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The heresy of homoeopathy
British Homoeopathic Journal January 1998, Vol. 87, pp. 28-32
The heresy of homoeopathy A brief history of 200 years of criticism EDZARD ERNST, MD, PHD, FRCP (EDIN)
Abstract Criticism of homoeopathy started in Germany as soon as this new form of medicine became widely known--and has not stopped since. Early criticism came from nonhomoeopaths and centred around the theme that homoeopathy's basic assumptions were not supported by demonstrable facts. Simultaneously, criticism from within homoeopathy attacked some of the rigid, dogmatic rules set out by Hahnemann. T o d a y ' s opponents of h o m o e o p a t h y argue predominantly that the efficacy of homoeopathic remedies beyond that of placebo has not been established. Polemic and emotive as this historical debate has been, much of it makes sense to the outside observer. Homoeopaths, it seems, would be well advised to take the reasoned elements of this criticism seriously. They might even attempt to turn seemingly unfair attacks into constructively working towards determining the truth. Introduction Two hundred years ago, Samuel Hahnemann (1755-1843) published his 'like cures like' (similia similibus curentur) principle, l one of the key axioms of homoeopathy. Since then, homoeopathy has been in and out of favour. 2 In spite of scientists asserting that its rationale flies in the face of science and its clinical efficacy remains doubtful, 3 homoeopathy is popular yet again. The latter point is perhaps best demonstrated by the fact that UK sales of h o m o e o p a t h i c remedies are presently increasing by 20% annually. 4 Numerous articles have commemorated the 200th anniversary of homoeopathy. Yet the history of the critique of homoeopathy, which is as old as homoeopathy itself, has been largely neglected. This short review represents a ('tongue in cheek') attempt to fill this gap.
the errors of Hahnemann's teachings in the Organon)P Heinroth wrote that medicine was wrong to accept from Hahnemann 'much that would not have stood the test of a sharp mind'. In particular, he felt that the 'like cures like' principle is deeply flawed '... the paramount law of nature should in effect be: contraria contraiis'. H o m o e o p a t h y was called 'the highest triumph of ignorance and mysticism '6 and ' a public scandal of our times ' 7 Hahnemann's opponents were not known for m i n c i n g their words, and neither was Hahnemann (see below). In the US, Oliver Wendel Holmes, one of the leading physicians at the Harvard School of Medicine, published a most biting critique of h o m o e o p a t h y . 8 H o l m e s a n a l y s e d H a h n e m a n n ' s three basic assumptions in detail: the 'like cures like' principle, infinitesimal dilutions, and the theory of the origin of all diseases. He concluded, 'when one man claims to have established these three independent truths, which are about as remote from each other as the discovery of the law of gravitation, the invention of printing, and that of the mariner's compass, unless the facts in their favour are overwhelming and unanimous, the question naturally arises, is not this man deceiving himself, or trying to deceive others?' An equally poignant and detailed analysis
19th century criticism from mainstream medicine O p p o s i t i o n to h o m o e o p a t h y started in Germany as soon as the new form of treatment became known. One of the earliest criticisms is by J. C. H. Heinroth, Professor of Neurology at the University of Leipzig. The title of his book referred directly to Hahnemann's major opus (Organon): 'Anti-Organon oder das I r r i g e der H a h n e m a n n s c h e n L e h r e im Organon der Heilkunst' (Anti-Organon or 28
29
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was published four years later by John Forbes, a physician to Queen Victoria. 9 He affirms that 'a large proportion of the experiments performed by Hahnemann and his friends, with the object of ascertaining the therapeutic properties of medicines, are altogether fallacious, and the alleged facts thereby elicited are not facts at all.' The method of preparing homoeopathic remedies, he concludes, bears 'a much closer resemblance to what we have heard or seen of magical ceremonies and the tricks of conjurors, demonstrations for effect and to produce an impression, than to any operation of a scientific or bona fide character'. Forbes speaks of the 'heresy of homoeopathy' (thus inspiring the title of this article) and describes early clinical trials of homoeopathy asserting that 'no unquestionable evidence exists as to the absolute power of homoeopathy to cure diseases'. He also severely criticises allopathy for its often harmful 'cures' and acknowledges the 'power of nature' in healing. A remarkable aspect of this treatise is the clear and repeated call for placebo-controlled, blinded trials (a good 100 years ahead of his time!) to evaluate the efficacy of homoeopathy. Even more remarkable is the fact that some orthodox physicians strongly disagreed with some of his favourable comments and that the ensuing debate apparently led to the closure of the British and Foreign Medical Review. A p r o m i n e n t G e r m a n o p p o n e n t of h o m o e o p a t h y was T h e o d o r Jtirgensen (1840-1907). He too extended the attack from the 'like cures like' principle to other axioms of homoeopathy. Jtirgensen stated, 'The law that all diseases are of dynamic origin ... and their origins cannot be recognised through our senses .. divides Hahnemann ... from our science ...'. He summed up his judgements of h o m o e o p a t h y by stating that ' e i t h e r Hahnemann is right, in which case our science and the basis of our thinking is nonsense, or he is wrong, in which case this teaching is nonsense. There is no third option', l~ The essence of the accepted view at the end of the 19th century is aptly summarised by the concluding paragraph of the 1891 entry on homoeopathy in the Encyclopaedia Britannica: 'Hahnemann's errors were great. His doctrine of specifics was highly retrograde and unscientific, and his disparagement of the principle of tolle causam and of those who aimed at discovering the causes of disease
was unphilosophical. He was fanciful and theoretical to a very high degree. He led his followers far out of the track of sound views of disease and the methods by which it can best be prevented and cured. But, with all his defects, it must be admitted that he had the great merit of disturbing and discrediting indefensible modes of practice'. H This latter point is of particular interest: even today critics of homoeopathy credit Hahnemann with his contribution in bringing about a decline in the overtly harmful orthodox treatments so abundant during his time.
