Home Publications Conference Papers n = 1. The Case Study. How Can We Learn More From Them?
n = 1. The Case Study. How Can We Learn More From Them? PDF Print

Author’s note: This paper was presented at the Australian Homoeopathic Association Conference, Bondi Beach, 2008. The presentation included a number of slides. These are not included below.

Kevin Ryan

This paper is not an exhaustive critical study of literature reports of studies involving a single patient receiving  homoeopathic  treatment.  It  is  presented essentially in  the  defense  of  the  use  of  the  homoeopathic  case  study presentation  of  raw and processed  patient  and medicine  data  as  a  legitimate teaching and learning tool. This paper is also presented to suggest the value of a variation  of  case  study  presentation  that  can  offer  evidence  of  the  long-term effectiveness of applied principles of the homoeopathic paradigm. 

An observation  is made  that  the process of conducting a proving allows  for  the collection of data  that has  ramifications  for homoeopaths when  it  is appreciated that  each  prover  is  an  n=1  case.  This  paper  also  reviews  the  homoeopathic proving  guidelines  that  have  been  described  in  relatively  recent  literature.  It presents  two  very  different  sets  of  outcomes  from  attempts  to  meld  the homoeopathic proving with the randomized clinical trial (RCT). It suggests that an opportunity exists for in-depth studies of the individual as they express the impact that  the  medicine  has  on  their  person.  In  the  broadest  sense  this  may  have profound effect on the materia medica.


Homoeopathic  literature abounds with case study presentations. This  is as  true for modern texts, as it is for 19th century publications. The works of J.T. Kent and H.C. Allen for example are punctuated with homoeopathic case studies. They are presented in support of homoeopathic law, particular indications for a medicine or an approach to treatment. 

Students of Homoeopathy will remember that case studies are presented  in  the classroom as a teaching and learning aid.  They are commonly used to:  
‚Äʬ† present information about a medicine
‚Äʬ† present information about posology
‚Äʬ† demonstrate¬† homoeopathic¬† philosophy¬† and/or¬† principles¬† in¬† a¬† clinical setting

They are however often presented  in  lectures, workshops and the  literature with the aim  to provide evidence of efficacy and of evidence  for  the paradigm. This use  of  case  information  is  one  reason  why  skeptics,  allopaths  and  medical science  describe  much  of  the  presented  evidence  for  Homoeopathy  as anecdotal. It is curious that if a clinical trial involving Homoeopathy is in any way flawed  through  low  cohort numbers  or  poor  selection  criteria or  any  number  of possible  faults  then  the  evidence  gained  from  that  trial may  be  added  to  the
anecdote  pile.  In  other  studies,  cries  by  homoeopaths  that  essential homoeopathic  principles  have  been  squeezed  out  of  the  RCT  protocol  are ignored or discounted. This process repeatedly dooms the results to equivocal at best.

 

This  is  not  to  criticize  the  scrutiny  of  science  but  rather  to  suggest  that research  involving  homoeopathic medicines  needs  to  be  carried  out within  the homoeopathic  model.  Homoeopathy  in  a  classical  sense  is  always  about  the
individual. This is as true for the medicine as it is for the patient.

EVIDENCE-BASED MEDICINE

An editorial  in  the British Medical Journal  (1996) offered  the  following definition, variations of which appear throughout the literature:

Evidence-based medicine is the conscientious, explicit, and judicious use  of  current  best  evidence  in making  decisions  about
the  care  of individual  patients. The  practice of evidence based medicine means
integrating individual clinical expertise with the best available external clinical  evidence from  systematic research.  By  individual  clinical expertise  we  mean  the  proficiency and  judgment  that  individual clinicians  acquire  through  clinical  experience  and clinical  practice. Increased expertise  is reflected in many ways, but especially  in more effective  and  efficient diagnosis  and  in  the  more  thoughtful identification  and  compassionate use  of  individual  patients' predicaments,  rights,  and  preferences in  making  clinical  decisions about their care.

Greenhalgh (2006) listed the hierarchy of evidence by weight in the order:  Systematic  reviews  and meta-analysis;  randomised  controlled  trials  (RCT) with definitive results; RCT with non=definitive results; cohort studies; case-controlled studies; cross-section surveys and case reports. 

