As preliminary to an intelligible discussion of this question, we must briefly define primary and secondary symptoms respectively, and state how, in our judgment, the discrimination between them bears upon the selection of the remedy. And this, notwithstanding these questions have been elaborately and lucidly discussed by other members of this bureau. For it will not have escaped the reader’s observation that these terms are used with different significations by different writers.
Symptoms may be called primary as being first in order of occurrence, in comparison with others which, occurring at a later period, are, with reference to time, secondary to them.
Or, symptoms may be called primary as being, in a sense, the exciting cause of other and apposing symptoms, which are then secondary to, as being contingent upon, the former.
Or, symptoms may me styled primary as being of greater importance or significance than others called, therefore, secondary.
The distinction, then, may be based on considerations of time, of opposition in nature, or of rank. And it is important not to confound or combine these ideas in our discussions.
Since most of our traditional notions on this subject originated in Hahnemann’s utterances upon it throughout his writings, I will briefly repeat his views before stating my practical conclusions.
In an essay entitled Suggestions for Ascertaining the Curative Powers of Drugs, published 1796 (S.W., 312), Hahnemann says: “Most medicines have more than one action; the first a direct action, which gradually changes into the second (which I call the indirect secondary action). The latter is generally a state exactly the opposite of the former. In this way most vegetables act. But few medicines are exceptions to this rule, e.g.; metals and minerals.” He illustrates what he means by the secondary action in the following note: “Under Opium, for example, a fearless elevation of spirit, a sensation of strength and high courage, an imaginative gaiety, etc., are part of the direct primary action of a moderate dose; but after eight or twelve hours an opposite state sets in- the indirect secondary action; there ensue relaxation, dejection, diffidence, fear, loss of memory, etc.”
In the preface of the Fragmenta de Vir. Medorrhinum Pos., etc., 1805, Hahnemann says: “Simple drugs produce in the healthy body symptoms peculiar to themselves, but not all at once, nor in one and the same series, nor all in each experimenter; but to-day perhaps these, nor all in each experimenter; but to-day perhaps these, to-morrow those; this first one in Caius, the third in Titus, but so that on some other occasion Titus may experience what Caius felt yesterday.
“A certain drug evokes some symptoms earlier and others later, which are somewhat opposed and dissimilar to each other; indeed may be diametrically opposed. I call the former primary, or of the first order, and the latter secondary, of the second order.
“For each individual drug has a peculiar and definite period of action in the human body, longer or shorter, and when this has passed, all the symptoms produced by the drug cease together.
“Of the drugs, therefore, the effects of which pass over in a brief space of time, the primary symptoms appear and disappear within a few hours. After these the secondary appear and as quickly disappear. But the exact hour in which any symptoms may be wont to show itself cannot be positively determined, partly because of the diverse nature of men, partly because of different doses.
“I have observed some drug the course of whose effects consisted in two, three or more paroxysms, comprising both kinds of symptoms, both the primary and the secondary; the former, indeed, as I have stated in general terms, appeared first and the latter second. And, sometimes, it seems to me i have seen symptoms of a kind of third order.
“Under the action of moderate or small doses, the symptoms of the first order come chiefly to view; less frequently those of the second order. I have chiefly preserved the former, as most suitable to the Medical Art and most worthy to be known.”
Finally he speaks of a class of symptoms which he denominates “reliquias,” generally the effects of very large doses, and which seem to indicate or depend upon more or less permanent alterations of tissue, including the symptoms of the “agony” in fatal cases.
As illustrating these views, I quote remarks prefixed or appended to the symptomatology of several of the drugs mentioned in the Fragmenta.
In a note a Aconite, Hahnemann says: “Through the whole course of action of this plant, its effects of the first and second order were repeated in short paroxysms, two, three, or four times before the whole effect ceased (eight to sixteen hours).” And he describes these effects as follows:
“Alternating paroxysms (during the third, fourth, and fifth hours); general sense of heat, with red cheeks and headache, worse on moving the eyeballs upward and laterally, then shivering of the whole body with red cheeks and hot head; then shivering and lachrymation with pressing headache and red cheeks.”
In a note to Chamomilla, Hahnemann says: “The course of its action is run in paroxysms of several hours’ duration, comprising symptoms of each order, free spaces of remissions being interjected, so, nevertheless, that in the earlier paroxysms, the symptoms of the first order, in the latter, those of the second order predominate.”
In a note to Ignatia, he says: “Ignatia is wont to display the curriculum of its operations in several paroxysms comprising both orders of symptoms, and repeated at intervals of several hours,” and concerning the mental symptoms: “Inconstancy, impatience, vacillation, quarrelsomeness, wonderful mutability of disposition, now prone to laughter, now to tears,” he says: “There mental symptoms are wont to be repeated at intervals of three or four hours.”