Criticism within homoeopathy H a h n e m a n n was a charismatic man; his f o l l o w e r s c a l l e d him ' t h e M e s s i a h of Medicine'. II He was also uncompromising and intolerant, and considered homoeopathy to be the 'only law consonant to nature' and maintained that 'cures never were effected by any other means than by means of medicine of h o m o e o p a t h i c power'.~2 The slightest departure from his teaching earned the severest c o n d e m n a t i o n s : ' H e who does not walk exactly on the same line with me is an apostate and a traitor'. Such attitudes rendered homoeopathic 'in-house fighting' virtually inevitable. Many homoeopaths disagreed with Hahnemann's ultra high potencies. Some also thought that the doctrine to always use only one remedy at a time was inadequate. Others wanted to c o m b i n e m a i n s t r e a m and h o m o e o p a t h i c remedies which, according to their master, was forbidden, and most homoeopaths never adopted Hahnemann's third axiom stating that the cause of all diseases is the 'itch' or 'psora'. Thus, homoeopathy soon became divided into different schools of thought and practice. In 1837, Paul Wolf, a German homoeopath of high reputation, published his 18 theses which are the first documented homoeopathic departure both f r o m high potencies and Hahnemann's psora theory. He also demanded that all homoeopaths should have essential medical knowledge in anatomy, physiology and pathologyl3--a notion that has not lost its relevance to the present day. In 1877, the vice president of the British Homoeopathic Society wrote in the Lancet: '... the views expressed by Hahnemann are often extravagant and incorrect ... Hippocrates was right when
30 he said that some diseases are best treated by similars and some by contraries ... although many believe that the action of the infinitesimal in nature can be demonstrated, its use in medicine is practically by a large number in this country all but abandoned'. 14 The decline of homoeopathy was brought about, at least in part, by such intra-homoeopathic disagreements. At the end of the 19th century it had 'no scientific recognition' and was 'universally condemned'." Homoeopaths had relaxed their adherence to Hahnemann's dictum more and more and the number of practitioners or institutions was rapidly dwindling. 2 The final decline took place in the second decade of the 20th century after Kentian ideas arrived and scientific medicine was rejected by the homoeopathic community.
Early 20th century In most countries, this decline gradually continued until homoeopathy's most recent r e v i v a l (see below). The e x c e p t i o n was Germany. Utterly unexpected support for homoeopathy came from the country's leading surgeon, August Bier. In an article in the then widely read journal Miinchner Medizinische Wochenschrift, he urged his colleagues in 1925 to reconsider homoeopathy which, in his view, had a lot to offer after all. ~5 This caused an outrage of untold proportions with polemic, and emotional personal attacks and counter-attacks) 6 The debate was essentially based on the well-rehearsed argument that high dilutions cannot possibly work and anyone who thinks otherwise is obviously deluded. Indirectly, it led to the systematic investigation of h o m o e o p a t h y during the Third Reich, which apparently (according to a report of one eyewitness) had only negative results. 17 Eventually, the Nazi officials withdrew their support and the interest in h o m o e o p a t h y decreased also in Germany?8
Present criticism In parallel with the present popularity of c o m p l e m e n t a r y medicine in general and homoeopathy in particular,19 'the opposition' has reformed and is again raising its voice. T o d a y ' s arguments against h o m o e o p a t h y have become focused on several recurring themes, some old some n e w . 20 The most elementary one is that homoeopathic remedies are physically, chemically and in
Volume 87, January 1998