A reality that cannot be ignored is that practicing homoeopaths are prescribing in a  health  care  world  where  there  is  increasing  demand  for  evidence-based medicine. They can believe  that  this means  that homoeopathic  research efforts must  be  directed  so  as  to  convince  scientific medicine  and  science  in  general that  there  is  evidence  of  efficacy  of  homoeopathic  medicine.  They  can  also believe  that  this evidence  is at  its most convincing when gathered  from double blinded  cross  over  trials  with  a  statistically  significant  cohort.  The  outcome  of
such  trials  should  ideally  demonstrate  that  a  single  homoeopathic medicine  is statistically better  than placebo for  treating a specific disease. Unfortunately  this is  not  Homoeopathy.  Homoeopaths,  as  testament  to  their  philosophy,  are primarily  concerned  with  understanding  and  treating  the  individual  in  each patient.  Medical  science  has  more  recently  made  attempts  to  investigate probably the greatest principle of homoeopathic philosophy, the proving. This has had  variable  outcomes.  Could  it  be  that  research  would  be  better  placed
gathering  and  presenting  data  from  well-conducted  provings  within  the homoeopathic model? There  is support  in  the  literature  for  the concept  that  if a health  care  provider  proceeds with  a  case using methods  that  they  have  used previously with success then they are using their own evidence-based approach.

If they rigorously apply themselves to a continuing learning process that starts in the classroom of a teaching institution and is continued in the greatest classroom of all, they will both gather and cast out. This is to be applauded.  Homoeopaths are  in a very unique position when prescribing medicines as  they are not  tied  to making a medical diagnosis of a disease and matching a drug  to  that disease.

They have an opportunity to understand the individual, apply the law of similars, prescribe  appropriately  and  wait.  They  may  then  observe  the  results  and prescribe  or  not  prescribe  accordingly.  It  is  possible  that  the  homoeopath interested in evidence-based medicine will learn more about the practice of their modality from every case they treat. If this is true then it is also possible that they can  find  evidence  in  the  cases  of  other  homoeopaths  and  learn  from  them.


Greenhalgh makes¬† the¬† comment¬† that while¬† case¬† reporting¬† is¬† considered¬† to¬† be weak scientific evidence ‚Äúa great deal of¬† information can be conveyed¬† in a case report¬† that would¬† be¬† lost¬† in¬† a¬† clinical¬† trial¬† or¬† survey.‚ÄĚ She¬† draws¬† parallels with story¬† telling¬† and¬† goes¬† on¬† to¬† state¬† ‚ÄúFurthermore¬† stories¬† are¬† highly¬† memorable (indeed¬† in most medical schools¬† they are¬† the unit of¬† teaching and¬† learning), but
we should not confuse the memorability of a clinical story with its contribution to research.‚ÄĚ

A CASE STUDY IN TWO PARTS

A previously  immunized six-year-old girl attended  in  the winter of 1986 with her mother  for  homoeopathic  treatment  for  a  condition  of  asthma  induced  by pertussis  infection.  The  onset  of  the  infection  occurred  ten weeks  earlier.  She presented with an explosive cough in paroxysms leading to a drawn out crowing inspiration  followed  by  vomiting.  This  was  complicated  by  a  consequent asthmatic  wheeze  that  required  medical  intervention  with  bronchodilator  and steroid pharmaceuticals. She was not  improving. The whooping  cough had not
resolved. The asthma was increasing in frequency and severity. Her medical and homoeopathic history was as below.

Prior to becoming ill
‚Äʬ† Chilly patient and sensitive to draft
‚Äʬ† Offensive perspiration
‚Äʬ† Apprehensive anxiety +++
‚Äʬ† Determined or Obstinate or Stubborn
‚Äʬ† Costive with loose bowels from anxiety


Acute presentation of Whooping cough with asthma
‚Äʬ† 1986 whooping cough induced asthma
‚Äʬ† Characteristic cough
‚Äʬ† Drenching night sweats
‚Äʬ† Great fatigue in the evening
‚Äʬ† Jerking falling asleep
‚Äʬ† Evening chill after paroxysm of cough
‚Äʬ† < exposure to cold, exertion
‚Äʬ† > covering up


Homoeopathic posology
‚Äʬ† Tuberculinum M qid ‚Ķ‚Ķ
‚Äʬ† Reducing frequency of doses
‚Äʬ† Cough resolved and asthma relieved
‚Äʬ† Silicea 200 qid until reaction established
‚Äʬ† Infrequent dosing according to reaction
‚Äʬ† Asthma resolved¬†¬†

Acute presentation of chicken pox
1987 presented with chicken pox with cough. 
The asthma was still absent. 

Homoeopathic posology
‚Äʬ† Silicea 200c tds until reaction established. Three doses.

