Cost effectiveness analysis of a randomised trial of acupuncture for chronic headache in primary care
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.38033.896505.EB (Published 25 March 2004) Cite this as: BMJ 2004;328:747
All rapid responses
Sir
The authors state that "total costs during the one year period of the
study were on average higher for the acupuncture group than for controls
because of the acupuncture practitioners' costs".
Surely this cannot be the case - most migraine sufferers I treat,
invariably of chronic protracted kind, will have seen GP and Specialist
before 'trying acupuncture' and I cannot see my costs measuring anywhere
near as high as the costs incurred by the NHS for those patients through
the previous months (perhaps years) of unsuccessful NHS interventions.
Invariably my patients will have spent months under GP treatment -
beginning (after blood and urine tests) with analgesics, then trying
NSAIDS, then prophylactics, probably at some stage receiving 'imigran for
rapid relief', until referral to a Consultant is realised through whom
the NHS funds MRI or CT scan, then another period of drug regimes until
(often several years after initial NHS visit) the patient presents for
acupuncture.
True NHS costs (of which every taxpayer should be aware, of a system
said to be 'free at the point of delivery') are massively above anything
my patients would expect to pay (often in total less than £200) to produce
lasting benefits - for which scan costs alone would heavily outweigh.
I am mindful of the very recent German Study "Measuring the effects
of acupuncture and homeopathy in general practice: An uncontrolled
prospective documentation approach" BMC Public Health 2004, 4:6 4th March
2004 (http://www.biomedcentral.com/1471-2458/4/6)which states...
"The costs of the alternative treatments offered within the test
phase are clearcut: Neither homeopaths nor acupuncturists employ fancy
technical products. They do not order large number of diagnostics, and the
number of sessions taken to achieve the results are modest: On average, 10
acupuncture and 2 to 3 homeopathy sessions were necessary to achieve the
effects with stability over 4 years, which translates to a rough estimate
of *300 per patient, with no hidden costs for expensive drugs. To treat a
migraine patient suffering 2 attacks per month over the course of one
year, using an effective triptane would cost at least the same in one
year, taking only the drug costs into account and without including the
cost of visits to the doctor and costs of diagnostics.."
Did the authors factor in these relatively expensive diagnostics,
drugs and Consultant sessions before deciding that acupuncture is more
expensive than medical intervention?
Regards
John H.
Competing interests:
None declared
Competing interests: No competing interests
Sir
I take Paulo's first paragraph as read.
For the remainder of his response I would refer him to
http://www.mac-tcm.demon.co.uk/background.htm
"Traditional Chinese Medicine - Beyond Reasonable Doubt"
to add flavour to counter his assertions....
Paulo's assertions remind me of those of scientists who appear to see
science as some kind of religion - and fail to acknowledge that unlike
true religions, scientific 'reality' is constantly changing as old beliefs
become obsolete through new discoveries.
TCM however, having stood the test of time, has hardly changed it's
basic tenets for thousands of years. The 5 Element formula has remained
the same for centuries - practitioners recognise its truths daily in TCMs
proportion of those 60% (US) and (40%) Europe patients who seek out these
long-standing interventions.
Vickers et al are not making new discoveries, as may be seen with the
pharmaceutical giants, they are merely rediscovering what TCM and its
practitioners already know; that TCM modalities work and are extremely
cost effective as compared to the thousands of pounds a single NHS patient
requires to be spent through the attention of one or more GPs, one or more
specialists, very expensive diagnostics, and a variety of expensive drugs
(the latter categories appear to have been overlooked by Vickers et al in
cost analyses) that are invariably ineffective for most migraine sufferers
hence their choice of TCM and other interventions.
Chinese surgeon Hwa To was performing surgical procedures two
millennia ago - I am sure he and his colleagues would have developed a
sense for anatomy and physiology during their term; one wonders what our
ancestors were doing then, or even two centuries ago?
Western microbiologists and neurologists seem lothe to, or are blind
due to limitations in their remit to, research meridians and their
activities. They are easily located as are acupoints through simple skin
impedance testing. Chinese scientists have identified numerous properties
of meridians and acupoints, and discovered neuromastocytic junctions
several decades ago that are believed to be a focus of certain known
meridian characteristic functions. I wonder if Paulo knows of any
neurologists or microbiologists who know of or can can explain what
neuromastocytic junctions are and what fucntions they perform?
