User:KOMF/Wiki4Cam Backups/Homeopathy

Homeopathy or homoeopathy &mdash; from the Greek hómoios (similar) and páthos (suffering) &mdash; is a system of alternative medicine based on the observation of "like cures like" or the "principle of similars", the idea that substances known to cause particular syndromes of symptoms can also, in low and specially prepared doses, help to cure diseases that cause a similar syndrome of symptoms.

Homeopathic remedies are prepared by diluting drugs and other compounds into extremely small doses, which are then vigorously shaken ("succussed") in water or ethanol and finally dispensed in pills or liquid form. In 2010, an Indian team claimed to have found that commercially manufactured metal-derived high-dilution remedies contain nanoparticles of the metals and their aggregates.

The founder of modern homeopathy was a medical doctor, many modern medical practitioners all over the world prescribe some homeopathic remedies, and most governments recognise homeopathy as legitimate treatment.

Homeopaths point to a long safety record for their very dilute remedies. On the other hand, homeopaths assert that there are much greater risks in utilizing conventional medical treatments even when these treatments have been "scientifically verified" because medical history is replete with evidence that such verification changes dramatically with time.

There are many clinical trials and studies which show that homeopathy is effective.

Principles
Some principles of homeopathy have been utilized in various forms in various medical systems for thousands of years in many diverse cultures, but they were first methodically set out by a German physician, Samuel Hahnemann (1755–1843), who observed that a medicine sometimes evoked symptoms similar to those of the illness for which it was prescribed. Related maxims such as the "Law of similars" are common in anthropological literature.

In traditional homeopathic theory, every person has a "vital force", with the power to promote healing and/or maintain good health. Homeopaths believe that this "vital force" is akin to what physiologists would call the body's "defense systems" or to qi in traditional Chinese medicine. In this theory, the signs and symptoms of a disease reflect efforts of the body to counter infection, or to resist damage from environmental toxins or from various stresses. Homeopathic treatment – it is claimed – attempts to strengthen this "vital force" with the help of remedies that are chosen for their ability (in large doses) to provoke the very symptoms that the remedy is intended to heal by stimulating the natural healing processes with the help of sub-physiological doses of a remedy.

"Classical homeopathy" or "Hahnemannian homeopathy" refers to the original principles of this medical system in which a single remedy is chosen according to the physical, emotional, and mental symptoms that the sick individual is experiencing rather than only the diagnosis of a disease. Two basic principles are the principle of similars ("like cures like") and the principle of infinitesimals - the idea that remedies become more potent if they undergo a process called potentization, which consists of repeated dilutions with vigorous shaking (succusion) between each dilution. Individualization of treatment is essential in classical homeopathy, whereby a remedy is chosen based on the person's overall 'syndrome of symptoms', not just a generic disease diagnosis.

"Commercial" or "user-friendly" homeopathy refers to the use of a mixture of remedies in a single formula containing individual ingredients that are generally chosen by the manufacturer for treating specific ailments.

Overview
Homeopaths assert that, in their view, the overall evidence for homeopathy, including clinical research, basic sciences research, historical usage of homeopathic medicines in the treatment of people in various infectious disease epidemics, and widespread and international usage of homeopathic medicines today, indeed provide extraordinary evidence for the benefits of this system.

Homeopathy has a rich history; many famous people over the past 200 years have been users and advocates of it, and it is an important element in the history of medicine generally. The growth of homeopathy in the 19th century had a significant influence in determining how conventional medicine organised and developed, and in how it came to formulate its present vision of evidence-based medicine, in contrast to practice based on individual clinical experience.

Homeopaths are proud of their history and are convinced of the efficacy of their remedies. Homeopathic medicines are used by many people throughout the world; like many other complementary and alternative therapies, homeopathy generally scores highly in "patient satisfaction" surveys, and it has a reservoir of public support. In the U.K. for instance, one of the countries where homeopathy has relatively strong public support, a survey cited by the British Homeopathic Association found that 15% of the public "trust" homeopathy. This same survey also found higher percentages of trust in homeopathy in other countries: 58% Brazil, 53% Chile, 49% Saudi Arabia, 40% France, 28% Russia, 27% Germany, and 18% USA.

Historical origins
The early Greek physician Hippocrates of Cos (c. 450 BCE - 380 BCE), who is considered to be the "father of medicine", is also claimed by homeopaths as a pioneer in their own tradition—notably because Hippocrates taught that "Natural forces within us are the true healers of disease," but also because he thought that some diseases could be cured by the same things that caused them—arguably an early expression of the principle of similars. In the 16th century the pioneer of pharmacology Paracelsus declared that small doses of “what makes a man ill also cures him", anticipating homeopathy. It was not until the late 18th century, however, that this theory was coupled with an experimental method to determine in detail what symptoms a substance causes and thereby what a particular medicine might cure. This experimental method was developed by the German physician Samuel Hahnemann with his method of "provings"—studies of the effects, in humans, of high dosages.

In 1783, disillusioned with the medicine of his time and the many toxic effects of its treatments, Hahnemann, who knew nine languages, gave up his medical practice and devoted himself to translating medical books, including many of the leading textbooks of the day. Among them was the Treatise on Materia Medica (1789) by William Cullen, the leading physician of the 18th century. Cullen had written that cinchona bark (which contains quinine) was effective in treating malaria because of its bitter and astringent properties. Hahnemann questioned this theory because he knew that other substances were as bitter and astringent, but had no therapeutic value in this deadly disease.

Hahnemann observed from his experiments with cinchona bark, used as a treatment for malaria, that the effects he experienced from ingesting the bark were similar to the symptoms of malaria. He therefore reasoned that cure proceeds through similarity, and that treatments must be able to produce symptoms in healthy individuals similar to those of the disease being treated. Through further experiments with other substances, Hahnemann observed the same results and therefore conceived of the law of similars, otherwise known as "let like be cured by like" (Latin: similia similibus curentur) as a fundamental healing principle. He believed that by inducing a syndrome of symptoms similar to the disease through the use of a remedy, the vis medicatrix naturae or natural healing processes of the body would get stimulated enough to neutralise and expel the original disease and that this artificial disturbance would naturally subside when the remedy was no longer being taken. It is based on the idea that a substance that in large doses will produce symptoms of a specific disease will, in extremely small doses, cure it. He used his experiments and the principle of similars to develop a new system of health care, as an alternative to the often toxic and ineffective drugs and treatments offered by conventional physicians of the time.

