HOMEOTHERAPY Definitions and Therapeutic Schools

HOMEOTHERAPY
Definitions and
Therapeutic Schools
HOMEOTHERAPY
2
DEFINITIONS AND
THERAPEUTIC SCHOOLS
PREAMBLE
Also in 2004, world-wide demand and popularity of
Complementary and Alternative Medicine (CAM) is increasing.
This sector of medicine comprises a significant number of
therapies and schools employing homeopathic medicinal
products. Market research conducted within the European
Union countries indicates that a significant part of the population uses these medicines or has an agreeable attitude to
treatment with such methods [Lewith, Aldridge 1991, European
Commission ‘971].
In this time, when patients are increasingly aware and
concerned of medicinal risks and side-effects, the use of
homeopathic medicines has gained ever-increasing significance.
The pharmaceutical quality is governed by (official)
homeopathic pharmacopoeias such as the European
Pharmacopoeia, BHP2, HAB3, HPUS4, and the PhF5.
The legal frame work governing homeopathy has been set out
in European Directives 2001/83/EC and 2004/27. This classifies
homeopathic medicinal products as medicines. Consequently,
they are subject to the relevant quality and safety requirements
like the Good Manufacturing Practice (GMP) which apply to all
pharmaceutical products.
This brochure aims at providing general definitions and gives a
bird’s eye view on the individual schools of therapy covered
under the heading of homeotherapy.
1
2
3
4
5
Commission Report to the European Parliament and Council on the Application of Dir. 92/73 and 92/74
BHP: BRITISH HOMEOPATHIC PHARMACOPOEIA
HAB: Amtliches Deutsches Homöopathisches Arzneibuch
HPUS: Homeopathic Pharmacopœia of the United States
PhF: PHARMACOPÉE FRANÇAISE
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1.
DEFINITION OF HOMEOPATHY
In the early 19th century, the physician and pharmacist
Dr. Samuel Hahnemann discovered an extraordinary form of
medicinal therapy: homeopathy.
Homeopathy is a system of medical practice
aiming at methodologically improving the level
of health of an organism by the administration
of potentised medicines, which are selected in
accordance with the Law of Similars6.
This therapy activates the body’s intrinsic self-healing powers in
a unique manner by giving it a treatment of stimulation and
regulation.
Since Hahnemann‘s time, the use of homeopathic preparations
has continued to develop in a variety of directions. Various
schools are known today under the umbrella of "homeotherapy" varying from classical, unicist and pluralistic schools of
homeopathy, to other schools of therapy, encompassing clinical
homeopathy, combination product homeopathy, antihomotoxic
therapy, anthroposophic medicine, biochemistry according to
Dr. Schüssler, spagyric therapy, etc. These therapeutic schools
differ from one another primarily in their conceptual framework
of illness, and the criteria employed in the selection of the
appropriate medication.
6
4
"Similia Similibus Curentur" (like cures like)
2.
HOMEOPATHIC MEDICATION
The European Directive defines a homeopathic medicinal
product as:
"Any medicinal product prepared from products,
substances or compositions called homeopathic
stocks in accordance with a homeopathic
manufacturing procedure described by the
European Pharmacopoeia or, in absence thereof,
by the pharmacopoeias currently used officially in
the Member States"
"A homeopathic medicinal product may also
contain a number of principles"
A characteristic which all homeopathic medications have in
common is their production from one or several source
materials to mother tinctures (abbreviated as MT, TM or Ø) or
stocks (= active constituent), generally followed by a process of
potentising: serial dilution and succussion (shaking in a vessel).
The following examples of attenuation-ratios are frequently
cited within the various pharmacopoeias:
Attenuation-Ratio
Labeling
1:10 (Decimal)
D, DH or X
1:100(Centesimal)
C, CH
1:50.000 (LM)
Q, LM
5
Potentising is carried out by means of either the single-glass
(for the execution of one production process one bottle is
used7) or multiple-glass method (for every potentising step a
new vessel is used). The process may be performed either
manually or by machine. In addition to the medicinal forms of
dilutions, globuli, and triturations introduced by Hahnemann,
homeopathic preparations are now available in the pharmaceutical forms of today.