I do not think Paulo's description 'Alcoholic extracts from field
flowers' accurately reflects Bach Flower Remedies - perhaps a Bach
practitioner can expand? The reference 'Placebos of Bach by english
physician' suggests a subjective reporter - could this be a 'Quackpot'
reference?
I am always surprised when physicians poor scorn and criticism on the
relatively harmless, well documented and researched, medicines and their
practitioners like TCM yet fail to convey the same zeal in demanding
greater scientific exploration of their own medicines and medics which are
said to be killing and maiming more people worldwide than anything other
than cancer and heart disease and have such an atrocious evidence base? A
little more even-handedness would improve arguments against alternatives,
without which I am sure the public suspects that criticism of alternatives
by physicians owes more to
protecting self-interests (Brazilians enjoy a high level of homeopathic
intervention I believe) than public interest.
As for 'forsaking the scientific escalade of the last 200 years'
being disasterous, I think the hundreds of millions of people who have
died, and continue to die, through modern medical science alone might have
chosen a better way to 'escalade' science than allow financial, political
and other vested interests to take complete contriol over what medical
science is, what it does, and who does it.
If physicians could do one thing to improve the lot of potential patients
it would be to remove control of 'scientific medical thought and
promotion' from vested interests and return control to where it belongs -
to the people. After all, it's their money that funds everything.
Regards
John H
John H.
Competing interests:
TCM specialist in acupuncture & moxibustion
Competing interests: No competing interests
The U.S.A headquarters the Quackwatch organization, the FDA
(established in 1937) and the AMA (founded in 1847). Americans landed on
the Moon in 1969 and this year (2004) they have two robots on Martian soil
sending real-time pictures. The USA is a great country and Americans are a
wonderful people, sciencewise.
However, if one wishes to analyze an assertion about a therapeutic
method, an essential question to ponder upon is: how has a certain
conclusion been reached? This is why a scientific paper describes the
materials and methods used in the experiment, so that others may judge
whether its conclusions are plausible and reproducible. Thus, when one
evaluates the possibility that a "traditional" therapy may work, one must
investigate how its ancient proponents have reached the conclusions
grounding the method. Through which methodology has one concluded that
liverwort (Hepatophyta sp) leaves would be suitable for treating liver
pathologies? [1] Why have alcoholic extracts from field flowers been used
as remedies? [2] Or, in this particular case, how has one concluded which
points, located on fictitious meridians, might be used for needle-
piercing, in order to treat heart or liver ailments? So how have these
maps been established? Barring sheer divination, there has never been a
reason as to why these needles might be able to cure heart, liver or lung
diseases. Tradition and faith oppose science and rationality.
At this point we can see that these maps had no consistent basis,
because their creators were totally ignorant in anatomy and physiology and
lacked elementary notions of pharmacology, microbiology and neurology.
However, acupuncture proponents claim it is suitable for treating all
kinds of diseases unknown to its creators. People who have abandoned
scientific method and medicine grounded on basic sciences, and have
adopted esoteric practices, never care about this lack of fundament. But
those who follow responsible medicine and question whether a method is
really doing any good to the patient, who trust scientific medicine those
people do worry about this. Those who have forsaken the scientific
principles learned in medical schools do not care about the lack of
coherence between their practice and the scientific knowledge they have
acquired. Even though they do not practice medicine, but Chinese folklore
(a fundamentalist tradition), they want to be called doctors outside of
traditional China. Nobody wants more be called healer or priest. (Who
treat the soul, seven bodies, Astral Bodies, seven chakras). It would be
disastrous to forsake the scientific escalade of the last 200 years, which
has provoked such a complete and irreversible rupture in therapies based
on the "tradition of occidental knowledge" [3], that one has abandoned any
treatment lacking a physiopathological, pharmacological or genetic basis.
It would disastrous to abandon such a tradition and start "guessing" at
extraordinary things that oppose all present knowledge. The medical
knowledge is used in the ambulatorial attendance, in the room of surgery,
in the emergency care, on the ICT or on a manned space capsule. This slow
and solid ascension has given medicine so much credibility that even
people totally unrelated to it wants to be called doctors. It is not
reasonable to revive the "Traditional Medicine of the Middle Age" espoused
by Gallenus or Paracelsus.
Such is the difference between modern medicine and therapies claimed
to be "alternatives" to worldwide scientific knowledge. An alternative
path leads to the same place. An alternative treatment may be considered
as such only if it leads to the same results, and this must be based on
evidence and not only on claims. If it does, then it will enjoy the same
status of scientific medicine, the only one deserving this adjective after
the evolution last two centuries.