Hahnemann named his system of health care "homoeopathy" (meaning "like disease") - but most people now spell it "homeopathy" - and coined the term "allopathy" ("different than disease") to refer to the conventional medicine of the day, because its drugs were sometimes "similar," sometimes "opposite," but usually just "different" to the symptoms of the sick person. For the first two decades of Hahnemann's practice of homeopathy, he used "crude" doses of various medicinal substances ("crude", in homeopathic use, means doses that still contain some of the original ingredient). He strove to find the lowest doses at which his remedies would still be effective, as he thought this the best way to avoid any adverse side-effects. To his surprise, it seemed that reducing the dose did not reduce the effectiveness of his treatments. Instead, he concluded that his remedies worked better the more he diluted them as long as he “potentized” them, i.e. serial dilution followed by vigorous shaking (succussion). Homeopathy thus became inextricably linked with this process of ultradilution—repeated dilution of substances followed by succussion. Hahnemann did not offer a clear explanation as to how or why these potentized medicines might have therapeutic benefits; he distrusted all theoretical explanations and argued that all that mattered was whether a treatment was therapeutically effective. . He believed that diseases were caused by "spirit-like derangements of the spirit-like power that animates the human body", beginning with 'indispositions' and that effective healing called for medicines that would stimulate this life force to reestablish homeostasis and health.

Homeopathy was introduced into the U.S.A. in 1825 by Hans Burch Gram, a Boston-born doctor who had studied homeopathy in Europe. In 1830, the first homeopathic schools opened (the first homeopathic medical college in the U.S.A. opened in 1835, in Allentown, Pennsylvania), and throughout the 19th century dozens of homeopathic institutions appeared in Europe and the U.S.A. Apart from his ventures into homeopathy, Hahnemann had been a prominent and respected public health reformer, and in the 1830s the Medical Society of the Country of New York had granted him honorary membership. However, a few years later the society rescinded this when they realized the "ideological and financial threat" that homeopathic medicine posed. In 1844, the first U.S. national medical association - the American Institute of Homoeopathy - was established.

By the end of the 19th century, 8% of American medical practitioners were homeopaths, and there were 20 homeopathic medical colleges (including Boston University, New York Medical College, and the Universities of Ohio State, Iowa, Minnesota and Michigan) and more than 100 homeopathic hospitals in the U.S.A. One reason for the growing popularity of homeopathy was its relative success in treating people suffering from the infectious disease epidemics that raged at the time. Cholera, scarlet fever, typhoid fever, and yellow fever were rampant and killed many people, but death rates in homeopathic hospitals were often very much lower than in the conventional hospitals, which did nothing to combat them. Death rates in conventional hospitals were typically two- to eight-fold higher than in homeopathic hospitals for patients with these infectious diseases.

In the early 20th century, the "Flexner Report," sponsored by the Carnegie Foundation with support from the American Medical Association, triggered major changes in American medical education. As a result, many medical schools and colleges, including those teaching homeopathy were closed down, while others became conventional medical schools (including Hahnemann Medical College, Boston University, New York Medical College, and Ohio State University). In the 1960s, the popularity of homeopathy began to revive again in the U.S.A, and a 1999 survey reported that over 6 million Americans had used homeopathy in the previous 12 months. According to the American Homeopathic Pharmaceutical Association, the 1995 retail sales of homeopathic remedies in the U.S.A. were estimated at $201 million and growing at a 20% per year; the number of homeopathic practitioners in the U.S.A. increased from fewer than 200 in the 1970s to approximately 3,000 in 1996.

Homeopathic "provings"
Homeopathic practitioners determine the specific therapeutic indications for their remedies from experiments in toxicology called provings, in which volunteers are given repeated doses of substances (usually in single-blind or double-blind trials), until symptoms of overdose are observed. The effects of each medicinal substance are recorded in textbooks, called Materia Medica and Repertory, or nowadays in expert system software. Homeopathic provings provide an experimental basis to determine what a substance causes in overdose and thereby what it is thought to cure. The symptom complexes that these substances cause are subsequently used to compare with a patient's physical and psychological symptoms in order to select, as the appropriate most similar remedy, the substance whose effects are closest to the patient's symptoms—called the "simillimum".

Homeopaths prescribe a remedy (in potentized doses) when a sick person has a syndrome of symptoms that resemble the syndrome of symptoms that it causes in drug proving. The recorded symptoms need to be interpreted by an experienced homeopath to understand the conditions for which the remedy might be considered as possibly useful.

In September 2006 the U.K.’s licensing body, the Medicine and Healthcare Products Regulatory Agency, altered their regulations to permit homeopathic remedies to be advertised using homeopathic provings to support their claims (justifying phrasing such as “For the relief of...”. This change elicited protests from scientists, who called it a departure from the principle that such claims should be justified by evidence of efficacy.

Homeopathic manufacture of remedies
In the U.S.A., the Homœopathic Pharmacopœia of the United States is a legally recognized handbook that describes how to manufacture homeopathic drugs. This reference is approved by the Food and Drug Administration (FDA), the governmental agency that regulates drugs. Medicines listed in the HPUS defines them as homeopathic drugs which grants them a different standard of drug regulation than conventional drugs and medical devices. A summary describes the principles: FDA regulates homeopathic drugs in several significantly different ways from other drugs. The Manufacturers of homeopathic drugs are deferred from submitting new drug applications to FDA. Their products are exempt from good manufacturing practice requirements related to expiration dating and from finished product testing for identity and strength. Homeopathic drugs in solid oral dosage form must have an imprint that identifies the manufacturer and which indicates that the drug is homeopathic. In 1938, the federal Food, Drug, and Cosmetic Act, sponsored by New York Senator Royal Copeland, a homeopathic physician (and former homeopathic medical school dean), gave the FDA the power to regulate drugs and granted legal recognition to the "Homeopathic Pharmacopeia of the United States" as a compendium of drugs. In contrast, non-homeopathic drugs for which a New Drug Application is required must be accompanied by approved evidence of safety and efficacy; simple listing in a reference is not sufficient. Today, homeopaths use about 3,000 different remedies, from animal, plant, mineral, or synthetic sources.