any other way indistinguishable from pure diluents. The intensity of this debate was highlighted by the ' B e n v e n i s t e a f f a i r e ' . Benveniste and his group had apparently shown that ultra-high dilutions can have biological activity. 21 Subsequently, a team of 'quack busters' visited Benveniste's laboratory and concluded that his experiments were flawed. 22 Later, a group of independent scientists was unable to replicate Benveniste's results. 23 The logical next step for opponents, it would seem, is to question the clinical efficacy/ effectiveness of homoeopathy. This clearly is the central feature of t o d a y ' s arguments against homoeopathy. Narrative or systematic reviews and meta-analyses of controlled clinical trials conclude that there is evidence to suggest that the effects of homoeopathic treatments are more than a placebo response, but methodological shortcomings invariably prevent definitive conclusions. 24-28Thus critics continue to reject the notion that homoeopathy is of proven efficacy. 29, 30 The problem, they say, is that there is no plausible mechanism of action and therefore homoeopathy cannot possibly work. In addition to these recurring themes, new ones have emerged. Some critics have questioned the notion that h o m o e o p a t h y is inherently and entirely risk-free. Reports of (perceived) adverse reactions to homoeopathic remedies do exist. 31, 32 Furthermore, there are indirect risks, for example the opposition of some (by no means all) h o m o e o p a t h s to immunisation33--and even if homoeopathic remedies are entirely safe, not all homoeopaths are in all circumstances. Others argue that homoeopathy is an outdated dogma based on principles that are unsustainable in the light of scientific discoveries made since Hahnemann's time. 34, 35 They agree that Hahnemann was right to attack the risky treatments of his time, but argue that today science has moved on and there is no longer a place for homoeopathy. Others say that homoeopathy as a unified school of thought does simply not exist, there are 'as many homoeopathies are there are homoeopaths'. 34 Others again attempt to demonstrate that Hahnemann's initial self-experiment which formed the basis of the 'like cure like' principle was flawed. 35 Finally opponents are keen to point out that homoeopathy has all the qualities
British Homoeopathic Journal
o f a sect and a cult; ' t h e m a r k e t i n g o f homoeopathic products and services fits the definition of quackery' .36 W h e n G e r m a n m e d i c a l schools were recently forced to include some basic elements of homoeopathy in their curriculum, a group of professors refused to comply, calling homoeopathy 'a media-hyped superstition' [cited in ref. 37]. A German pharmacologist s u b s e q u e n t l y p u b l i s h e d his L e c t u r e s on Homoeopathy which sums up the 'state of the art' of criticism of homoeopathy and (in my view) represents one of the best argued cases against homoeopathy during recent years. 37 Perhaps not surprisingly, in view of this continuous debate, the attitudes towards homoeopathy differ vastly. At least one country has taken the drastic step of the outright banning of homoeopathic remedies. 38 In the US and Europe, the regulatory authorities are more liberal and allow registration of highly diluted homoeopathic remedies without evidence of safety or efficacy.39 This attitude of benign laissezfaire is the most prevalent today and forms the ground on which the present popularity of homoeopathy can grow. As for evidence of clinical efficacy for homoeopathy, most non-homoeopaths would go along with the conclusions of systematic reviews and meta-analyses 24-28 which state unanimously that there is some evidence in favour of homoeopathy but that it is as yet inconclusive (eg40). But some critics still insist that 'no practice can be deemed effective until proved to be so; and the burden of proof is upon proponents', 36 and that 'sensational claims could be sustained only by data of exceptional quality' .22 In terms of research, most open minded physicians conclude that more and better investigations ought to be done in order to determine whether homoeopathic remedies are more than placebos [eg 3, 24-28.40]. Others s t r o n g l y hold against this strategy: 'Its [homoeopathy's] study ... would be a great waste of time and effort'. 36 They argue that, considering the expense of research and the limited resources available, one ought to focus on investigations that are promising in one way or another. Homoeopathy, they feel, is not. 29, 30 Conclusions C r i t i c i s m of h o m o e o p a t h y is as old as