Why should we forsake knowledge based on modern science and attempt
to fly to Mars a Chinese kite instead of a modern robot? By the same
token, there is no sense in trying to “develop our understanding of these
forms of medicine (?)”, which have an esoteric fundamentalist base
(Taoism) and totally outdated principles related to the "five elements"
(metal, wood, earth, water and fire). We would be ignoring present
knowledge to adopt a mere prescription book. A physician is no vaudeville
artist who decides to practice "these forms of medicine which are
attracting large numbers of their patients (60% in the USA and over 40% in
Europe)". The history of medicine is overloaded with fads and inconsistent
therapies that have sold a lot, but have not helped patients, even though
many of them satisfy their users, as in the aforementioned case of
bloodletting, a therapy that attracts many patients in present India.
[1] The old doctrine of signatures.
[2] The placebos of Dr. Edward Bach (1886 - 1936), english physician.
[3] The Clinical Effect of Bloodletting Therapy in the Treatment of
Herpes Zoster, Issue 52, Treatment of Acute Sore Throat With Bloodletting,
Therapy Issue 68, The Journal of Chinese Medicine :
http://www.eastlandpress.com/Journal/journal.htm
Competing interests:
None declared
Competing interests: No competing interests
Sir
Cobie Brinkman makes some rather naive comments thus I suspect comes
from a 'medical' acupuncture oriented background therefore is not
'traditionally equipped' to understand 'acupuncture' usage.
There is no 'theory of acupuncture', acupuncture is merely the
technique of sticking needles into acupoints - part of a modality that
necessarily includes acupuncture & moxibustion (yin and yang
considerations in the treatment of disorders). The theory that underpins
its use is referred to as Traditional Chinese Medicine (TCM). The 'needle'
of "TCM" is analogous to the 'screwdriver of "electronics".
There is no 'acupuncture' that can be applied to meridian points for
'kidney disease' that has 'nothing to do with headaches'. Any kidney
malfunction could induce 'kidney type headaches', or headaches that are a
consequence of kidney malfunction and these would have to be ruled out for
each individual patient with a proper formal TCM diagnosis.
The naivity is not Cobie's alone, it is an inevitable naivity one
associates with 'medical acupuncture', and its practitioners, who believe
that the doctrine of TCM, which has underpinned and developed acupuncture
as a useful tool to fulfil its practices, is of little value.
This stance, to TCM practitioners, is absurd and dangerous and is
analogous to physicians tinkering with electronic circuits (TCM) using
screwdrivers (needles) to manipulate circuits whilst believing that
electronic theory is of no value. The outcome of such tinkering can be
equally devastating to patient and electronic circuit alike. When will
'medical acupuncturists' wake up to this fact and leave the manipulation
of the human body to those trained, experienced and skilled in TCM theory,
its protocols and practice?
Perhaps Cobie can tell us what 'kidney disease', according to
'acupuncture theory' excludes all possibilities of related headache?
One of the problems with certain 'studies into acupuncture' completed
by 'medical acupuncturists' is the use of sham needling - sticking needles
into bodily parts they do not associate with any effect. I can assure
Cobie that Sham points do not exist, they have never been identified,
partly for the reason given above.
However, Cobie suggests a more reasonable question at conclusion -
had use of the 'placebo needle', that was recently developed, been
considered by the authors? There are other problems associated with such
a 'needle' but I would leave the authors to comment.
Regards
John H.
Competing interests:
None declared
Competing interests: No competing interests
This study is a randomised trial of "doing something additional"
against "doing nothing additional". Result: "doing something additional"
leads to a cost effective improvement in QALY's, which the authors do not
specify (less pain?). As indicated in Cobie Brinkman's response, this
study leaves a strong opportunity for placebo influence.
The conclusion must be that the editorial board of BMJ regards
acupuncture as an effective therapy a priori, since this is a necessary
assumption for the study to have any meaning and for publication. However,
many scientists and physicians would not agree to this effectiveness.
Check the Cochrane Reviews (www.cochrane.org). Effectiveness should be
proven before cost effectiveness. What are BMJ's arguments for publishing
this article?