By convention, the first letter of the Latin-derived name of such preparations is capitalized. When the source is well-defined, the traditional name rather than chemical, International Nonproprietary Name or biological nomenclature, is preferred, such as Natrum muriaticum rather than sodium chloride. Ultimately, any substance can become a homeopathic medicine if "drug provings" (tests to determine the symptoms produced by toxic doses) are first conducted to determine what it causes in overdose and therefore what it can cure in potentized doses. Remedies used in homeopathy are commonly made from plants, trees, fungi, and algae, as well as from a wide variety of mineral and animal sources. Even some unusual substances, called imponderables, can and are made into homeopathic medicines, including electricity, X-ray, and magnetic north and south poles.

Homeopathic remedies are available in several different forms (single medicine, homeopathic formula or complex medicines, and a limited number of external applications). Remedies for internal consumption come either in pill form or as liquid. Most do not require a doctor's prescription, but some may need one if the dosage is in a non-potentized or low potency dose and if the substance is potentially toxic (in Europe, a medicine must be diluted at least 1:10 three times to be deemed homeopathic). In the U.S.A., if a homeopathic remedy is claimed to treat a serious disease such as cancer, it can be sold only by prescription. Only products sold for “self-limiting conditions” — colds, coughs, fever, headaches, and other minor health problems — can be sold without a prescription (over-the-counter).

Preparation of homeopathic remedies
The most characteristic principle of homeopathy is that the efficacy of a remedy can be enhanced and its side-effects reduced by a process known as "dynamization" or "potentization". In this process, liquids are diluted (with water or ethanol) and shaken by ten hard strikes against an elastic body ("succussion"), to get the next, succeeding higher potency. For this, Hahnemann had a saddlemaker construct a wooden "striking board", covered in leather on one side and stuffed with horsehair. When insoluble solids such as oyster shell are used for remedies, they are diluted by grinding them with lactose ("trituration"). The original serial dilutions by Hahnemann used a 1 part in 100 (centesimal; "C" potencies), or 1 part in 50,000 (quintamillesimal; "LM" or "L" potencies). Dr. Constantine Hering of Philadelphia later introduced the Decimal potencies ("D" or "X" potencies). A large number of homeopathic medicines sold in health food stores and pharmacies are "low potencies," that is, doses that are 3X, 3C, 6X, 6C, 12X, and 12C, all of which, except the last dose, have material doses of the original substances in the medicine. The higher potencies (30, 200, 1,000 and higher) are more commonly prescribed by professional homeopaths, and typically homeopaths have found these doses to be powerful enough to only need a single dose to have a long-term effect (from several weeks to several months or longer). Research studies that determine the efficacy of homeopathic medicines are discussed elsewhere in this article.

The dilution factor at each stage is 1:100 ("C" potencies), 1:50,000 ("LM" potencies) or 1:10 ("D" or "X" potencies) ; Hahnemann advocated $$30C$$ dilutions for most purposes (i.e. dilution by a factor of 10030 = 1060). The number of molecules in a given weight of a substance can be calculated by Avogadro's number (see the section "Attempts to provide a scientific foundation for homeopathy" below), and it is extremely unlikely that even one molecule of the original substance would be present in a $$30C$$ dilution. Thus, homeopathic remedies of a high "potency"' contain just water, but according to homeopaths, the structure of the water has been altered (see memory of water).

"Classical homeopathy" or "Hahnemannian homeopathy" refers to the original principles of this medical system in which a single remedy is chosen according to the physical, emotional, and mental symptoms that the sick individual is experiencing rather than only the diagnosis of a disease. "Commercial" or "user-friendly" homeopathy refers to the use of a mixture of remedies in a single formula containing individual ingredients that are generally chosen by the manufacturer for treating specific ailments. Such homeopathic remedies are used by consumers all over the world for self-treatment of common self-limiting ailments and injuries.

Similia similibus curentur : the law of similars
Similia similibus curentur or "let likes cure likes", is the assertion that a disease/problem can be cured by remedies that (in macroscopic, milligram doses) produce the same symptoms as those of the disease. This assertion, known as "the law of similars", is a guiding principle in homeopathy. Homeopaths consider that two conventional concepts, vaccination, and hormesis, can be considered as analogous to homeopathy's law of similars and the use of small doses.

Scientists and medical doctors today do not think that the principle of similars is generally true or useful, and they explain the efficacy of vaccination without referring to it. Physicians of the 19th century however did consider that the principle could be valuable. For example, Emil Adolph von Behring (1854-1917), who won the first Nobel Prize in medicine in 1901 for discoveries that led to vaccines against tetanus and diphtheria, and who some consider to be the father of immunology, asserted that vaccination is, in part, derived from the homeopathic principle of similars.

In spite of all scientific speculations and experiments regarding smallpox vaccination, Jenner’s discovery remained an erratic blocking medicine, till the biochemically thinking Pasteur, devoid of all medical classroom knowledge, traced the origin of this therapeutic block to a principle which cannot better be characterized than by Hahnemann’s word: homeopathic.

Although homeopathic remedies and vaccinations both use low doses of active ingedients, there are important differences. First, the doses used in homeopathic remedies are always very much lower than used in vaccines. Second, vaccines produce a measurable immune response (e.g., immunoglobulin production). Homeopathic remedies do not routinely produce a measurable immune response. Thus conventional treatments involve application of measurable doses of substances, at levels known to activate a cellular response. In contrast, homeopathic preparations above the $$24X$$ ($$12C$$) potencies do not contain enough molecules to activate any known metabolic or signalling pathway.

There are many different mechanisms by which tolerance can develop - and exposure to repeated small doses does not always result in tolerance. A herpetologist who receives many small doses of snake venom may indeed become tolerant to them. A beekeeper, however, may become hypersensitive to the venom and, after receiving a sting, go into anaphylaxis. This type of response to small, not necessarily precisely measured, doses is not predictable on an individual basis. "Allergic desensitization" is a technique used in conventional medicine to treat individuals who have a specific allergy to something that they cannot easily avoid. This involves exposing the patient repeatedly to tightly controlled doses, increasing the doses gradually over time. This treatment can be dangerous (exposure of sensitive individuals to an allergen can produce anaphylaxis), and it has very inconsistent efficacy, so is normally only attempted when the allergy poses serious restrictions on the patient's normal life.

Both mithridatization and homeopathy might be considered as instances of hormesis, which describes the phenomenon that some chemicals at high concentrations have opposite biological effects to those at low concentrations.

Recent research has shown that some conventional drugs, which are normally used to do something, can lead to the opposite effect, when stopped - a rebound effect                ; homeopathy uses the rebound effect of a remedy to stimulate natural healing.