2.1
SOURCE MATERIALS IN
HOMEOPATHIC MEDICATION
The active constituents of homeopathic
medications may consist of substances, materials,
or concentrated preparations of either synthetic
or natural (organic/inorganic) origin
[Pharm. Eur. "Homöopathische Zubereitungen"
("Homeopathic Preparations"), 1995]
The general requirements for the various classifications of
raw materials are stipulated within the homeopathic pharmacopoeias. Brief descriptions of the most important sourcematerial categories are given below.
2.1.1. PLANT PRODUCTS
Depending upon the substance, mother tinctures are prepared
either from the whole plant or specific parts of the plant.
The plants utilised must be free of any visibly diseased, rotten,
withered, or decomposed portions. Requirements as to species
and time of harvest must be fulfilled.
7
6
The potencies derived from this process are also called Korsakov potencies or K-potencies, named after the
physician of the Czar. Korsakov received permission from Hahnemann to make his medicines according to
the proposed one flask method, so that during his travels with the Czar he was not compelled to carry in his
luggage a freight of bottles to prepare the required medicines.
2.1.2. CHEMICAL COMPOUNDS
Prior to potentising, substances such as minerals, elements,
salts, acids, and synthetic materials are either dissolved in a solution of alcohol and water, or triturated with lactose. The choice
depends on the characteristics of the individual substance.
Specifications in each monograph as to origin (natural or
synthetic) and degree of purity are strictly observed. Minerals
and salts from natural sources frequently contain traces of
additional substances which are considered to contribute to
their homeopathic activity spectrum.
2.1.3. ANIMALS AND ANIMAL SUBSTANCES
Entire animals - primarily lower animals such as insects - or parts
of animals, or secretions are used. The animals must be healthy
and processing must meet satisfactory hygienic conditions.
All applicable laws in the area of animal protection are
observed.
2.1.4. ORGAN PREPARATIONS (SARCODES)
Healthy organs, tissues and metabolic factors of animals (as a
rule, bovine cattle, sheep, or swine) collected under veterinary
controlled hygienic conditions are used in the manufacture
of sarcodes. The collected material is processed either immediately after slaughter, or from a freeze-dried state.
7
2.1.5. NOSODES
A nosode is a homeopathic preparation of organic material
derived from inactivated disease products or cultures of microorganisms (e.g. bacteria, fungi and viruses) or parasites or
infected or pathologically changed material or decomposition
products from animals or humans, rendered safe during the
homeopathic manufacturing process.
The pharmacopoeias require sterilisation of either the source
material or the first attenuation, and meeting sterility requirements prior to further processing.
2.2.
COMMERCIAL QUALIFICATIONS
OF HOMEOPATHIC PHARMACEUTICALS
Homeopathic preparations are evaluated by the following
criteria:
• Quality
• Safety
• Effectiveness
2.2.1. QUALITY
Factors which influence the quality of a homeopathic medicinal
product are:
• Identification and precise definition of source material
• Execution of each production-step as stipulated in the
official or authorised homeopathic pharmacopoeia
• In-process controls
8
• Testing of the final product
• Verification of the stability of the end product and the
selection of appropriate packaging
In order to meet all requirements, every manufacturer of
homeopathic pharmaceuticals is obliged to comply with the
requirements of the GMP8.
In contrast to conventional pharmaceuticals, it is frequently
impossible to perform a qualitative and/or quantitative analysis
of the active constituents present in the final pharmaceutical
product of a homeopathic preparation. Therefore the homeopathic manufacturer is required to validate each manufacturing
procedure in addition to providing exact documentation of the
results of examinations such as in-process controls and stability
control.
2.2.2. SAFETY
Due to their degree of dilution, most homeopathic preparations
pose no toxicological risk.
8
Good Manufacturing Practices
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2.2.3. EFFECTIVENESS
Homeopathic drug provings, gained over almost 200 years,
constitute a wealth of experience and provide a comprehensive
knowledge of the clinical effectiveness of homeopathic medicinal products. Homeopathic medicines are selected in
accordance with the concepts, insights, and experience gained
in each individual therapeutic school (internal acknowledgment)
[Zuck 1991].
The procedures commonly used today in clinical research, for
example randomised clinical studies, are applicable to homeopathic medication only to a limited degree. Proof of the
efficacy of homeopathic single remedy and/or combination
preparations can be documented through methods such as
single case studies, observational studies, etc. [Hornung 1994,
Kienle 1996, Kiene 1993]
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3.