Competing interests:
None declared
Competing interests: No competing interests
I would be more convinced of the benefits of acupuncture if the study
had included a control group who had had acupuncture applied to meridian
points that, according to the theory of acupuncture, have nothing to do
with head ache (say, to those against kidney disease); since the only
control was a non-acupuncture group, the possibility of a placebo effect
is quite strong, even if only from more visits to a practioner of some
kind. If I remember correctly, someone has also developed an acupuncture
needle that does everything except puncture or otherwise affect the skin,
to test for placebo; that would be another powerful control.
Competing interests:
None declared
Competing interests: No competing interests
Sir
I'm not sure whether Paulo resides on this planet or planet Quackpot
(the term of endearment given by many alternative medicine practitioners
to the heavily criticised US-based organisation Quackwatch(1)
Why is it that alternative medicine reviews, and very positive
revellations about the various disciplines often classed as alternative
medicines, in various medical journals and newspapers seem to attract the
same dissenters - Quackpots - but rarely honest-to-goodness physicians
keen to develop their understanding of these forms of medicine which are
attracting large numbers of their patients (60% in the USA and over 40% in
Europe) who invariably have good experiences to return again and again for
alternative treatments? It would be marvellous to see an open dialogue
emerge that included GPs and Specialists -many of whom seem afraid to show
their acceptance of alternatives fearing ridcule or worse from their ill-
informed colleagues. I think the Quackpots serve only other Quackpots -
they regularly reference their own material replete with pseudoscience,
innuendo and opinion rather than solid scientific material, and the
pharmaceutical trade, not physicians or patients.
Why do Quackpots maintain an almost hysterical view about
'alternatives' rather than acknowledge those which show merit in
scientific trials in many countries? They should save their
psuedoscientific rhetoric for those interventions, allopathic and
alternative, which constantly add to human suffering?
Paulo denigrates Vickers et al implying they have 'given up
scientific principles to practice shamanism, divination'...'and believe
the implausible' and what they have trialled equates to bloodletting,
snake oil, or rhino horn powders - none of which has anything to do with
acupuncture treatment of migraine or cost-effectiveness. Bloodletting has
more to do with modern medical leeching activities redeveloped in Wales;
divination can more readily be applied to the daily game of chance played
by GPs as they apply BNF remedies to patients until one is found to fit.
The "methodlogy China is using to fight SARS" includes several which
emerged early in the fight against SARS from the Chinese University in
Hong Kong, whose prestigious Medical Faculty released two formulae based
on Traditional Chinese Medicine herbalism in the fight against SARS. Paulo
seems to ignore this important message from China preferring to wait until
patients land in ICU?
I can assure Paulo that acupuncture is not a 'primitive practice' but
emerges out of the centuries virtually unchanged as a technique therefore
it is as modern a practice as preparing drugs from age-old herbal
remedies; state of the art production methods are used, as modern as the
most modern drug - which ironically could be divined to remain in the BNF
for less than 10 years only to be relieved of its status to join tens of
thousands of other modern drugs superceded through scientific discovery -
not least HRT.
It beggars belief that a physician could refer to 'patient
satsifaction' as 'patient fantasy' and discredit patient satisfaction as
unimportant in their quest for health and welbeing? Does Paulo listen to
patients, or prescribe drugs despite patient claims of dissatisfaction?
What of side effects, does Paulo ignore patients' claims of side effects,
is that not a form of dissatisfaction?
How does a psychiatrist measure success of drugs if not through
patient satisfaction? How does a neurologist assess the effects of anti-
migraine treatment if not through patient satisfaction? How does the
endocrinologist assess the effects of HRT for menopause without assessing
patient satisfaction - especially if oestrogen and/or progesterone markers
are unavailable to assess effectiveness?
Methinks Paulo is deluded about the methodology and philosophy of
modern medical practices and believes that somehow alternative medicine
relies solely on patient satisfaction to confirm effectiveness. It does
not, but nor does it exclude such an important aspect of the whole as a
measure of success. Many drugs have no scientific basis for effectiveness,
scientific literature states that it is not known how or why they work,
but they are prescribed and deemed to work as long as patient satisfaction
is recorded.
"We cannot project a long-term economy if the event has not been
verified" states Paulo criticising Vickers et al. As if one could project
said economy for any drug despite 'verification of so many drugs over so
many years' - so why ask the impossible of this research?
If Paulo belives that 'studies that consider only 255 patients are
not significant to determine consequent medical practices' - then why not
condemn GlaxoSK's 'Zyban works for stop-smoking' studies, or Quackpot
(HealthWatch member) Ernst & White for their well propagated
'acupuncture does not work for stop-smoking' study, and the very many
other pharmaceutical industry studies that unleashed millions of doses of
drugs on an unsuspecting public over many years based on fewer patients?