Homeopathy in practice
Users of homeopathy gain access to it in a number of ways: in some countries, it is sold over-the-counter in both pharmacies and health food or other retail outlets that cater towards those seeking alternative medicine. Many people approach a homeopath: some countries allow homeopaths to describe themselves in equivalent ways to doctors, with a system of qualification and oversight. In India, homeopathy has the status of a 'national system' of medicine. In the United Kingdom, physicians can refer patients to homeopaths in some areas, and there are a number of homeopathic hospitals.

In addition to those homeopathic remedies prescribed in the professions practicing homeopathy, remedies are used by consumers all over the world for self-treatment of common self-limiting ailments and injuries. Some medical doctors, particularly in Germany, France, and several other European countries prescribe homeopathic medicines for wide variety of both self-limiting conditions and serious diseases with a high rate of patient satisfaction. Other physicians work with patients who self-prescribe homeopathic remedies or receive them from other practitioners.

There are no universal standards for homeopathic education, so licensing and regulation varies from country to country and from state to state within the U.S.A. In some countries, all (or virtually all) professionals that use homeopathic treatments are MDs (such as France, Spain, Argentina, Colombia). Some countries have exclusively homeopathic medical schools (India, Pakistan, Mexico etc.), some have naturopathic medicine colleges in which students are taught homeopathy as part of their curriculum (Germany has its "Heilpraktiker"/health practitioners; the U.S.A., Canada, and Australia have naturopathic medicine schools that include homeopathy), and some countries certify "professional homeopaths" who have attended homeopathic schools and who then pass independent examinations that grant "certification" as homeopaths. In the U.S.A., there is also a separate certification process available only to MDs and DOs (there are similar choices of certification available in the U.K. for medical doctors, who've done at least MBBS). Also in the U.S.A., naturopathic physicians have their own homeopathic certifying agency.

In Europe homeopathy is practiced by many conventional physicians, including 30-40% of French doctors and 20% of German doctors. Some homeopathic treatment is partly covered by some European public health services, including in France and Denmark. In France, 35% of the costs of homeopathic medicine prescribed by a medical doctor are reimbursed from health insurance. In the U.K., five homeopathic hospitals are funded by the National Health Service (NHS) and homeopathic remedies are sold over the counter, and there, homeopathy is one of the most popular alternative and complementary treatment modalities

In 2007, the over-the-counter market in homeopathy was around £40million in the U.K. ; the total over-the-counter market was £1.2 billion in 1994. Family doctors in the U.K. issued 796 million prescriptions in 2007, of which 49,300 were for homeopathic remedies, down from 83,000 in 2005. In January 2008, it was reported that the NHS was progressively withdrawing funding for homeopathic treatments because of doubts about their efficacy. Of 248,000 registered practitioners of medicine in the U.K., about 400 are members of the Faculty of Homeopathy. However, homeopathy is still not a fully regulated profession in the U.K.—anyone can declare themselves to be a homeopath and practice without any qualification ("common law" that allows freedom of choice in medical care in England has a long history)

In France and Denmark licenses are required to diagnose any illness or to dispense any product whose purpose is to treat illness. In many countries, however, there are no specific legal regulations concerning homeopathy. In Austria, the public health service generally requires proof of effectiveness to reimburse medical treatments, but makes an exception for homeopathy.

In India, where there are more than 300,000 registered practitioners of homeopathy, homeopathy is formally recognised by the Government as one of the Indian "National Systems of Medicine", under the Department of AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy), while conventional, western medical education is controlled by the Medical Council of India. About 10% of the Indian population depends solely on homeopathy for their health care needs. In India it is illegal to practice as a homeopath without a license and professional qualifications.

Almost 70% of all over-the-counter homeopathic remedies are sold in Western Europe. France is the largest market for homeopathic remedies in the world, worth over 300 million euros in 2003 (in a total over-the-counter drug market of over 770 billion euros), followed by Germany (200 million euros). The global self-medication market is estimated at 48.2 billion dollars (13.4% of the world pharmaceuticals market), of which sales of homeopathic remedies account for 0.3%.

A typical homeopathic visit
Homeopathic remedies can be prescribed by professional homeopaths, naturopaths, acupuncturists, chiropractors, and physicians with additional homeopathic training and certification, and how these decide what to prescribe will differ accordingly. Classical homeopaths place emphasis on the patient's unique symptoms and their psychological state, and they gather this information from an interview, typically lasting from 15 minutes to two hours (comparable to conventional physicians), with one or more follow-up consultations of 15 to 45 minutes. They place special emphasis on the way the patient experiences their disease—i.e. they give priority to the overall syndrome of symptoms and the unique and idiosyncratic symptoms which they consider different than the conventional medical approach of trying to identify the causes of the disease. The goal is to determine the factors that might predispose the patient to disease and find a treatment that will strengthen that particular patient's "overall constitution".

After the interview, the homeopath consults the references described in the table on the right. Some homeopaths make quick prescriptions based on "keynotes"—the highlights of the best known characteristics of a remedy. The real challenge of homeopathic practice, though, is to find the remedy that best matches the patient's syndrome of physical and/or psychological symptoms—the "similimum". A fundamental reason for conflict between conventional medicine and homeopathy is that homeopathy rejects the concept of treatments that target mechanisms of disease, and instead uses remedies that target syndromes of symptoms that they believe strengthen a person's overall constitution. Some homeopathic protocols might look like the following:


 * A physician qualified in both homeopathy and conventional medicine, after diagnosing a chronic condition that does not indicate the need for medical urgency, will usually first prescribe a homeopathic remedy which he feels may be more effective and is likely to have fewer side effects than conventional drugs.
 * Homeopaths recognize that trauma might require conventional medical attention but may complement the conventional treatment with homeopathy.
 * Homeopaths disagree with conventional medicine about the role of immunization and chemoprophylaxis for infectious diseases and prefer to prescribe homeopathic remedies that they believe will strengthen a person's immune and defense system.
 * For some disease conditions, such as asthma and acute bronchitis, homeopathic remedies are often prescribed not only to alleviate chronic symptoms, but also to treat acute attacks. Homeopathic remedies might also be used after an asthmatic episode with the intent to prevent recurrences.
 * An adequately trained homeopath is expected to recognize symptoms that indicate an acute and potentially fatal condition. The practitioner is expected to have emergency medical training and equipment appropriate to his or her level of training in the place of practice (e.g., dressings and basic airway management tools for an individual with training at the Emergency Medical Technician (EMT) of Basic or higher level, and preferably an automatic external defibrillator and advanced cardiac life support resources generally accepted as appropriate for an office. Potentially serious acute ailments may require medical supervision, but homeopaths sometimes prescribe remedies either for adjunctive use or as alternatives to conventional treatment.