THE CASE STUDY IN HEALTH CARE LITERATURE


Is the case study with its cohort of one, a serious deficiency or an important and useful  tool  in  primary  and  continuing  education  in  homoeopathic  theory  and practice?  Is  there  any  reliable  evidence  or  proof  of  efficacy  that  can  be  drawn from such presentations?

While¬† the¬† literature¬† debates¬† the¬† usefulness¬† of¬† the¬† single¬† case¬† study,¬† many ‚Äėmedical‚Äô¬† journals¬† provide¬† for¬† and¬† encourage¬† their¬† publication.¬† Examples presented are¬† the online version of¬† the Medical Journal of Australia,¬† the Journal of¬† the American Medical Association,¬† the online Australian¬† journal, Chiropractic and Osteopathy and the Journal of Evidence-Based Integrative Medicine.

Case  study  presentations  found  in  these  and  other  journals  of  medicine  and alternative health care have common  features. They have a  function  to provide for the continuing education of the profession that the journal services. The case studies clearly support  the health care paradigm of the parent profession and  to promote  learning.  The  paradigm  that  is  supported  by  the  eMJA,  JAMA is essentially the medical model. The Chiropractic and Osteopathy and the Journal of Evidence-Based  Integrative Medicine directly address  the perceived  thrust of
the  professions  that  they  represent.  Each  journal  publishes  instructions  to authors. The eMJA separates  the case studies  into notable cases,  lessons from practice and diagnostic dilemmas. They  require  referencing and are given 1000 word  limits;  pictures  are  encouraged where  appropriate.  JAMA instruction  their authors  to separate  the studies  into Brief Reports. These manuscripts are short
reports  of  original  studies  or  evaluations  or  unique,  first-time  reports  of  clinical case series. 

Commentary.  These  papers  may  address  virtually  any  important  topic  in medicine,  public  health,  research,  ethics,  health  policy,  or  health  law  and generally  are  not  linked  to  a  specific  article.  Commentaries  should  be  well focused,  scholarly,  and  clearly  presented  and  should  have  no  more  than  2 authors.

Chiropractic  and  Osteopathy
offers  the  following  instructions  to  authors submitting  case  studies.  Note  that  these  instructions  draw  the  line  where  it  is thought that the case narrative is out of its depth:

‚ÄĚCase¬† reports:¬† reports¬† of¬† clinical¬† cases¬† that¬† can¬† be¬† educational, describe a diagnostic or therapeutic dilemma, suggest an association,
or present an  important adverse  reaction.  It  is  important  to note  that case reports highlighting preventive or therapeutic intervention will, as
a¬† rule,¬† not¬† be¬† published,¬† because¬† establishing¬† the¬† clinical merits¬† of either requires stronger evidence.‚ÄĚ


Evidence-Based  Integrative Medicine is  an  international,  peer-reviewed  journal that  focuses on an evidence basis  for  integrating  complementary or alternative health care practices with conventional medical approaches,  to  form a wellness model of health care. Case study presentation is encouraged.

Instructions¬† to authors¬† suggest¬† that¬† areas¬† of¬† interest¬† include¬† ‚Äúconsiderations¬† in utilising different forms of evidence for improved decision-making (eg randomised clinical¬† trials; non-randomised studies; empiric evidence, clinical experience and case studies)‚ÄĚ.

The way¬† in¬† which¬† topics may¬† be¬† addressed¬† includes¬† through¬† ‚Äúcase¬† studies¬† of developing,¬† implementing, monitoring and assessing evidence-based¬† integrative models of health care‚ÄĚ.


N = 1 THE PROVER AS A CASE STUDY


Homoeopathy in a classical sense is all about the number one. From rules such as  one  medicine  at  a  time  to  finding  the  one  medicine  that  matches  the symptoms of the individual patient.  The homoeopathic proving protocol appears on  first  inspection  to  be  a  group  of  healthy  people  taking  an  unknown homoeopathic medicine  in order  to  reach consensus about what symptoms  the medicine will  treat  in  an  unhealthy  patient. However  again  the  situation  is  that each prover is an individual and their experience of the effects of the medicine is a rich and somewhat untapped source of information. 