Let's cut the hysteria, return to science, and operate even-handedly
to eliminate the dangerous and damaging medical and alternative medical
interventions, and ensure patient satisfaction remains one of the
hallmarks of successful medicine.
Regards
John H.
1 http://www.quackpotwatch.org/default_t.htm
Competing interests:
I am a Traditional Chinese Medicine practitioner specialising in acupuncture & moxibustion
Competing interests: No competing interests
We should not give up the scientific principles in our vision of the
world and – for us, physicians – the medical-scientific knowledge to
practice shamanism, divination, or start to believe in the implausible
only because people who deny those scientific principles claim to be
following an ancient tradition. Nothing in modern medicine should pivot
around orthodoxy, tradition, or authority. In a modern ICU (Intensive Care
Unit)only physiopatological and pharmacological bases have their place,
and it is by understanding their effects and limitation that we reach a
successful outcome. Which the methodology that China is using to fight the
SARS (Severe Acute Respiratory Syndrome)?
In this sense, I believe it is foolhardy to measure a medical
practice by the degree of patient “satisfaction” on the procedure itself.
Since Hippocrates bloodletting has been practice to eliminate the excesses
of the organism. The practice brought about spectacular results due to the
placebo effect. Patients believed that bad humors were being eliminated
from their bloodstream. Bloodletting is currently practiced in India by
medicine man in public settings, and patients feel greatly purified by the
procedure [1]. Here, in our country, we have seen the return of that
procedure by acupuncturists and practitioners of Chinese “Medicine”, who
claim to represent an alternative to scientific medicine, and who use
bloodletting to balance the “Chi” (chi energy). It is hard to defend this
primitive practice, however ancestral and supposedly beneficial to
patients prone to fantasy it may be.
To evaluate the subjective symptoms of a treatment whose “quality and
amount of evidence is not fully convincing” [2] only by the patient’s
response is unreasonable, especially when it comes to prove the
effectiveness of the treatment. The classical research investigating
placebo effects on cardiac surgery comes to mind. In a classical double-
blind study, bypass surgery using the mammary artery was evaluated against
mere skin incisions, showing the enormous potential for placebo effects in
surgery [3]. That is why the comparison between two drugs or treatments
has to be double blind, for the ease with which favorable results can be
induced. Cephalea, which is highly subjective and a symptom only, doesn’t
lend itself to the evaluation of effectiveness of an intervention in
twelve sections against none on the control group. The Hawthorne effect
should also be considered, since a weekly section of emotional
reinforcement for three months can lead the patient to believe that he or
she is being well cared for, and consequently, improving.
We cannot project a long-term economy [Fig. 2] if the event has not
been verified. How will be the migraine incidence in the future years in
this group? See, for instance, the spectacular promises of HRT, which
were based in large population samples and were shown later to be false.
Studies that consider only 255 patients (sample size in Table 2:
acupuncture = 136, control = 119) are not significant to determine
consequent medical practices.
The economy of visits after treatment (made 25% fewer visits to
general practitioners), is another interesting conclusion of the study,
considering that 12 more sections were spent on the treatment than on the
control group.
If we were to validate medical treatments by user satisfaction, we
would have to accept bloodletting, rhinoceros horn powder for impotence,
snake oil, and Naja snake blood as a “tonic” – all of them quackery but
satisfying to millions of users. This most certainly is not how clinicians
compromised with the truth treat their patients. We should expect a
demonstration of effectiveness before engage patients in a determined
treatment. There are many examples of this type of error in the history of
medicine to grant caution.
[1] Bloodletting attracts daily patients in Índia
http://www.cnn.com/HEALTH/9806/27/india.bloodletting/
[2] Acupuncture for idiopathic headache (Cochrane Review)
Melchart D, Linde K, Fischer P, Berman B, White A, Vickers A, Allais G
The full text of the review is available in The Cochrane Library
(ISSN 1464-780X).
[3] Cobb LA, Thomas GI, Dillard DH, et al. An evaluation of internal
mammary artery ligation by a double-blind technique. N Engl J Med.
1959;260:1115-1118.
Competing interests:
None declared
Competing interests: No competing interests
Wonderful Americans?