The homeopathic treatment of acute problems does not need the same depth or breadth of interview as treatment of chronic conditions. According to homeopaths, because the symptoms of a common cold or a headache or an allergy vary from person to person, each may need a different remedy. However, they believe that people who experience an injury generally have similar symptoms, so they think that some homeopathic remedies might be routinely useful in such cases.

Homeopaths who practice "classical homeopathy" prescribe just one remedy at a time—a remedy that best fits the overall syndrome of the patient. The same remedy might thus be prescribed for patients suffering from very different diseases; conversely, patients suffering from what would be diagnosed conventionally as the same disease may be prescribed different remedies. For example, hay fever would be treated with any of several remedies, usually based on the specific symptoms, but sometimes on the etiology of the allergy. Some common remedies are: Allium cepa (onion, which causes tears to flow and a clear burning nasal discharge that irritates the nostrils), Euphrasia (eyebright, which causes a clear and bland nasal discharge along with tears that burn and irritate the skin where the tears flow), Ambrosia (ragweed) and Solidago (goldenrod); ,ragweed and goldenrod are herbs whose pollen is aggravating to some hay fever sufferers. These remedies are commonly given during the acute symptoms of hay fever. At other times, a professional homeopath will often treat these patients with a constitutional remedy based on the patient’s genetic history, health history, and present overall physical and/or psychological state, with the intent to strengthen the person’s general health, thereby reducing the frequency and/or intensity of the symptoms of hay fever.

The claims for homeopathy
Homeopaths view illness as a systemic condition, a disturbance in the overall homeostasis of the total being and accordingly, consider that almost any sick person, may benefit from proper homeopathic treatment. "'homeopathy is designed to treat the whole person and can therefore be considered in almost any situation where a person's health is depleted.'"

As the American Institute of Homeopathy puts it in their "Standards of Practice": "The physician must remember that he is treating a patient who has some disorder; he is not prescribing for a disease entity.".

Homeopathic practitioners claim that their remedies are useful for a wide range of minor ailments, from cuts and bruises to coughs and colds. Patients often come to homeopaths with long-term problems which have not responded to conventional medicine, and homeopaths prescribe remedies to people with these conditions. Some of the common ailments for which patients seek homeopathic care are eczema, chronic fatigue syndrome, asthma, migraine, irritable bowel syndrome, allergic disorders, arthritis, fibromyalgia, hypertension, Crohn's disease, premenstrual syndrome, rhinitis, anxiety and depression. They also treat patients with the most serious diseases, including multiple sclerosis, chronic obstructive pulmonary disease, and cancer. and AIDS For gangrene, for example, homeopathic remedies are prescribed in the belief that they will strengthen a person's own defenses and to initiate healing; a very different approach than medical therapy Some homeopathic remedies for gangrene include Arsenicum Album, Secale (from rye/ergot), and Carbo vegetabilis (from charcoal), amongst many others.

Homeopaths claim that there is objective evidence that some of their treatments are beneficial (see Tests of the efficacy of homeopathy), and they believe that the success of homeopathy for the last 200 years is itself an indication of its value.

Homeopaths, and some other researchers, also claim that there is scientific evidence that homeopathy helps in many problems and diseases.

Conflict with conventional medicine
The theory underlying homeopathy is not considered plausible by most scientists working in academic institutions in Europe and the U.S.A., and in key respects, the treatment advice offered by homeopaths is in disagreement with conventional medicine.

The conventional view is that homeopathy, insofar as it has any effect at all, exploits the placebo effect - i.e. that the only benefits are those induced by the power of suggestion, by arousing hope, and by alleviating anxiety. Conventional medical opinion does not deny the efficacy of placebo treatments in many cases, and placebos have played a large part in conventional medicine since their first deliberate use by William Cullen in the 18th century.

...we all recognise the strong placebo effect in, probably, all aspects of medical treatment, whether they are conventional or not" - Professor Tom Mead

Cullen used regular drugs as placebos, but at much lower doses than were thought to be effective. He gave them "to comfort and please the patient" rather than with any hope of a specific effect. He used the word "placebo" in this sense in lectures given in 1772. . Many modern physicians, however, consider it unethical to deliberately mislead their patients ; rather than prescribing placebos themselves for conditions they feel they cannot treat or do not need treatment (like abnormal sensations), some prefer to refer patients to regulated practitioners of alternative medicine.

Some homeopaths, especially with medical training, will use conventional techniques to treat asthmatic and other respiratory medicine, but will use homeopathic methods for long-term care.

One of the challenges here is that the standard of medical therapy for asthma is to prevent inflammation, which commonly involves inhaled corticosteroids that are not absorbed beyond the respiratory system. Homeopaths assert that corticosteroids are immunosuppressant drugs that only provide temporary relief of asthma symptoms and may lead to more serious chronic disease and to increased chances of death. Medical opinion is that this assertion is uninformed scare-mongering. They advise that corticosteroids prevent inflammation that can have serious consequences and symptom relief is a result of this anti-inflammatory action. Inhaled corticosteroids that stay on the breathing passages and do not spread through the body are medically preferred to systemic corticosteroid therapy and thus reduce immune-suppressing effects of these drugs.

Most homeopaths believe that the fundamental causes of disease are internal and constitutional and that infectious disease is not just the result of infection but also of susceptibility. This leads them to seek to avoid conventional treatments that suppress symptoms. Physicians accept that some disease is indeed a disturbance in normal function, whether due to external, genetic, or internal reasons. However, they consider that most diseases are caused by a combination of external causes (such as viruses, bacteria, toxins, dietary deficiency, physical injury) and physiological dysfunction (including genetic defects and mutations such as those which trigger cancers). The main goal of conventional medical treatment is to eliminate these causes, although physicians often also use drugs to suppress the symptoms of a disease (to alleviate the pain, injury, and distress that they cause).