31 h o m o e o p a t h y itself. Amidst the heat and polemic of the attacks and counter-attacks, much of what is being expressed makes sense. S o m e of the well a r g u e d cases a g a i n s t h o m o e o p a t h y (eg 8, 9, 37) should b e c o m e e s s e n t i a l reading for all h o m o e o p a t h s . Homoeopathy as a science would profit from taking these arguments seriously and working constructively and systematically towards determining the truth. Acknowledgement The author wishes to thank Dr Ted Kaptchuk, Harvard Medical School, for his help and advice with this manuscript. References 1 Hahnemann S. Versuch tiber ein neues Prinzip zur Auffindung der Heilkr~ifte der Arzneisubstanzen. J Prakt Arzneykunde u Wundarzneykunst 1796; 2: 391-439. 2 Ernst E, Kaptchuk TJ. Homoeopathy revisited. Arch Intern Med 1996; 156: 2162-4. 3 Kleijnen J, Knipschild P, ter Riet G. Clinical trials of homoeopathy. BMJ 1991; 302:316-32. 4 Fasihi A. Complementary Medicine Vol L Medicinal Remedies. London: ~ Pharmaceuticals and Healthcare Publications 1996. 5 Heinroth J, Chr A. Anti-Organon. Leipzig, 1825. 6 Cited in: Giese Ch, Gellert M. Zur Geschichte der Veterin~irhom6opathie in Deutschland. Berl Miinch Tieriirztl Wschr 1995; 108: 305-12. 7 Diepholz G. Einige Bemerkungen fiber die Kritik der Zooiasis, besonders aber der gesamten Homtiopathie. Magazin fiir gesamte Thierheilkunde 1836; 8: 299. 8 Holmes OW. Homoeopathy and its kindred delusions, 1842. republished in: Stalker D, Gylmour C (eds). Examining holistic medicine. Buffalo: Prometheus Books 1985. 9 Forbes J. Homoeopathy, allopathy and 'young physic'. British and Foreign Medical Review 1846; 21: 225-65. 10 Jfirgensen Th. Die wissenschaftliche Heilkunde und ihre Widersacher. Volkmanns Sammlung Klinischer Vortriige 1876; 106: 879-916. 11 Encyclopaedia Britannica. "Homoeopathy" 1891; 12: 126-9. 12 Hahnemann S. Organon der Heilkunst. 5th Edition, Dresden: Arnold 1833. 13 Wolf P. Achtzehn Thesen ffir Freunde und Feinde der Hom6opatik. Arch homOop
32 Heilkunde 1837; 16: 1. 14 Wyld D. Homoeopathy. Lancet 1877; 2 June. 15 Bier A. Wie sollen wir uns zur HomOopathie stellen? Miinch Med Wschr 1925; 72:713-7 and 773-6. 16 Ernst E. August Bier and German homoeopathy in the early 20th century. Br Hom J 1996; 85: 49-52. 17 Donner F. Bemerkungen zu der Oberprtifung der Hom6opathie durch das Reichsgesundheitsamt 1936-1939, Perfusion 1995; 8 : 3 - 7 (part 1), 35-40 (part 2), 84-8 (part 3), 124-9 (part 4), 164--6 (part 5). 18 Ernst E. Naturheilkunde im Dritten Reich. Dtsch ]~rzteblatt 1995; 92: 800-4. 19 Ernst E. Patients' Perception of Complementary Therapies. Forsch Komptementiirmed 1995; 2: 326--9. 20 Ernst E. Hom6opathie, Argumente und Gegenargumente. Dtsch ]{rzteblatt 1997; 94: A-2340-2. 21 Devenas E, Beauvais F, Amara J, et al. Human basophil degranulation triggered by very dilute antiserum against lgE. Nature 1988; 333: 316-8. 22 Maddox J, Randi J, Stewart WW. "High dilution" experiments a delusion. Nature 1988; 333: 287-90. 23 Hirst S J, Hayes NA, Burridge J, Pearce FL, Foreman JC. Human basephil degranulation is not triggered by very dilute antiserum against human JgE. Nature 1993; 366: 525-7. 24 Ernst E. Is homoeopathy a placebo? Br J Clin Pharmacol 1990; 30: 173-4. 25 Kleijnen J, Knipschild P, ter Riet G. Clinical trials of homoeopathy. BMJ 1991; 302:316-32. 26 Homoeopathic Medicine Research Group. Overviews of data from homoeopathic medicine
Address f o r correspondence Professor E. Ernst Department of Complementary Medicine Postgraduate Medical School University o f Exeter 25 Victoria Park Road Exeter EX2 4NT e-mail [email protected]
Volume 87, January 1998 trials. Brussels: Europ. Commission, 1996. 27 Barnes J, Resch KL, Ernst E. Homoeopathyfor post-operative iteus: a meta-analysis. (in press). 28 Linde K, Clausius N, Ramirez G, Melchart D, Eitel F, Hedges LV, Jonas W. Are the clinical effects of homoeopathy placebo effects? A meta-analysis of placebo-controlled trials. Lancet 1997; 350: 834--43. 29 Vandenbrouk JP. Homoeopathy trials, going nowhere. Lancet 1997; 350: 824. 30 Langman MJS. Homoeopathy trials, reasons for good ones but are they warranted. Lancet 1997; 350: 825. 31 Ernst E. The safety of homoeopathy. Br Horn J 1995; 84: 193--4. 32 Abbot NC, White AR, Ernst E. Complementary Medicine. Nature 1996; 381: 361. 33 White AR, Ernst E. Homeopathy and immunization. BrJofGen Pract 1995; 25: 629-30. 34 Prokop O, H o p f f W. Erkl~irung zur Hom/3opathie. Dtsch Apotheker Zeitung 1992; 132: 1630ol. 35 Kr~mer H J, Habermann E, Ein Vorlesungsversuch zur Homi3opathie. Dtsch ]4rzteblatt t997; 94: 1811-2. 36 Jarvis W. Homeopathy, a position statement by the National Council Against Health Fraud. Sceptic 1994; 3: 5007. 37 Meyer FP. Vorlesungen iiber HomOopathie. Jena: G Fischer, 1996. 38 Menczel E. Outlawing homeopathy in Israel. Am J Health-Pharm 1995; 52: 2471. 39 Baker EA. European regulations covering homoeopathic medicines. Forsch Komplement~irmed 1996; 3:311. 40 Ernst E, Barnes J. The medicine that cannot work? Pharm J 1996; 257: 339.