THERAPEUTIC SCHOOLS OF HOMEOTHERAPY
3.1.
CLASSICAL HOMEOPATHY
In classical homeopathy, medications are chosen in strict
accordance with the Law of Similars, formulated as the basis
of homeopathy by Hahnemann in 1796. The Law of Similars
is applied by comparing the symptom complex of each
medication with the symptom complex of the diseased
individual. Selection of the correct homeopathic remedy, i.e.
that which achieves the greatest possible similarity between the
symptom picture of the medication and the symptoms of the
patient, is essential for therapeutic success [Hahnemann
(Publisher: Hochstetter, 1989)].
The therapeutic profile of each homeopathic medication is
based on the homeopathic drug-proving, which is conducted on
healthy subjects and constitutes the first fundamental rule of
classical homeopathy.
During a homeopathic drug proving, the medicinally-active
substance is administered to healthy subjects for a predetermined period of time. The symptoms which occur in all subjects
are recorded and systematically compiled. These data form the
basis of the so-called "proving" (drug picture).
The second fundamental rule of classical homeopathy calls for a
precise determination of the unique constellation of symptoms
presented by each individual patient. A detailed case history
11
must take into consideration all physical, mental, and
emotional symptoms. For this purpose, the physician lists
meticulously the patient’s individual, peculiar and unusual
symptoms and develops a constitutional picture of the patient.
The objective of this procedure which focuses on the human
person as a whole is to reach not only a precise clinical
diagnosis, but also the selection of the correct medication in
compliance with the Law of Similars (the third fundamental rule
of classical homeopathy).
In classical homeopathy, therefore, only single constituent
homeopathic remedies are employed, which have been
selected in accordance with the Law of Similars [Wünstel 1987,
Köhler 1994].
3.2.
CLINICAL HOMEOPATHY
In clinical homeopathy, the selection of the medication is based
on the chief clinical symptoms of the illness to be treated. This
so-called "abridged method" of selecting the medicine is
primarily employed in cases of acute illness9. Here, the 'Similar'
concept relates above all to the local and/or acute syndromes
displayed by the patient. In clinical homeopathy, constitutional
characteristics play only a minor role in the choice of the
remedy. Over many years, the consolidated experiences of
numerous homeopathic physicians have made prescribing on
the basis of "reliable indications" an established practice in
treatment of certain clinical pictures [Dorcsi 1970, Eichelberger
1987, Köhler 1994].
9
12
Hahnemann dealt with the treatment of the wounded after the battle of Leipzig in 1813. When typhus
broke out he achieved remarkable results by using homeopathy (Trevor M.Cook, M.Sc, PhD., in Samuel
Hahnemann; the Founder of Homoeopathic Medicine).
3.3.
COMBINATION PRODUCT HOMEOPATHY
Homeopathic combination preparations are mixtures of two or
more reliable, active, homeopathic agents (single remedies).
The formulae for the combined preparations are based on the
clinical experiences of therapists actively practicing homeopathy. Each combination is composed so as to induce the
individual active agents to target the corresponding illness with
cumulative or synergistic force. Homeopathic combinationpreparations have an extensive range of action and are
consequently appropriate for treatment of numerous common
illnesses. Use is generally carried out according to clinical
indications [Ersfeld et al. 1991].
3.4.
ANTIHOMOTOXIC THERAPY
AND HOMOTOXICOLOGY
In his dissertation of 1955, "The Problems of Treating
Homotoxicosis", Dr. Hans-Heinrich Reckeweg provided the
scientific fundamentals for a therapy by means of antihomotoxic pharmaceuticals concluding with their consolidation under
the term "homotoxicology". As all expressions of life - physiological or pathological - are determined by the transformation
of chemically identifiable agents, it follows that all life processes
fall subject to the laws of chemistry and biochemistry
[Reckeweg 1955, John 1991].
According to Bertalanffy [1932], the human organism may be
considered a flow system. During illness, the state of balance
13
within this system, or homeostasis, is disturbed and defensive
reactions within the body are triggered. All pathological
processes - expressing themselves as disease (named by
Reckeweg "homotoxicosis") and hindering homeostasis - are
caused by toxins. Reckeweg termed these "homotoxins" or
"human poisons".