Whereas homeopaths emphasize that they provide remedies tailored to the individual patient's symptoms, conventional medicine focuses on treatments with demonstrable efficacy when given in a standard form to large populations of patients with a given disease. Large clinical trials also seek to identify subgroups of patients (identifiable by age, gender, ethnicity, lifestyle, comorbidities etc.) that are "responders" or "non responders" to a new treatment, to provide a rational basis for individualization of treatments. Conventional physicians have access to a very large repertoire of prescription drugs for this purpose (11,706 in the U.S. Food and Drug Administration Approved Drug Products with Therapeutic Equivalence Evaluations 26th Edition Electronic Orange Book (EOB)4 ), a repertoire that is constantly changing as less effective drugs are replaced by better drugs.

Medical organizations' attitudes towards homeopathy
The American Medical Association (AMA) was founded in 1847, three years after the American Institute of Homeopathy. From the 1860s to the early 20th century, the AMA's ethical code forbade its members to consult with fellow MDs who practiced homeopathy. Although the AMA did not enforce many of its ethical guidelines, the "consultation clause" was one of the few that it did. Today, the AMA is no longer overtly antagonistic to homeopathy, but their current policy statement says: "There is little evidence to confirm the safety or efficacy of most alternative therapies. Much of the information currently known about these therapies makes it clear that many have not been shown to be efficacious."

Homeopathy is available on Britain's publically funded National Health Service since it was created in 1948. The NHS funds homeopathic hospitals in Glasgow, Liverpool, Bristol and London and there are several NHS homeopathic clinics in Scotland, treating approximately 55,000 patients per year by some 600 doctors. However in 2010 the British Medical Association passed a vote to stop funding it on the service. In addition they agreed that pharmacists should remove homeopathic remedies from their shelves in order to prevent them from being confused with medicines, and instead they should be labelled as placebos. Although the British Medical Association and other skeptics of homeopathy sought to get Britain's National Health Service to stop reimbursement for homeopathic treatment from medical doctors, the British government and its health minister declared that British citizens deserve a choice on the type of medical care they receive, and because homeopathic care has a long record of safety and patient satisfaction, homeopathic care remains a part of Britain's National Health Service.

Safety and efficacy of homeopathy
In conventional medicine (see New Drug Application), the basic phases of evaluating a drug are determining if it causes dangerous effects in healthy volunteers, if it is adequately present in the body to achieve an effect, and if it is more effective than established treatments, against a disease. Not all trials are placebo controlled, but only those where there is no accepted treatment; new drugs must be compared with the best available existing treatment. See informed consent.

In conventional medicine, traditional randomized controlled trials rely on statistical analysis of large groups of patients all of whom are given the same treatment to determine whether that treatment is indeed effective. This conflicts with an approach that believes that treatments must be individually tailored to each patient. In reality, some homeopathic trials do use some standardization, but not always to an extent which would make the trials statistically robust. Clinical trial specialists for several techniques involving individualized treatment, such as homeopathy and pharmacogenomics, propose protocols to test "low responding" or individualized therapies in statistically valid clinical trials. For homeopathy, by having a group of people who identify as ill and asking a qualified homeopath to diagnose them - then having real homeopathic medication given to a subset of them, and medicines that share the same physical properties but are homeopathically inert according to homeopaths (for instance, by using ordinary water rather than homeopathically diluted water in preparing the substance). This method thus tests the standard diagnostic method as the experimental treatment, rather than the specific medications. There have not been,however, many homeopathic trials using this method.

Few people question the safety issues in choosing homeopathic medicines themselves, and the U.S. F.D.A. determines what dose is basically safe for over-the-counter sales of homeopathic medicines. However, homeopaths discourage the general public from using the homeopathic high potency medicines (the 200th potency and higher potencies) unless the person is adequately trained in homeopathy. Homeopaths warn the public that repeated doses of high potency medicines can lead the person to experience a "drug proving," a situation in which the person experiences symptoms akin to an overdose of the substance (the symptoms are generally known to resolve themselves shortly after the person stops taking the medicine).

Attempts to provide a scientific foundation for homeopathy
Homeopathy was developed at a time when many important concepts of modern chemistry and biology, such as molecules and germs, were understood poorly, if at all. In Hahnemann's day, many chemists believed that matter was infinitely divisible, so that it was meaningful to talk about dilution to any degree. Although the hypothesis of atoms can be traced back to the ancient Greeks, their size was not calculated until 1865 (by Josef Loschmidt).

We now know that, for example, a teaspoon of seawater (roughly 5 ml) contains about 160 mg of NaCl. The molecular weight of NaCl is 58.4, so by Avogadro's number, (or, in German-speaking countries, Loschmidt's number), 58.4 g of NaCl (one mole) contains 6.02×1023 molecules. We can thus calculate that our teaspoon contains about 2×1021 molecules of NaCl. A 12C dilution of seawater will have about one molecule of NaCl per litre.

Thus homeopathic remedies diluted to more than about 12C are virtually certain to contain not even a single molecule of the initial substance. This is recognized by advocates of homeopathy, who assert that the essential healing power is not to be found in the chemical action of molecules, but perhaps in the arrangement of the water molecules, giving rise to the expression "the memory of water". In the homeopathic literature widely differing explanations are proposed for the alleged existence of this water memory. It appears that the community of homeopaths has not yet converged on a single explanatory paradigm.

For instance, homeopaths like to point out that water is not simply a collection of molecules of H2O, but contain isotopologues, molecules with different isotopic compositions such as HDO, D2O and H218O. Mass spectroscopy can indeed detect different isotopologues, but their relative concentration is the same before and after homeopathic treatment&mdash;the concentration ratios can only be changed by nuclear reactions&mdash;so that the presence of isotopologues in water cannot explain its memory.

Also the fact that the molecules H2O appear in two proton-spin forms (ortho and para) has been suggested as a source of memory of water. These two spin forms, which appear in a ratio 3:1, are chemically non-distinguishable and are very difficult to separate or to convert into each other. It is therefore highly unlikely that a homeopathic treatment could change this ratio. Moreover, even if it is assumed that homeopathic tinctures would give somehow rise to ortho:para ratios other than 3:1, it requires much further explanation that these (chemically undetectable)  ratios have different healing qualities.