The heresy of homoeopathy A brief history of 200 years of criticism EDZARD ERNST, MD, PHD, FRCP (EDIN)
Abstract Criticism of homoeopathy started in Germany as soon as this new form of medicine became widely known--and has not stopped since. Early criticism came from nonhomoeopaths and centred around the theme that homoeopathy's basic assumptions were not supported by demonstrable facts. Simultaneously, criticism from within homoeopathy attacked some of the rigid, dogmatic rules set out by Hahnemann. T o d a y ' s opponents of h o m o e o p a t h y argue predominantly that the efficacy of homoeopathic remedies beyond that of placebo has not been established. Polemic and emotive as this historical debate has been, much of it makes sense to the outside observer. Homoeopaths, it seems, would be well advised to take the reasoned elements of this criticism seriously. They might even attempt to turn seemingly unfair attacks into constructively working towards determining the truth. Introduction Two hundred years ago, Samuel Hahnemann (1755-1843) published his 'like cures like' (similia similibus curentur) principle, l one of the key axioms of homoeopathy. Since then, homoeopathy has been in and out of favour. 2 In spite of scientists asserting that its rationale flies in the face of science and its clinical efficacy remains doubtful, 3 homoeopathy is popular yet again. The latter point is perhaps best demonstrated by the fact that UK sales of h o m o e o p a t h i c remedies are presently increasing by 20% annually. 4 Numerous articles have commemorated the 200th anniversary of homoeopathy. Yet the history of the critique of homoeopathy, which is as old as homoeopathy itself, has been largely neglected. This short review represents a ('tongue in cheek') attempt to fill this gap.
the errors of Hahnemann's teachings in the Organon)P Heinroth wrote that medicine was wrong to accept from Hahnemann 'much that would not have stood the test of a sharp mind'. In particular, he felt that the 'like cures like' principle is deeply flawed '... the paramount law of nature should in effect be: contraria contraiis'. H o m o e o p a t h y was called 'the highest triumph of ignorance and mysticism '6 and ' a public scandal of our times ' 7 Hahnemann's opponents were not known for m i n c i n g their words, and neither was Hahnemann (see below). In the US, Oliver Wendel Holmes, one of the leading physicians at the Harvard School of Medicine, published a most biting critique of h o m o e o p a t h y . 8 H o l m e s a n a l y s e d H a h n e m a n n ' s three basic assumptions in detail: the 'like cures like' principle, infinitesimal dilutions, and the theory of the origin of all diseases. He concluded, 'when one man claims to have established these three independent truths, which are about as remote from each other as the discovery of the law of gravitation, the invention of printing, and that of the mariner's compass, unless the facts in their favour are overwhelming and unanimous, the question naturally arises, is not this man deceiving himself, or trying to deceive others?' An equally poignant and detailed analysis
19th century criticism from mainstream medicine O p p o s i t i o n to h o m o e o p a t h y started in Germany as soon as the new form of treatment became known. One of the earliest criticisms is by J. C. H. Heinroth, Professor of Neurology at the University of Leipzig. The title of his book referred directly to Hahnemann's major opus (Organon): 'Anti-Organon oder das I r r i g e der H a h n e m a n n s c h e n L e h r e im Organon der Heilkunst' (Anti-Organon or 28
29
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was published four years later by John Forbes, a physician to Queen Victoria. 9 He affirms that 'a large proportion of the experiments performed by Hahnemann and his friends, with the object of ascertaining the therapeutic properties of medicines, are altogether fallacious, and the alleged facts thereby elicited are not facts at all.' The method of preparing homoeopathic remedies, he concludes, bears 'a much closer resemblance to what we have heard or seen of magical ceremonies and the tricks of conjurors, demonstrations for effect and to produce an impression, than to any operation of a scientific or bona fide character'. Forbes speaks of the 'heresy of homoeopathy' (thus inspiring the title of this article) and describes early clinical trials of homoeopathy asserting that 'no unquestionable evidence exists as to the absolute power of homoeopathy to cure diseases'. He also severely criticises allopathy for its often harmful 'cures' and acknowledges the 'power of nature' in healing. A remarkable aspect of this treatise is the clear and repeated call for placebo-controlled, blinded trials (a good 100 years ahead of his time!) to evaluate the efficacy of homoeopathy. Even more remarkable is the fact that some orthodox physicians strongly disagreed with some of his favourable comments and that the ensuing debate apparently led to the closure of the British and Foreign Medical Review. A p r o m i n e n t G e r m a n o p p o n e n t of h o m o e o p a t h y was T h e o d o r Jtirgensen (1840-1907). He too extended the attack from the 'like cures like' principle to other axioms of homoeopathy. Jtirgensen stated, 'The law that all diseases are of dynamic origin ... and their origins cannot be recognised through our senses .. divides Hahnemann ... from our science ...'. He summed up his judgements of h o m o e o p a t h y by stating that ' e i t h e r Hahnemann is right, in which case our science and the basis of our thinking is nonsense, or he is wrong, in which case this teaching is nonsense. There is no third option', l~ The essence of the accepted view at the end of the 19th century is aptly summarised by the concluding paragraph of the 1891 entry on homoeopathy in the Encyclopaedia Britannica: 'Hahnemann's errors were great. His doctrine of specifics was highly retrograde and unscientific, and his disparagement of the principle of tolle causam and of those who aimed at discovering the causes of disease
was unphilosophical. He was fanciful and theoretical to a very high degree. He led his followers far out of the track of sound views of disease and the methods by which it can best be prevented and cured. But, with all his defects, it must be admitted that he had the great merit of disturbing and discrediting indefensible modes of practice'. H This latter point is of particular interest: even today critics of homoeopathy credit Hahnemann with his contribution in bringing about a decline in the overtly harmful orthodox treatments so abundant during his time.