When Paulo Bandarra asks “why have alcoholic extracts from field
flowers been used as remedies?” [Bandarra] and then calls these “the
placebos of Dr. Edward Bach (1886-1936), English physician,” [Bandarra]
then he makes errors both of fact and of interpretation. Firstly, of
course, the flower remedies are not prepared in the manner he describes,
and secondly, his contention that they are “placebo’s of Dr Edward Bach,”
is actually an assumption he has made about their use—some would say an
impertinent assumption—rather than a sober judgement based upon any kind
of familiarity, neutral evaluation, intelligent trial and error or
personal use.
It is not difficult to locate the simple facts about his form of
therapy. Around 1929, Dr Bach abandoned his lucrative Harley Street
medical practice and “went to Wales to find new remedies, which is where
he also discovered the new method of ‘potentisation’ involving placing the
fresh flowers…in a bowl with spring water and exposing them to direct
sunlight.” [van Haselen, 122] He “claimed to have found a simple…method of
energisation,” [van Haselen, 123] by which the “healing energy of
plants…concentrated in its flowers…could be passed into a carrier [water]
by the energy of the sun.” [van Haselen, 123] For some plant species he
employed “boiling the fresh flowers and twigs of trees, bushes,” [van
Haselen, 123] etc to obtain a decoction or infusion of the plant’s healing
energy.
The Bach Flower system aims “to transfer the healing energy contained
in the source material to a pharmaceutical medium and involves a form of
energisation.” [van Haselen, 123] To prepare his essences, Bach used
“water from a certain spring,” [Franz, 30] and being “inspired by the
sunlit morning dew, he developed a new method for capturing the ethereal
plant quality in remedies.” [Franz, 30] As Franz says, Bach also ‘cooked’
some remedies “in water over a wood fire to utilise the sun’s energy of
the past few years.” [Franz, 30-31]
The remedies are thought to work “through their subtle vibrational
energy,” [Shaw, 7] for “no physical part of the plant remains in the
remedy.” [Shaw, 10] For this reason, it is assumed—by those who use
them—that the remedies “contain the energy or imprint of the plants from
which they were made.” [Shaw, 10] Bach came increasingly to believe “that
the personality type and mood of an individual is a vital element in
avoiding disease.” [Shaw, 8] What might be termed “the special method of
Bach Flower potentisation,” [Richardson, 27] using sunlight and spring
water, “enables Bach to achieve the desired vibrational power and healing
effect within the personality sphere of the human being.” [Richardson, 27]
The problem with errors of fact and interpretation is that they lead
people to doubt everything else you say; as they snowball, the greater the
doubt becomes. In this case, due to the inaccurate and prejudicial nature
of his remarks, it is hard to trust reliably a single view Bandarra
expresses. It is abundantly clear that he detests alternative medicine and
is unlikely to ever change this view. However, his views would enjoy
greater credibility if they reflected some evidence of impartial study and
intelligent thinking on his own part about the subject he is so keen to
proselytise about, instead of so much impatient and impassioned blather.
Paulo Bandarra also offers BMJ readers the benefit of his rather rosy
view of Americans, who “landed on the Moon in 1969 and this year (2004)
they have two robots on Martian soil sending real-time pictures. The USA
is a great country and Americans are a wonderful people, sciencewise.”
[Bandarra] The connection does not seem very clear. If Americans are so
wonderful and so scientific, as Bandarra claims, then why do so many of
them choose to use and practise acupuncture, not to say many other
unorthodox medical practices?
Sources
Paulo Bento Bandarra, BMJ letter, Re: Re: Should we believe in the
improbable, 27 March 2004
http://bmj.bmjjournals.com/cgi/eletters/bmj.38033.896505.EBv1#54768
Angelika Franz, Bach-Blüten und Homöopathie, Allgemeine
Homöopathische Zeitung, 240-1, 1995, 28-34 [with English translation]
Cornelia Richardson-Boedler, Doctrine of Signatures: a Historical,
Philosophical and Scientific View [part II], British Homeopathic Jnl 89,
2000, 26-28
Non Shaw, Bach Flower Remedies a Step-by-Step Guide, Shaftsbury:
Element Books, 1998
R A van Haselen, The Relationship Between Homeopathy and the Dr Bach
System of Flower Remedies: a Critical Appraisal, British Homeopathic Jnl
88, 1999, 121-127
Acknowledgement
I gratefully acknowledge that some of my reference sources were
kindly supplied by Mike Price and Gregory Vlamis.
Competing interests:
None declared
Competing interests: No competing interests