Another suggestion is that double-distilled and deionized water contains trace amounts of contaminating ions. In particular, water, as a result of repeated vigorous shaking, might include dissolved atmospheric gases in the form of nanobubbles, molecular ions produced from water reacting with airborne contaminants, and silicates&mdash;tiny glass "chips". These possibilities are discussed in Ref. and Ref. But see for further discussion Ref. in which it is concluded that: "it [observed variation in NMR relaxation rates upon ultra dilution] might merely reflect a trivial air-dependent phenomenon, or an unsuspected bias, and should not be extrapolated to the so-called memory of water, often alleged to explain the effectiveness of homeopathy." In January 2009, Luc Montagnier, the Nobel Laureate French virologist who discovered HIV, claimed that the DNA of pathogenic bacteries and viruses massively dissolved in water emit radio waves that he can detect. This, he claimed, can also be used to detect the medicine in a homeopathic remedy. The claim has been received with skepticism in the scientific community. .

Some homeopaths believe that there might be an effect of successive shaking on water structure leading to "clustering" of water molecules. This contradicts the dominant scientific view that motions in liquid water are on the picosecond (10&minus;12 second) time scale and that such clusters could not live longer than a few picoseconds.

People sometimes wonder if the water used to make homeopathic medicines already has other memory imprints from its history prior to use in medicine. However, the water used by homeopathic manufacturers undergoes double-distillation, a process that homeopaths contend eliminates or substantially reduces previous memory. This raises the question: how do homeopaths know that this reduction is sufficient? If the presence of homeopathic qualities is below detection threshold, then surely the absence of such qualities is also undetectable.

In brief, for homeopathy to receive serious scientific consideration, there needs to be plausible explanations for the following:
 * how the process of manufacturing a homeopathic remedy could yield a biologically active substance or solution
 * why the principle of similars might apply in the case of homeopathic remedies
 * how a biological mechanism could have evolved to recognize the specific nature of homeopathic remedies

There also needs to be
 * clear and irrefutable evidence for the efficacy of homeopathic remedies, evidence that cannot be explained by placebo effects

These stringent demands are often summarised by the maxim "Extraordinary claims require extraordinary proof".

Meanwhile, homeopaths, working towards an elucidation of the effectiveness of their medicines, complain that they are up against a double standard in medicine and science. They point out that there is a long history of conventional medical treatments that are applied with positive effects, although  their mechanism of action is not known. Only relatively recently, for instance, has it been understood how aspirin works, but before that doctors used it regularly despite an inadequate understanding of its actual mechanism. In due time, the homeopathic community asserts, the scientific basis of their methods will be unveiled.

In 2010, an Indian team claimed to have found that commercially manufactured metal-derived high-dilution remedies contain nanoparticles of the metals and their aggregates.

Clinical trials testing the efficacy of homeopathic remedies
The “balance of evidence” as to whether homeopathy has any effects other than placebo effects depends on who is balancing the evidence. Homeopaths strongly value the evidence of their own experience in treating patients, supported by the satisfaction reported by their patients in surveys; they believe that this is sufficient evidence of efficacy, but also state that most published clinical trials have shown some beneficial effects. A 1991 global meta-analysis of homeopathic clinical trials published in the BMJ (British Medical Journal) of 105 trials, 81 with positive outcomes, concluded that the placebo response could not explain the positive responses,"Based on this evidence we would be ready to accept that homoeopathy can be efficacious, if only the mechanism of action were more plausible"

Another meta-analysis published in the Lancet in 1997 drew similar conclusions."The results 'were not compatible with the hypothesis that the effects of homoeopathy are completely due to placebo.'" Several meta-analyses evaluating the homeopathic treatment of specific diseases have found positive results, including the treatment of childhood diarrhoea, some post-surgical conditions and respiratory allergies.

Other meta-analyses have suggested that the effect from a homeopathic remedy was no better than a placebo The Cochrane Collaboration is an organisation that publishes meta-analyses of trial results, and most of their analyses of homeopathic treatments indicate some treatment benefits but not adequate statistically significant benefit. The most supportive of their analyses is of the possible benefits of Oscillococcinum for influenza and influenza-like syndromes. Cochrane Reviews did a meta-analysis of seven randomized controlled trials, three prevention trials (number of participants, $$N = 2265$$) and four treatment trials, $$(N = 1194)$$. This was a meta-analysis of seven randomized controlled trials, three prevention trials (number of participants, $$N = 2265$$) and four treatment trials, $$(N = 1194)$$. Overall, the authors found no evidence of any benefits in preventing influenza, but evidence of a small effect on the duration of symptoms. The outcome was sufficiently promising that further trials were recommended, but not strong enough for the remedy to be recommended for first-line therapy.

Why do most trials report positive outcomes for homeopathy, but some show no effect, and how is it that the positive evidence does not persuade most scientists and leaders of academic medicine? In the U.S.A., The National Center for Complementary and Alternative Medicine (NCCAM) administers public-funded research into alternative medicine, and some studies have reported positive outcomes, but NCCAM's acting deputy director, Jack Killen, said, in a Newsweek article, "There is, to my knowledge, no condition for which homeopathy has been proven to be an effective treatment." . In the U.K., the NHS recognizes that there have been about 200 randomised controlled trials evaluating homeopathy, some show efficacy of treatment and some don't. They conclude, "Despite the available research, it has proven difficult to produce clear clinical evidence that homeopathy works".

Homeopaths believe that such attitudes reflect bias against alternative medicine, and that because homeopathy does not lend itself to controlled trials, those with a negative outcome may be false negatives.

According to critics of homeopathy, the published trials of specific homeopathic remedies have been mostly small and flawed in design "“Examples of problems they noted include weaknesses in design and/or reporting, choice of measuring techniques, small numbers of participants, and difficulties in replicating results. A common theme in the reviews of homeopathy trials is that because of these problems and others, it is difficult or impossible to draw firm conclusions about whether homeopathy is effective for any single clinical condition." While many of these have indicated positive effects, generally, trials that are larger high-quality trials have tended to show little or no statistically significant effects, as was concluded by the authors of the second Lancet study cited above when they re-analyzed these trials. "“There is increasing evidence that more rigorous trials tend to yield less optimistic results than trials with less precautions against bias.”" Homeopaths respond that the vast majority of the larger high-quality trials simply tested a single homeopathic medicine, without the requisite individualization of treatment common to homeopathic treatment.

But this does not explain why small trials should have more strongly positive outcomes than large trials. In fact this is a feature of trials of conventional medicine also – and it is believed that the explanation lies mainly in ‘’publication bias’’ – the tendency of trial outcomes to be published only if the outcome is clearly positive; many small trials with negative or inconclusive outcomes simply go unreported, because they are thought to be uninteresting.