The various diseases constituting homotoxicosis are divided into
groups according to severity. A clear overview of these
fundamental mechanisms of the organism’s toxic-defense was
presented in the form of his 6-Phase Table of Homotoxicosis
[Schmid et al. 1996, John 1991, Schmid 1990, Reckeweg
1981]. The objective of antihomotoxic therapy is the
detoxification, elimination, or the deposition of homotoxins, in
order to preserve the organism’s capability to live as extensively
as possible (Principle of Biological Expediency) [Reckeweg
1981].
In addition to the active substances from animal, vegetable, and
mineral origin employed in classical homeopathy, antihomotoxic
medicines also contain nosodes, tissues or organ preparations,
homeopathic preparations of synthetic materials, vitamins, trace
elements, etc. [Schmid et al. 1996]. Other ingredients frequently employed in antihomotoxic medications are the
so-called potency accords. These are mixtures of various
potencies of the same active agent, conjoined within one single
galenic form. The objective of such potency accords is to
intensify therapeutic effects as well as to improve tolerance
[Reckeweg 1981].
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3.5.
ISOPATHY
Isopathy is a therapeutic school of homeopathy which became
established during the course of development and propagation
of homeopathy. While classical homeopathy concerns itself
with the tenet similia similibus curentur (like cures like),
isopathy operates on the theory that equals are cured by
equals - aequalia aequalibus curentur. The ison [Göhrum 1904]
is employed not only for the purpose of curing diseases, but also
for defending respectively strengthening the organism
(compare with vaccination).
Isopathic medicine may be divided into three categories
[Göhrum 1904, Brutzer 1852]:
• Isopathic medicine in a strict sense
• Isopathic medicine in a broader sense
• Organ preparations
Isopathic medicine in a strict sense involves direct employment
of the pathogenic substance to treat the illness it has caused.
An excellent example is amalgam expulsion therapy which
administers potentised amalgam (D12 and higher).
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3.6.
ANTHROPOSOPHIC MEDICINE
Founded by Rudolf Steiner (1861-1925), Anthroposophy
(Greek: anthropos = human, and sophia = wisdom) is a
spiritual science based on the comprehensive view of the
human being. Steiner described in great detail a method by
which the scientific exploration of the transcendental, spiritual
side of man and nature can be directly incorporated into
everyday life. Anthroposophic medicine is an extension of scientific medicine and as such also includes anthroposophic
methods of research. The objective of anthroposophic medicine
is to look at a human being as a whole entity within the art
of healing [Glöckler et al. 1991, Glöckler et al. 1993].
In evaluating health, illness and healing, the anthroposophic
physician bases his/her considerations not only on the physical
laws of natural scientific medicine but also takes into consideration those aspects that cannot be encompassed by natural
science. Anthroposophy perceives the human being as consisting of four essential elements: the physical body, the
organisation of vital forces, the organisation of feelings within
the soul, and the spiritual organisation of the ego. The
interaction of these four elements, in turn, results in a three-fold
division of the physical as well as spiritual being.
Furthermore, a three-fold order manifests itself throughout the
entire organism, both morphologically as well as functionally.
Polar processes taking place within the sensory/nervous system
(catabolism / percepts / stillness) and the metabolic/locomotive
system (anabolism / elimination / motion) are brought into
harmonious relationship with one another by means of the
rhythmic system (circulatory/respiratory system). Health is
16
understood as a state of equilibrium - requiring continual
reinstatement - among the influences exerted by these various
processes of the human being. A disturbance in the interrelation
of these forces initiates illness.
Every patient receives comprehensive information, enabling him
or her to actively participate in the healing process. In addition
to the therapy with homeopathically produced anthroposophic
preparations, anthroposophic treatment also incorporates other
modes of therapy, and medication. These measures help to
activate the self-healing powers within the patient.
Selection of the appropriate medication is based on the
consideration of two factors: the relationship between the
human organs and certain processes on one hand; and the
relationship between these organs and nature (the animal,
vegetable, and mineral - particularly metals - realms) on the
other [Glöckler et al. 1993, Schmid 1993].
Anthroposophical medicine applies a holistic approach.
It consequently includes the use of advanced pharmacological
medications in individual cases based on the specific need
and indication.
3.7.
BIOCHEMISTRY ACCORDING TO DR. SCHÜSSLER
Schüssler practiced as a homeopathic physician for many years.