Criticism within homoeopathy H a h n e m a n n was a charismatic man; his f o l l o w e r s c a l l e d him ' t h e M e s s i a h of Medicine'. II He was also uncompromising and intolerant, and considered homoeopathy to be the 'only law consonant to nature' and maintained that 'cures never were effected by any other means than by means of medicine of h o m o e o p a t h i c power'.~2 The slightest departure from his teaching earned the severest c o n d e m n a t i o n s : ' H e who does not walk exactly on the same line with me is an apostate and a traitor'. Such attitudes rendered homoeopathic 'in-house fighting' virtually inevitable. Many homoeopaths disagreed with Hahnemann's ultra high potencies. Some also thought that the doctrine to always use only one remedy at a time was inadequate. Others wanted to c o m b i n e m a i n s t r e a m and h o m o e o p a t h i c remedies which, according to their master, was forbidden, and most homoeopaths never adopted Hahnemann's third axiom stating that the cause of all diseases is the 'itch' or 'psora'. Thus, homoeopathy soon became divided into different schools of thought and practice. In 1837, Paul Wolf, a German homoeopath of high reputation, published his 18 theses which are the first documented homoeopathic departure both f r o m high potencies and Hahnemann's psora theory. He also demanded that all homoeopaths should have essential medical knowledge in anatomy, physiology and pathologyl3--a notion that has not lost its relevance to the present day. In 1877, the vice president of the British Homoeopathic Society wrote in the Lancet: '... the views expressed by Hahnemann are often extravagant and incorrect ... Hippocrates was right when
30 he said that some diseases are best treated by similars and some by contraries ... although many believe that the action of the infinitesimal in nature can be demonstrated, its use in medicine is practically by a large number in this country all but abandoned'. 14 The decline of homoeopathy was brought about, at least in part, by such intra-homoeopathic disagreements. At the end of the 19th century it had 'no scientific recognition' and was 'universally condemned'." Homoeopaths had relaxed their adherence to Hahnemann's dictum more and more and the number of practitioners or institutions was rapidly dwindling. 2 The final decline took place in the second decade of the 20th century after Kentian ideas arrived and scientific medicine was rejected by the homoeopathic community.
Early 20th century In most countries, this decline gradually continued until homoeopathy's most recent r e v i v a l (see below). The e x c e p t i o n was Germany. Utterly unexpected support for homoeopathy came from the country's leading surgeon, August Bier. In an article in the then widely read journal Miinchner Medizinische Wochenschrift, he urged his colleagues in 1925 to reconsider homoeopathy which, in his view, had a lot to offer after all. ~5 This caused an outrage of untold proportions with polemic, and emotional personal attacks and counter-attacks) 6 The debate was essentially based on the well-rehearsed argument that high dilutions cannot possibly work and anyone who thinks otherwise is obviously deluded. Indirectly, it led to the systematic investigation of h o m o e o p a t h y during the Third Reich, which apparently (according to a report of one eyewitness) had only negative results. 17 Eventually, the Nazi officials withdrew their support and the interest in h o m o e o p a t h y decreased also in Germany?8
Present criticism In parallel with the present popularity of c o m p l e m e n t a r y medicine in general and homoeopathy in particular,19 'the opposition' has reformed and is again raising its voice. T o d a y ' s arguments against h o m o e o p a t h y have become focused on several recurring themes, some old some n e w . 20 The most elementary one is that homoeopathic remedies are physically, chemically and in
Volume 87, January 1998