In 1999, the government of Switzerland, for a trial period of 5 years, allowed health costs for treatment with homeopathy and four other CAM modalities to be reimbursed under the country’s compulsory health insurance scheme, and set up a programme to evaluate the cost-effectiveness of these treatments (the Complementary Medicine Evaluation Programme (Programm Evaluation Komplementärmedizin, PEK). Under this programme, a team of scientists and practitioners, including a homeopath, conducted an innovative meta-analysis that became the single most cited study of homeopathy, arousing considerable media attention and a storm of protest from homeopaths. The study, which was also published in the Lancet (by Shang et al.) adopted a novel approach; whereas traditional meta-analyses have tried to combine all studies of a given condition, this was a "global" meta-analysis of homeopathy testing the hypothesis that all reported effects of homeopathic remedies are placebo effects. If so, the authors reasoned, then the reports of positive effects reflect publication bias, and if this is the case then the magnitude of such effects should diminish with sample size and study quality, and for the largest and best studies there should be no effect.

They analyzed 110 placebo-controlled homoeopathy trials and 110 matched conventional-medicine trials. Overall, the conventional medicine trials showed some real effect of treatment, in that some effect was still present in the largest and best trials, but the trials of homeopathy remedies did not. The authors concluded that their analysis was consistent with homeopathy being no better than placebo treatment, and controversially suggested that no further research on homeopathy is necessary. The article was accompanied by an unsigned editorial titled “The end of homeopathy” " and a signed editorial by Jan Vandenbroucke, professor of clinical epidemiology, at Leiden University, the Netherlands . The Lancet subsequently published a selection of critical correspondence, and received an angry open letter from the Swiss Association of Homoeopathic Physicians (SVHA). which declared:

''“The meta-analysis may be statistically correct. But its validity and practical significance can be seen at a glance: not one single qualified homoeopath would ever treat one single patient in clinical practice as presented in any of the 110 analysed trials! The study cannot give the slightest evidence against homoeopathy because it does not measure real individual (classical) homoeopathy. It confounds real homoeopathic practice with distorted study forms violating even basic homeopathic rules.”'' In the Shang et al. review, 21 of the homeopathic trials were judged of “high quality”; these studies, overall, showed a benefit of homeopathic treatment. In the final phase of analysis, the researchers included only the largest of these studies; the 8 largest homeopathic trials showed that homeopathic treatment was comparable with a placebo, while 6 similarly large conventional medical trials were not compatible with a placebo effect. Of the 8 largest and best homeopathic trials, only one used an individualized approach to treatment, the other seven used a single medicine prescribed to homeopathic treated subjects. Such non-individualized treatment is common in the larger clinical trials (one of the trials even tested a rarely used homeopathic medicine, Thyroidinum, in the treatment of weight-loss, in a previously untested treatment protocol).

Subsequent critics of the Shang et al. analysis have questioned how definitive it actually is, noting that it involved subjective judgements of study quality. Several studies defined as "high quality" by Linde et al. (1997) were not defined by high quality by Shang et al. most of which showed a positive effect of homeopathic treatment.The Shang et al. analysis also excluded a relatively large study of chronic polyarthritis (N=176) by Wiesenauer because no matching trial could be found. The authors of an article in the Journal of Clinical Epidemiology say "This result can be interpreted differently. Following Shang's perspective it can be explained by small study bias (which includes publication bias). In contrast, one may hypothesize that Shang's result is falsely negative." The authors noted that four of the 21 best trials selected by Shang et al. dealt with preventing or treating muscle soreness—these consistently found no benefits to homeopathy, so if it is accepted that homeopathy is not useful in this condition, the remaining 17 trials show an overall significant effect, mainly determined by two trials on influenza-like diseases. Thus they argue that it is still possible that homeopathy might be effective for some conditions and not for others.

Proponents of homeopathy also note that some of the conventional medical studies analysed by Shang et al. may have shown a treatment effect but that some of these have since been withdrawn because of side effects found subsequently. Critics of homeopathy agree—they say that in conventional medicine, treatments are abandoned when trials show them to be ineffective or unsafe, or when a better drug is found; by contrast, no homeopathic treatment has ever been withdrawn after a trial showed it to be ineffective. Homeopaths contend that flawed trials cannot be used to show that homeopathic treatment is ineffective (please read the previous paragraph for information about the positive trials).

There are many clinical trials and studies which show that homeopathy is effective.

Safety

 * The highest ideal of cure is the speedy, gentle, and enduring restoration of health by the most trustworthy and least harmful way (Samuel Hahnemann)

The U.S. Food and Drug Administration's view of homeopathy is that there is no real concern about the safety of most homeopathic products because of the extremely small dosages. The F.D.A. has deemed that the vast majority of homeopathic medicines are over-the-counter drugs (OTC), that is, drugs that do not need a doctor's prescription and that are safe enough for home care. In the U.S.A., homeopathic remedies must have at least one indication for usage for a disease or condition that is self-limiting and that does not require medical diagnosis or medical monitoring. The European Union allows homeopathic medicinal products, if they are at least 3X, that is, they may not contain either more than one part per 10,000 of the mother tincture or more than 1/100th of the smallest dose of an active substance. No specific therapeutic indication may be given on the label of the product. Some physicians, however, maintain that homeopathic treatment is relatively unsafe, because it might delay other treatment/s, if it fails to work. Homeopaths respond to these concerns by noting that using homeopathic medicines can delay or reduce the use of conventional medicines that are ineffective and dangerous.

Probably every modern pharmacologist would agree with Hahnemann that the drugs prescribed by conventional physicians in the nineteenth century were at best ineffective and often dangerous. However, some homeopaths question whether even modern medical drugs are safe and effective, and recommend homeopathic remedies instead. For example, a 2006 survey by the U.K. charitable trust Sense About Science revealed that homeopaths were advising travelers against taking conventional anti-malarial drugs, instead recommending they take a homeopathic remedy.

Another concern of conventional physicians is that some homeopaths discourage the use of vaccines. Many homeopaths think that vaccination for common diseases, such as measles and chicken-pox, is unnecessary, and some believe that vaccines can even be damaging to health, because of the mercury and aluminum in them, because the bacterium or virus in the vaccine may neither be dead nor weak enough, and/or because some childhood infectious diseases may strengthen immune responsiveness.