The student and professional homoeopath  rely on  the accuracy and usefulness of the materia medica and repertory data. It is the interests of every homoeopath that new provings of either current or new medicines are conducted according to guidelines  that provide  for  reproducibility.   Authors  such as O.A.  Julian  (1979), Sherr (1994), Riley (1997) and Wieland (1997) have written on the subject. David Riley made  a  simple  point  of  observation  in  the British Homoeopathic  Journal:

‚ÄúThere has been a¬† lack of consistency¬† in¬† the way symptoms are extracted¬† from homoeopathic provings‚ÄĚ. He suggested recommendations¬† for a proving protocol in¬† order¬† to¬† improve¬† consistency.¬† Wieland¬† in¬† the¬† same¬† edition¬† of¬† the¬† BHJ presented¬† a¬† paper¬† titled¬† ‚ÄėGood¬† homoeopathic¬† provings:¬† ‚ÄúThe¬† need¬† for¬† GHP guidelines.¬† A¬† brief¬† survey¬† of¬† recent¬† developments¬† in¬† methodology¬† of homoeopathic drug provings in Europe‚ÄĚ. This proposed ‚Äúa minimum standard for homoeopathic drug proving protocols ‚Ķ..¬† that¬† takes account of¬† the substantially
different approaches of clinical trials and homoeopathic drug provings.‚ÄĚ


The homoeopathic proving is an essential element of the homoeopathic process. Without  it  there  would  be  no  detailed  data  on  which  to  base  either  an understanding of  the case or selection of  the similium. The Therapeutic Goods Administration  allows  traditional  evidence  of  use  of  a  therapeutic  substance  to support a therapeutic claim if there is clear evidence of at least three generations of  use.  In  the  case  of  homoeopathic medicines  or  homoeopathically  prepared substances  it  is not each substance  that must have  the appropriate evidence of
time of use but rather it is those processes that make a medicine homoeopathic that has been  recognized by  the TGA. These are  the  traditions of manufacture through  serial  dilution  and  of  the  process  of  proving  the  substance  in  diluted form. This means that any new substance can be presented as a homoeopathic medicine  providing  it  has  been  prepared  using  the  appropriate  homoeopathic method  and  has  been  evaluated  through  a  well  conducted  homoeopathic proving. This is a remarkable situation ensuring that in Australia at least, classical
Homoeopathy  did  not  go  into  regulated  suspended  animation  from  the  1960’s.
The TGA  also  recognizes  the work  that  the profession  has  done  to  clarify  and systematize  the  proving  process.  In  2001  it  acknowledged  the  guideline monograph published by the European Council for Classical Homoeopathy in this area. This document has been under  review  for some  time and  is not currently available  online.  The  delay may  be  due  to  continuing  considerations  of  safety and legal responsibility issues involving the participants in a proving.

The homoeopathic proving¬† ideally would consist of a¬† large cohort with perhaps n=50+. There would be multiple participant experience of each symptom. There would¬† be¬† statistically¬† relevant¬† data¬† eg:¬† 12¬† experiencing¬† ‚Äė1000¬† little¬† hammers knocking¬† on¬† the¬† brain‚Äô,¬† 15 with¬† consistent mental¬† symptoms¬† and¬† a¬† useful¬† time line of symptom development.¬† However the homoeopathic proving in a practical sense produces a smattering of symptoms expressed¬† in¬† idiosyncratic¬† language by¬† the majority of¬† the cohort. On some occasions a small number of¬† ‚Äėsensitives‚Äô may¬† present¬† detailed¬† patterns¬† of¬† symptoms¬† that¬† turn¬† out¬† to¬† be¬† clinically significant. Each participant however represents an example of n=1 data. Within
the proving process the healthy subject expresses symptoms that are considered to  be  as  a  direct  result  of  the  medicine.  Each  participant  is  important  as  an individual  expression  of  the  symptoms  that  the medicine may  treat  in  the  sick.
Hahnemann’s  guidelines  included  that  the  participant  should  be  healthy.  This stipulation was enough for him to regard all symptoms expressed after ingestion of the medicine to be due to that substance.  
Julian (1979) had the following to say about this requirement. 

“In  support  of  Hahnemann  it  must  be  admitted  that  to  distinguish between  the  symptoms  caused  by  such  a  substance  and  those  not
caused  by  it,  but  appearing  after  ingestion  of  the  substance,  is impossible. To state that certain symptoms are the fruit of the prover’s
imagination  is  no  answer,  since  the  substance  may  be  working through his imagination. To state that it is the effect of idiosyncrasy is
also  no  answer,  since  who  of  us  does  not  have  some  physical or mental  idiosyncrasy?  Medicines  are  continually  being  used  to  treat
persons with¬† idiosyncrasies,¬† and¬† in¬† Homoeopathy¬† the¬† symptoms¬† of the individual‚Äôs idiosyncrasy are precisely the most useful ones.‚ÄĚ