any other way indistinguishable from pure diluents. The intensity of this debate was highlighted by the ' B e n v e n i s t e a f f a i r e ' . Benveniste and his group had apparently shown that ultra-high dilutions can have biological activity. 21 Subsequently, a team of 'quack busters' visited Benveniste's laboratory and concluded that his experiments were flawed. 22 Later, a group of independent scientists was unable to replicate Benveniste's results. 23 The logical next step for opponents, it would seem, is to question the clinical efficacy/ effectiveness of homoeopathy. This clearly is the central feature of t o d a y ' s arguments against homoeopathy. Narrative or systematic reviews and meta-analyses of controlled clinical trials conclude that there is evidence to suggest that the effects of homoeopathic treatments are more than a placebo response, but methodological shortcomings invariably prevent definitive conclusions. 24-28Thus critics continue to reject the notion that homoeopathy is of proven efficacy. 29, 30 The problem, they say, is that there is no plausible mechanism of action and therefore homoeopathy cannot possibly work. In addition to these recurring themes, new ones have emerged. Some critics have questioned the notion that h o m o e o p a t h y is inherently and entirely risk-free. Reports of (perceived) adverse reactions to homoeopathic remedies do exist. 31, 32 Furthermore, there are indirect risks, for example the opposition of some (by no means all) h o m o e o p a t h s to immunisation33--and even if homoeopathic remedies are entirely safe, not all homoeopaths are in all circumstances. Others argue that homoeopathy is an outdated dogma based on principles that are unsustainable in the light of scientific discoveries made since Hahnemann's time. 34, 35 They agree that Hahnemann was right to attack the risky treatments of his time, but argue that today science has moved on and there is no longer a place for homoeopathy. Others say that homoeopathy as a unified school of thought does simply not exist, there are 'as many homoeopathies are there are homoeopaths'. 34 Others again attempt to demonstrate that Hahnemann's initial self-experiment which formed the basis of the 'like cure like' principle was flawed. 35 Finally opponents are keen to point out that homoeopathy has all the qualities
British Homoeopathic Journal
o f a sect and a cult; ' t h e m a r k e t i n g o f homoeopathic products and services fits the definition of quackery' .36 W h e n G e r m a n m e d i c a l schools were recently forced to include some basic elements of homoeopathy in their curriculum, a group of professors refused to comply, calling homoeopathy 'a media-hyped superstition' [cited in ref. 37]. A German pharmacologist s u b s e q u e n t l y p u b l i s h e d his L e c t u r e s on Homoeopathy which sums up the 'state of the art' of criticism of homoeopathy and (in my view) represents one of the best argued cases against homoeopathy during recent years. 37 Perhaps not surprisingly, in view of this continuous debate, the attitudes towards homoeopathy differ vastly. At least one country has taken the drastic step of the outright banning of homoeopathic remedies. 38 In the US and Europe, the regulatory authorities are more liberal and allow registration of highly diluted homoeopathic remedies without evidence of safety or efficacy.39 This attitude of benign laissezfaire is the most prevalent today and forms the ground on which the present popularity of homoeopathy can grow. As for evidence of clinical efficacy for homoeopathy, most non-homoeopaths would go along with the conclusions of systematic reviews and meta-analyses 24-28 which state unanimously that there is some evidence in favour of homoeopathy but that it is as yet inconclusive (eg40). But some critics still insist that 'no practice can be deemed effective until proved to be so; and the burden of proof is upon proponents', 36 and that 'sensational claims could be sustained only by data of exceptional quality' .22 In terms of research, most open minded physicians conclude that more and better investigations ought to be done in order to determine whether homoeopathic remedies are more than placebos [eg 3, 24-28.40]. Others s t r o n g l y hold against this strategy: 'Its [homoeopathy's] study ... would be a great waste of time and effort'. 36 They argue that, considering the expense of research and the limited resources available, one ought to focus on investigations that are promising in one way or another. Homoeopathy, they feel, is not. 29, 30 Conclusions C r i t i c i s m of h o m o e o p a t h y is as old as