Hahnemann’s teachings on this subject in the Organon (in which all the editions substantially agree) have been so fully given by Dr. C. Wesselhoeft in the preceding section of the report of this bureau, that I am spared the necessity of quoting them.
It appears that Hahnemann, in the Fragmenta and the Organon, teaches that among the symptoms of a drug, there appear series which are opposed to each other in different degree of diversity, from being “somewhat opposed” to “diametrically opposite;” and that, of these series, that which occurs first in order of time, is to rank among the primary, and the occurring subsequently among the secondary symptoms. But he calls attention to the fact that there are some kinds of symptoms in every proving, to which there can be no series of an opposite nature, i.e., to which an opposite cannot be predicated; for, he says, “Our organism always bestirs itself to sep up in opposition to this effect (first drug action), the OPPOSITE, condition, WHERE SUCH A CONDITION CAN EXIST.” (1 Organon, 2d and 3d ed., aphorism 74; 4th ed., aphorism 63.
In his definition of primary and secondary symptoms, therefore, Hahnemann blended the elements of time and of causation or nature (viz., that these classes were opposed in their nature). The secondary symptoms were not an independent series, but were secondary by virtue of their relation of opposition in nature to a series of preceding symptoms. And such symptoms as did not in their nature admit of an opposite condition (as, for example, pain, cutaneous eruption, etc.) could not be called primary, because, in the nature of things, they could not be followed by an opposite class of symptoms. Nor could they be called secondary, because, in the nature of things, they could not have been preceded by an opposite series, which could stand to them in the relation of primary symptoms. Hahnemann, then, appears to have recognized in the pathogenesis of drugs, symptoms which being opposed in nature could be arranged into series of primary and secondary, and other symptoms not susceptible of such arrangement.
He distinctly tell us (1 Organon, 2d and 3d ed., aphorism 59; 4th ed., aphorism 152) that the primary or positive symptoms of drugs are those on which we are to base our prescriptions.
These statements in the Organon, as quoted by Dr. Wesselhoeft, embrace not only a description of various classes of symptoms as observed by Hahnemann in drug- proving, but also a theory of the nature and genesis if these various classes. A man’s observations of natural phenomena, if he be a keen and accurate observer, as Hahnemann unquestionably was, are generally correct. His theoretical explanation of them is pretty sure to be tinctured with the philosophy of the period in which he wrote, and is not likely to be accepted without qualification by men of a subsequent period. And, at the present day, few would accept Hahnemann’s explanation of the genesis of primary and secondary symptoms as representing respectively a state of passivity followed by a state of intensified activity on the part of the vital force; this conception of a vital force, in the sense in which Hahnemann used the term, being one which, itself, has been discarded by most physiologists. But the rejection of the explanation offered by Hahnemann does not involve the rejection of the observations to which he attached it.
Among the symptoms which he called primary (Erst wirkungen), Hahnemann recognized the occasional occurrence of what he called alternate (Wechselwirkungen), opposed, sometimes contradictory symptoms, which, nevertheless, were not secondary. He does not tell us how to recognize these, nor how to distinguish them from the secondary symptoms. But he does give us instances of what he regards as secondary symptoms, as follows: (1 Organon, 2d and 3d eds., aphorism 76; 4th ed., aphorism 65) “The gaiety which follows the use of coffee is a primary symptoms; the subsequent drowsiness and lassitude are secondary symptoms. The sleep which follows Opium is a primary and the subsequent insomnia a secondary symptom; the purging of cathartics is a primary and the subsequent constipation a secondary symptom. The constipation of Opium is a primary and the subsequent diarrhoea a secondary symptoms.” And consistently with Hahnemann’s instructions, we should not expect to base our prescriptions on these secondary symptoms.
But when we examine Hahnemann’s remarks on the individual drugs of the Materia Medica Pura, we find deviations from his definitions and illustrations as given in the Organon. In the preface to Belladonna we read: (2 Materia Medica Pura, 1st ed.) “There is not known drug of long action which expresses itself in so manifold drug of long action which expresses itself in so manifold (two and three fold) alternate conditions as Belladonna. Only compare symptom 15 with 16 and this with 17, 56 with 58, and this with 60, 61 and 114, and these with 113 and 152; again, 62 with 63, 64, and these with 70, and 62 with 72, 158 with 159, and this with 160 and 165, and this with 163; and 172 with 174 and 175, and these with 176. Of none of these alternate conditions (wechesl-wirkungen) can it be said that they are beyond the primary action.”
The symptoms thus referred to describe opposite conditions as follows:
Contracted pupils and dilated pupils.
Abdominal pains compelling to bend backward and to sit still, to move forward and not admitting of motion.
Suppressed stool and urine and involuntary stool and micturition, and constant tenesmus.
Sleeplessness and deep slumber.
Raging delirium and wild fear, and foolish madness, etc.