To  the  scientist  a  proving  can  look  like  a  great  place  to  prove  or  disprove  the basis  of  homoeopathic  medicine.  There  is  a  cohort  selected  according  to established criteria. There are measurable outcomes albeit made difficult by  the uniqueness  of  the  endeavor  and  the  sheer  quantity  of  data.  There  is  the opportunity to use placebo control and to perform cross over in the trial. Blinding is easily applied to the process. One of the problems encountered however is  in the analysis of results. It is hardly likely that a blinded clinical trial with crossover would  not  be  the  subject  of  statistical  analysis.  For  example  examining  the number of provers who expressed the same or similar symptoms and performing
mathematical slight of hand  to demonstrate believability  in  large part misses  the point of the prover’s individual expression of the medicine.

A clinical  trial approach can produce some strange  interpretations. For example Möllingera and colleagues  (2004)  in a double-blind,  randomized, homoeopathic pathogenetic  pilot  study  with  healthy  persons,  compared  two  high  potency Calendula officinalis and Ferrum muriaticum preparations. 

The main Outcome Measure was¬† the¬† total number of¬† symptoms produced and number of specific symptoms produced. The authors made the following curious statement: ‚ÄúThe results showed that both remedies¬† ‚Äėproduced‚Äô significantly more symptoms¬† than placebo. With¬† regard¬† to¬† the specificity,¬† the Calendula officinalis group displayed more remedy-specific symptoms¬† than placebo. However,¬† in¬† the Ferrum¬† muriaticum¬† group¬† more¬† Calendula¬† symptoms¬† than¬† placebo¬† were¬† also recorded.‚Ä̬†

Perhaps more¬† worrying¬† than¬† this¬† were¬† the¬† conclusions¬† drawn¬† by¬† Vickers¬† and colleagues (2001) in their paper¬† ‚ÄúCan Homeopathically Prepared Mercury Cause Symptoms¬† in¬† Healthy¬† Volunteers?¬† This¬† randomized,¬† double-blind¬† placebo-controlled¬† ‚Ķ¬† ‚Äúpilot¬† study¬† failed¬† to¬† find¬† evidence¬† that¬† Mercury¬† 12C¬† causes significantly more symptoms in healthy volunteers than placebo... If drug-proving phenomena exist, they appear to be rare.‚ÄĚ
Julian in a chapter on the Provings of Homoeopathic Medicines describes the re-proving  of  Belladonna  in  the  early  twentieth  century  by  Howard  Bellows, Professor  of  Otology  Boston  University  School  of  Medicine.  Fifty  provers accurately  reproduced  the  symptomatology  of  Belladonna  as  described  in previous century texts. This proving was blind to the provers and the interviewing homoeopaths.  It  seems  that Hahnemann  and  others  have  been  able  to  prove homoeopathic medicines without the need for RCT protocols and statistics.


THE CASE IN QUESTION PART 2

20 years later in the autumn of this year the ‚Äėcured‚Äô case of asthma re-presented with mild¬† wheeze¬† from¬† two¬† ‚Äėflu‚Äô¬† like¬† viral¬† infections,¬† three months¬† apart¬† in¬† the previous winter and¬† spring. She exhibited episodic heaviness of breathing with mild wheeze that was triggered by exertion and exposure to cold air. She had no homoeopathic care during the intervening years. Her health was maintained with only¬† the¬† occasional¬† head¬† cold¬† of¬† short¬† duration.¬† Menarche¬† at¬† age¬† 12. Menstruation regular and normal. No acne at puberty. Anxiety¬† levels have been consistently¬† low. A¬† classical¬† approach¬† to¬† the¬† new¬† data¬† revealed¬† that¬† the¬† same two medicines that were used 22 years earlier had a role to play in the patient‚Äôs
care. 

Homoeopathic posology

‚Äʬ† Silicea 200 qid until reaction established (1 day)
‚Äʬ† Single dose repeated after 4 weeks with no effect¬†¬†
‚Äʬ† Tuberculinum 1M 1 dose¬†
‚Äʬ† Heaviness and wheeze relieved for 2w
‚Äʬ† Silicea 200 1 dose¬†
‚Äʬ† Heaviness and wheeze relieved
‚Äʬ† Infrequent dosing (2 doses of Silicea 200 after the Tuberculinum)
‚Äʬ† Case resolved 11 weeks

This follow-up case after 20 years without homoeopathic intervention represents a  variation  of  case  study  presentation. As  a  retrospective  study  it  offers  some evidence of the long-term effectiveness of applied principles of the homoeopathic paradigm. Homoeopathic philosophy suggests  that a  lengthy period of wellness should follow  the  judicious use of homoeopathic medicine. As a continuing case it suggests  that  improved wellbeing, equated with  the notion of  increased vitality indicates  a  posology  that  takes  into  account  increased  sensitivity  to  the
homoeopathic medicine.