31 h o m o e o p a t h y itself. Amidst the heat and polemic of the attacks and counter-attacks, much of what is being expressed makes sense. S o m e of the well a r g u e d cases a g a i n s t h o m o e o p a t h y (eg 8, 9, 37) should b e c o m e e s s e n t i a l reading for all h o m o e o p a t h s . Homoeopathy as a science would profit from taking these arguments seriously and working constructively and systematically towards determining the truth. Acknowledgement The author wishes to thank Dr Ted Kaptchuk, Harvard Medical School, for his help and advice with this manuscript. References 1 Hahnemann S. Versuch tiber ein neues Prinzip zur Auffindung der Heilkr~ifte der Arzneisubstanzen. J Prakt Arzneykunde u Wundarzneykunst 1796; 2: 391-439. 2 Ernst E, Kaptchuk TJ. Homoeopathy revisited. Arch Intern Med 1996; 156: 2162-4. 3 Kleijnen J, Knipschild P, ter Riet G. Clinical trials of homoeopathy. BMJ 1991; 302:316-32. 4 Fasihi A. Complementary Medicine Vol L Medicinal Remedies. London: ~ Pharmaceuticals and Healthcare Publications 1996. 5 Heinroth J, Chr A. Anti-Organon. Leipzig, 1825. 6 Cited in: Giese Ch, Gellert M. Zur Geschichte der Veterin~irhom6opathie in Deutschland. Berl Miinch Tieriirztl Wschr 1995; 108: 305-12. 7 Diepholz G. Einige Bemerkungen fiber die Kritik der Zooiasis, besonders aber der gesamten Homtiopathie. Magazin fiir gesamte Thierheilkunde 1836; 8: 299. 8 Holmes OW. Homoeopathy and its kindred delusions, 1842. republished in: Stalker D, Gylmour C (eds). Examining holistic medicine. Buffalo: Prometheus Books 1985. 9 Forbes J. Homoeopathy, allopathy and 'young physic'. British and Foreign Medical Review 1846; 21: 225-65. 10 Jfirgensen Th. Die wissenschaftliche Heilkunde und ihre Widersacher. Volkmanns Sammlung Klinischer Vortriige 1876; 106: 879-916. 11 Encyclopaedia Britannica. "Homoeopathy" 1891; 12: 126-9. 12 Hahnemann S. Organon der Heilkunst. 5th Edition, Dresden: Arnold 1833. 13 Wolf P. Achtzehn Thesen ffir Freunde und Feinde der Hom6opatik. Arch homOop
32 Heilkunde 1837; 16: 1. 14 Wyld D. Homoeopathy. Lancet 1877; 2 June. 15 Bier A. Wie sollen wir uns zur HomOopathie stellen? Miinch Med Wschr 1925; 72:713-7 and 773-6. 16 Ernst E. August Bier and German homoeopathy in the early 20th century. Br Hom J 1996; 85: 49-52. 17 Donner F. Bemerkungen zu der Oberprtifung der Hom6opathie durch das Reichsgesundheitsamt 1936-1939, Perfusion 1995; 8 : 3 - 7 (part 1), 35-40 (part 2), 84-8 (part 3), 124-9 (part 4), 164--6 (part 5). 18 Ernst E. Naturheilkunde im Dritten Reich. Dtsch ]~rzteblatt 1995; 92: 800-4. 19 Ernst E. Patients' Perception of Complementary Therapies. Forsch Komptementiirmed 1995; 2: 326--9. 20 Ernst E. Hom6opathie, Argumente und Gegenargumente. Dtsch ]{rzteblatt 1997; 94: A-2340-2. 21 Devenas E, Beauvais F, Amara J, et al. Human basophil degranulation triggered by very dilute antiserum against lgE. Nature 1988; 333: 316-8. 22 Maddox J, Randi J, Stewart WW. "High dilution" experiments a delusion. Nature 1988; 333: 287-90. 23 Hirst S J, Hayes NA, Burridge J, Pearce FL, Foreman JC. Human basephil degranulation is not triggered by very dilute antiserum against human JgE. Nature 1993; 366: 525-7. 24 Ernst E. Is homoeopathy a placebo? Br J Clin Pharmacol 1990; 30: 173-4. 25 Kleijnen J, Knipschild P, ter Riet G. Clinical trials of homoeopathy. BMJ 1991; 302:316-32. 26 Homoeopathic Medicine Research Group. Overviews of data from homoeopathic medicine
Address f o r correspondence Professor E. Ernst Department of Complementary Medicine Postgraduate Medical School University o f Exeter 25 Victoria Park Road Exeter EX2 4NT e-mail [email protected]
Volume 87, January 1998 trials. Brussels: Europ. Commission, 1996. 27 Barnes J, Resch KL, Ernst E. Homoeopathyfor post-operative iteus: a meta-analysis. (in press). 28 Linde K, Clausius N, Ramirez G, Melchart D, Eitel F, Hedges LV, Jonas W. Are the clinical effects of homoeopathy placebo effects? A meta-analysis of placebo-controlled trials. Lancet 1997; 350: 834--43. 29 Vandenbrouk JP. Homoeopathy trials, going nowhere. Lancet 1997; 350: 824. 30 Langman MJS. Homoeopathy trials, reasons for good ones but are they warranted. Lancet 1997; 350: 825. 31 Ernst E. The safety of homoeopathy. Br Horn J 1995; 84: 193--4. 32 Abbot NC, White AR, Ernst E. Complementary Medicine. Nature 1996; 381: 361. 33 White AR, Ernst E. Homeopathy and immunization. BrJofGen Pract 1995; 25: 629-30. 34 Prokop O, H o p f f W. Erkl~irung zur Hom/3opathie. Dtsch Apotheker Zeitung 1992; 132: 1630ol. 35 Kr~mer H J, Habermann E, Ein Vorlesungsversuch zur Homi3opathie. Dtsch ]4rzteblatt t997; 94: 1811-2. 36 Jarvis W. Homeopathy, a position statement by the National Council Against Health Fraud. Sceptic 1994; 3: 5007. 37 Meyer FP. Vorlesungen iiber HomOopathie. Jena: G Fischer, 1996. 38 Menczel E. Outlawing homeopathy in Israel. Am J Health-Pharm 1995; 52: 2471. 39 Baker EA. European regulations covering homoeopathic medicines. Forsch Komplement~irmed 1996; 3:311. 40 Ernst E, Barnes J. The medicine that cannot work? Pharm J 1996; 257: 339.