He developed a method of biochemical therapy which has been
utilised since 1872. This technique employs a limited number of
mineral compounds, which analysis reveals to be present
within the human body in elementary form. Based on his
experience in the field of homeopathy and encouraged by
17
Virchow´s findings in the realm of "cellular pathology" as well
as further discoveries of his contemporaries, Schüssler developed the theory that interprets illness as the result of a
disturbed mineral balance within individual cells of the body.
From the great wealth of homeopathic preparations, Schüssler
selected a limited number of specific medications for use in his
mineral-salt (or cell-salt) therapy. As in homeopathy, these are
used in a potentised form attuned to the constitution of each
patient. Like Hahnemann, Schüssler viewed his form of
treatment as a stimulation therapy assisting the body to regain
its regulatory capabilities, thereby restoring it to a state of good
health [Schüssler 1933].
Based on Schüssler´s concept, Schöpfwinkel expanded on
biochemical medication therapy [Schöpfwinkel 1929, 1932].
On the grounds of his theories, biochemical therapy today
encompasses not only the 12 biochemical medications
designated by Dr. Schüssler, but includes 12 additional,
so-called adjunctive agents as well.
3.8.
SPAGYRIC THERAPY
Dating from the times of Paracelsus, the terms spagyric and
spagyrism are derived from the Greek verbs "span" (to
separate) and "ageirein" (to unify). They designate the art of
creating medications of enhanced efficacy by performing the
two fundamental alchemical operations. The valuable portions
are first separated from those which are impure, processed and
subsequently reunited to yield an improved medicinal form
[Helmstädter 1990]. The source materials of spagyric medicines
18
are exclusively from botanical origin. Depending upon the
manufacturing process, differentiation is made among
spagyrism according to Krauss, Zimpel, Pekana, and
Strathmeyer.
3.8.1. SPAGYRIC THERAPY ACCORDING TO KRAUSS
Two central pillars exist in spagyrism according to Krauss:
phytotherapy, and homeotherapy. Within the present context,
phytotherapy is to be understood as the traditional art of
healing with plants. Factors common to both homeopathy and
Krauss´ spagyric therapy are the potentising process and observance of the Law of Similars. The spagyric medications are
administered in either their 4th or 10th decimal potency. The
clinical properties of the active medicinal substances within each
preparation help determine the selection of the appropriate
medication.
In the Krauss’ school of spagyric therapy, pathological processes
are not viewed simply as isolated instances of dysfunction in
individual organs or within the mind. Therefore, the objective is
to detect and treat the course of disease in the interactions with
all body processes. In order to adequately cover the multi-level
interconnections of an illness, this type of therapy employs
complex medications consisting of a combination of numerous
single-ingredient spagyric remedies.
Selection of the appropriate spagyric agents to be included
within a complex is based on the physiological and anatomical
relationships existing among individual body functions, organs,
and organ groups. The single-ingredient agents are combined
in such a manner to influence a group of organs closely
19
associated with one another in either a physiological or
anatomic-histological manner. Contained within one spagyric
medication are single-ingredient agents with similar fields of
action as well as those that influence the pathological condition
from a variety of aspects. The constituents are combined to
target the illness synergistically while mutually supplementing
their effects. Thus they selectively direct their effects within the
diseased organism at multiple levels, each in correspondence
with its individual range of action, thereby collectively creating
stimulation of the body’s intrinsic defensive and regenerative
powers [Bruch 1939, Krauss 1989].
3.9.
OTHER HOMEOPATHIC SCHOOLS
3.9.1. GEMMOTHERAPY
Gemmotherapy was established by Dr. Henry from Brussels. The
homeopathic medications employed in this therapeutic method
are produced utilising glycerin macerates made from fresh,
embryonic plant-tissue, such as young shoots, rootlets, and the
inner bark of roots and stems. These possess drainage
stimulating properties. As the selected plant tissues are in a
phase of cellular multiplication at the time of processing, they
are correspondingly rich in growth-factors such as hormones,
auxins, and gibberellins. Therapeutic use of such glycerin
macerates is exclusively at a potency of D1. The stimulative
action exerted by these products on the reticulo-endothelial
system (RES) has been demonstrated by means of the Halpern
test. This test is primarily employed in allergology. Application of
drainage-stimulating preparations in weak concentration (D1)
activates the eliminatory organs, thus facilitating detoxification
20
of the organism. Each embryonic plant tissue possesses an
affinity to a certain organ. Based on this fact, it is possible to
allocate a series of clinical indications to each medication.