IN SUMMARY

‚Äʬ† n=1¬† in¬† a Homoeopathy¬† teaching¬† sense¬† is¬† useful¬† if we¬† are¬† preaching¬† to¬† the converted. The paradigm itself is a giant leap of faith for the non-homoeopath reader.¬† This¬† means¬† that¬† simple¬† case¬† study¬† presentations¬† are¬† primarily¬† for homoeopaths and students of Homoeopathy to learn from.
‚Äʬ† The homoeopathic proving may be a rich source of n=1 evidence primarily for ourselves. This has not been adequately utilized in the literature.¬†
‚Äʬ† n=1¬† revisited¬† in a¬† ‚Äė7 up‚Äô manner can be used¬† to offer evidence of¬† long¬† term efficacy of either a medicine or of parts of the paradigm itself. This experience enables the homoeopath to discover more about both the evolutionary nature of¬† disease within¬† the human¬† condition and¬† the¬† concept of¬† the¬† constitutional type. Homoeopaths have an opportunity to learn more than just the similimum from cases where many years have elapsed between doses. n still equals 1 but the power of the experience has increased many fold.


References

Allen, HC 1982, The Materia medica of the Nosodes with Provings of the X-Ray. Jain Publishing Company. New Delhi. Pp. 502-529 ‚ÄėTuberculinum.‚Äô
Chiropractic and Osteopathy from http://www.chiroandosteo.com/info

Editorial: 1996, ‚ÄėEvidence based medicine: what it is and what it isn't.‚Äô British Medical Journal, vol. 312, pp. 71-72.

eMedical Journal of Australia. Instructions to authors. http://www.mja.com.au/

Evidence-Based Integrative Medicine. Instructions to authors http://pt.wkhealth.com/pt/re/eim/authors

European Council for Classical Homoeopathy Guidelines for Good Homeopathic Provings. http://www.homoeopati.dk/artikler/ECCH.pdf

Greenhalgh, T 2006, ‚ÄėHow to read a paper ‚Äď the basics of evidence-based medicine.‚Äô Third edition. Blackwell Publishing.

Julian, OA 1979, Materia Medica of New Homoeopathic Remedies. Beaconsfield Publishers, England.

Journal of the American Medical Association http://www.jama.ama-assn.org/

Kent, JT 1970, Lectures on Homoeopathic Materia Medica. Roysingh & Company, Calcutta, pp. 949-956. ‚ÄėTuberculinum‚Äô.

Matur, KN 1972, Systematic Materia Medica of Homoeopathic Remedies. B.Jain Publishing Company. Pp. 998-1006 ‚ÄėTuberculinum‚Äô.

M√∂llinger, H Schneider, R L√∂ffel, M & Walach, H 2004 ‚ÄėA Double-Blind, Randomized, Homeopathic Pathogenetic Trial with Healthy Persons:
Comparing Two High Potencies’. Forsch Komplementärmed Klass Naturheilkd, vol. 11, pp. 274-280. Abstract.

Riley, DS 1997, ‚ÄėExtracting symptoms from homoeopathic drug provings‚Äô, British Homoeopathic Journal, volume 86, issue 4, pp. 225-228.

Sherr, J 1994, The Dynamics and Methodology of Homeopathic Provings. West Malvern: Dynamis Books, England.

Therapeutic Goods Administration. ‚ÄėGuidelines for levels and kinds of evidence to support indications and claims.‚Äô Available from http://www.tga.gov.au/

Vickers, AJ Van Haselen, R Heger, M 2001, ‚ÄėCan Homeopathically Prepared Mercury Cause Symptoms in Healthy Volunteers? A Randomized, Double-Blind Placebo-Controlled Trial‚Äô, The Journal of Alternative and Complementary Medicine, vol. 7, no. 2, pp. 141-148.

Wieland, F 1997, ‚ÄėGood homoeopathic provings: The need for GHP guidelines. A brief survey of recent developments in methodology of homoeopathic drug provings in Europe‚Äô, British Homoeopathic Journal, vol. 86, issue 4, pp. 229-234.

 
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