and want cool, fresh air. That person would be treated with a potency of the purple cone flower (Pulsatilla) because these symptoms are more characteristic of those produced by this plant. Both patients have the same diagnosis (upper respiratory tract infection), but each is treated with a different homeopathic drug based on their characteristic symptoms.

This situation can complicate clinical research in homeopathy when the experimental sample is selected according to conventional criteria but the therapy is based on homeopathic criteria (5). In addition, homeopathy has developed numerous approaches to this matching process over the last 200 years, further complicating establishment of a uniform prescribing standard.

The Rise, Fall, and Rise of Homeopathy in the United States

Soon after its discovery, homeopathy spread rapidly across Europe and to other countries, especially the United States. Its rise is partly attributed to the barbaric practices in orthodox medicine of the time, such as bloodletting, high-dose cathartics, and heavy metals (6).

By the turn of the century, 8% of all medical practitioners in the United States were homeopaths and there were 20 homeopathic medical colleges, including Boston University School of Medicine, New York Medical College, and Hahnemann Medical College (7, 8).

Allopathic medicine’s reaction to homeopathy was consistent and harsh (9). The American Medical Association (AMA) was formed a year after the American Institute of Homeopathy, partly to combat such "irregulars" (10).

In 1852, the predecessor journal of The New England Journal of Medicine proclaimed that homeopathy is "a cheat" with little advantage "over the Indian meal and table salt (placebos) of an earlier date and worthy of the disembodied spirits in the Paradise of Odin, where the inhabitants feed on shadows" (11, 12).

Foreshadowing contemporary debates, homeopaths responded with statistics and helped pioneer comparative quantitative information and large-scale comparative trials (13-16). For example, during the cholera epidemic of 1854, homeopathic hospitals had dramatically lower mortality rates than allopathic institutions (17).

Obviously, such outcomes could have many explanations, such as homeopaths’ eschewing violent purgatives. Orthodox physicians criticized the quality of the data and questioned the reliability of any "complex" mathematical method that portrayed homeopathy favorably (15, 17).

Toward the end of the century, a rapprochement between homeopaths and conventional physicians gradually unfolded. Exchanges took place: Homeopaths adopted new orthodox treatments, such as diphtheria antitoxin, while allopaths borrowed homeopathic remedies, such as nitroglycerin (18, 19). In 1903, after long antagonism, the AMA—in need of homeopathic referrals for its newly proliferating medical specialties and allies to oppose emerging alternatives, such as osteopathy—invited homeopaths to join. This merger greatly accelerated the assimilation and demise of homeopathy (20, 21).

A new revival of homeopathy in the United States began in the 1960s and 1970s and is closely allied to interpretations of homeopathy that emphasize "high" potencies and psychological symptomology (22). The resurgence continues: The number of patients using homeopathy in the United States is estimated to have increased 500% in the last 7 years, most involving self-treatment with over-the-counter remedies (23).

Homeopathic Practice

Patterns of Practice

In the United States, patients seen by homeopathic physicians tend to be more affluent, more frequently be white, present more subjective symptoms, and be younger than patients seen by conventional physicians (24).

Conventional physicians see almost twice the number of patients older than 65 years of age, spend less than half as much time with each patient (12 minutes vs. 30 minutes), and order more tests than homeopathic physicians (24).

In the United States, much homeopathic practice is integrated with conventional care because homeopathic physicians use conventional medications in a quarter of the patients they see (28% for homeopathic physicians vs. 69% for conventional physicians) (24).

Patients seeking homeopathic care are liable to find various approaches depending on their clinician’s philosophy and training. "Classical" homeopathy usually involves a detailed history (often lasting over an hour) and infrequent doses (every month or less) of a single remedy.

The total patient response is followed and evaluated for specific patterns of improvement characteristic of a healing response. "Clinical" homeopathy uses combinations of remedies to "cover" the symptomatic variations of a clinical condition, similar to conventional drug treatment.

The American Institute of Homeopathy is the oldest organization for licensed health care professionals, and there are licensing organizations for chiropractors, naturopaths, and, more recently, "professional" homeopaths who do not hold medical degrees.

While the classical approach to homeopathy is fairly standardized, some practitioners use electronic instruments, electroacupuncture devices, pendulums, their own intuition, or metaphysical principles to select remedies, with little regulatory oversight of these approaches. This presents a confusing array of approaches for patients under the term "homeopathy" (1).

In addition, many patients self-prescribe homeopathic remedies and never consult a practitioner.

Adverse Events and Drug Labeling

The Food, Drug, and Cosmetic Act of 1939 allowed homeopathic medicines to be on the market. These medicines are classified as safe for over-the-counter use. The U.S. Homeopathic Pharmacopoeia Convention meets regularly with members of the Food and Drug Administration to set standards for good laboratory practices and assure quality and uncontaminated production of homeopathic medicines.

Dilutions in a ratio of 1:10 are labeled with an X or a D (for decimal), and those diluted in a ratio of 1:100 are labeled with a C (for centesimal). Thus, 6X (or 6D) has been diluted 1:10 six times and 6C has been diluted 1:100 six times. Because of the small doses, almost all authorities assume that homeopathy is safe and will not interact with conventional drugs as long as patients also receive good conventional care.

However, the benign nature of high dilutions should not be assumed without systematic investigation. Adverse effects have been reported with homeopathy in both the clinic and the laboratory (25, 26).

Annals of Internal Medicine

4 March 2003 | Volume 138 Issue 5 | Pages 393-399

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