Gemmotherapy may either be employed as a stand alone
therapy, or in combination with other homeopathic medications. In certain cases, classical homeopathy prescribes
prophylactic administration of such medications; e.g. for
the purpose of dampening initial homeopathic aggravation
[Tetau 1978].
3.9.2. LITHOTHERAPY
Lithotherapy, also called "dechelating lithotherapy", involves
the therapeutic application of naturally-occurring rocks and
minerals in homeopathically attenuated form. The homeopathic
form of these substances is generally employed as D8 ampoules
for oral consumption, aiming at normalising specific metabolic
disturbances.
3.9.3. RESONANCE HOMEOPATHY
In 1992, Schimmel conducted a study on the resonant behavior
of selected homeopathic medications in reference to healthy
human organs and organ structures.
In early 1993, the first organ-specific, homeopathic complex
preparations were created under the auspices of the
International Society for Research on Functional Medicine and
Resonance Homeopathy.
21
Shortly thereafter, resonance relationships were discovered to
exist between single ingredient homeopathic preparations and
microorganisms. This led to the development of fungus-specific
and virus-specific homeopathic complex remedies, by means of
which systemic viral and fungal infections may be successfully
treated.
4.
OTC HOMEOPATHY
Over the years in many EU Member States homeopathic combination remedies but also single remedies are on the market
with a marketing authorisation. This means that the medicinal
products have permission to mention a therapeutic indication
on the package.
It is a tendency that patients and consumers take increasing
responsibility for their own health. They inform themselves
thoroughly and don’t hesitate to ask an expert advice from a
pharmacist or a practitioner. The internet has become an important source of information. Also literature on health issues is
readily available nowadays.
Consumers suffering from minor self limiting ailments buy their
self medication remedies themselves instead of paying a visit to
a physician. Since homeopathy has acquired a high degree of
social acceptance it is no problem for the consumer to choose
between a conventional drug and a homeopathic alternative.
Homeopathic OTC* remedies have a long track record of
safety and effectiveness. In a number of Member States
homeopathic self medication remedies rank among the top ten
*
22
Over-The-Counter medicaments are defined to be non-prescription medicinal products generally distributed
by pharmacies.
of most purchased OTC remedies. The indications for which
homeopathic OTC medicines enjoy great confidence of the
consumer and patient are cold and flu, muscular pains, skin injuries
and teething with little children.
Self care and self medication means empowerment of the citizen. In
times with an ageing population and increasing pressure on the
national healthcare budgets the availability of OTC medicines tends
to reduce that pressure. At the same time the practitioners can
concentrate on the cases that really matter. A study executed in The
Netherlands demonstrated that a policy shift encouraging self
medication saved the social security tens of millions of Euros. In this
respect more examples are known.
5.
SUMMARY
In a regulatory or legal context, classification of a pharmaceutical as
a homeopathic medicinal product is not the manner of use, but
solely the aspect of manufacture which is decisive. Homeopathic
medicinal products are manufactured in accordance with
today’s pharmaceutical-galenical criteria, as outlined in the official
homeopathic pharmacopoeias and incorporated in the legislation
of the European Union.
Homeopathic medications are employed by various therapeutic
schools, applying techniques which can be united under the term
homeotherapy. The selection of medication to be used is done in
accordance with the specific criteria of each therapeutic system.
23
LITERATURE
24
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Bruch, O. M.
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Regensburg: Johannes Sonntag, 1939.
Brutzer
Isopathie. 1852: All. Hom. Z. 44; 13, 193-201.
Cook, Trevor M.
Samuel Hahnemann; the Founder of Homoeopathic Medicine,
Wellingborough: Thorsons Publishers 1981
Dorcsi, M.
Personotrope Medizin und Homöopathie. Praktikum der homöopathischen
Medizin. Heidelberg: Haug Publishers, 1970.
Eichelberger, O.
Klassische Homöopathie. Praxis und Forschung.
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Ersfeld, A., Hahn, G.
Komplexmittelhomöopathie. In: Zentrum zur Dokumentation für
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25
Hornung, J.
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Preis, S.
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Krankheitsbegriff.
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27
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1st edition, December 2004
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