It is evidently Hahnemann’s meaning, and surely experience justifies him, that Belladonna may be given (other symptoms corresponding) when either the one or the other (the opposite) of these conditions is present. And these opposites belong to the class described in the Organon as secondary, and on which we are told, we are not to base our prescriptions.
In the introduction to Nux vomica (Materia Medica Pura, 1st ed.) Hahnemann says: “The symptoms of a single dose of Nux vomica are wont to recur several days in succession, at the same time of day, even at the same hour, or every other day. Hence the usefulness of this drug in some typical diseases when the symptoms otherwise correspond. Besides this periodicity of the symptoms, and besides the alternation of heat and cold, there follow also upon one another, here and there (as is the case also with other drugs), symptoms which differ very much from one another, and appear to be opposed to each other, although they all these alternate actions (Weschselwirkungen).”
And among the symptoms of Nux vomica, Hahnemann calls attention to 232 and 233 “anorexia,” as contrasted with 236-238, “great appetite,” and says these are alternate action, and belong to the primary symptoms, and are, therefore, to be used as bases of prescriptions,” etc.; and to 357-259, “Diarrhoea with desire and tenesmus,” etc.: and says, in a note, “Diarrhoea, constant, abundant, strictly so called, is not, according to my observation, to be expected in the primary action of Nux vomica; and that which here appears among the symptoms as diarrhoea is partly very small, mostly mucous discharges with tenesmus and pain” etc.
Again, in a note to 456, he says: “Discharge of mucus from the nose is an alternate action with dry obstructions of the nose.” There is, clearly, a discrepancy between Hahnemann’s general propositions in the Organon and his practical instructions in the Materia Medica Pura. For we find from the later that Belladonna, for instance, may be given for the primary symptoms, “sopor,” as well as for what in the Organon is called the secondary, but in the Materia Medica Pura the alternate symptom “sleeplessness,” and that nux vomica may be given for the primary symptom “constipation,” and likewise for what is called in the Organon the secondary, but in the Materia Medica Pura the alternate symptom “diarrhoea.”
The very terms primary and secondary, as thus illustrated, seem to imply a succession of symptoms, more or less opposed in character, and all of them differing from the equilibrium of function which we recognize as health. The instances given, and, indeed, the only possible instances, relate to functions of which a “more” or “less”, or an “opposite,” may be predicated; as, for example, temperature, sleep, certain mental conditions, and the secretions and excretions generally. Thus we may have an unnaturally prolonged sleep or wakefulness, gaiety, or despondency, and a plus or minus of sweat, alvine discharge, urine, etc., etc. But how could we have an opposite condition to any specified pain or subjective sensation, to parenchymatous deposit, to cutaneous eruption, etc., etc.? The absence of these phenomena would be pro tanto a state of health; it would not be an opposed morbid conditions or sensation.
The possibility, then of classifying symptoms into primary and secondary on the basis of the relative nature of the symptoms, is not co-extensive with symptomatology; it is partial, confined to a moderate number of conceivable morbid phenomena.
Shall, we, then, in the second place, base the distinction on the elements of time, and call the symptoms which first occur primary, and those which come later, secondary? Where then shall be draw the line? how many hours r days shall we allow for the development of primary symptoms? In view of the immense differences in the rapidity with which the curriculum of action of different drugs in run, it is obvious that a special rule must be established for each drug. Nor is this the only difficulty. The results of different doses on the same proves, and of different doses or even of the same dose on different provers, are so various that, 1st, as Hahnemann intimates in the preface to the Fragmenta, the symptom which appears in one prover to-day will not appear for several days in another prover; and, 2d, a very small dose two series of opposed symptoms; a still larger dose two series differently opposed; and a very large dose again only one series. This point has been so well illustrated by Prof. Allen with whose views I am glad to express my entire concurrence, that I need not dwell upon it, but may content myself with two illustrations from our Materia Medica.
On looking over the register of symptoms of Argentum nitricum, (1 Oest. Zeit.I) we find reported as occurring early in the proving, irritation of the bladder and urethra and increased frequency and quantity of urine, and as occurring later in the proving, diminution in frequency of micturition and in the quantity of urine. Surely one might pronounce the former to be primary and the later secondary symptoms. But on examining the provers’ day-books we find that the majority of the provers (being those who took large doses) report the former and not the latter symptoms. It was the prover who took the 30th who reported diminished urine, and he did not report any increase at any time.
These symptoms, therefore, which appear in the register to be opposed, and properly distinguishable as primary and secondary, did not bear to each other any relation of apposition or correlation, as they might have done had they occurred in the same individual. They are different, unrelated, independent effects of different doses in different individuals. And let me suggest, in passing, that the beautiful pictures of primary and secondary effects of drugs which we find in works of Old-School writers, and which have been made the basis of “laws of the dose” by writers of our own school, are composite pictures made up from a variety of observations on patients and from cases of poisoning, and bear no more resemblance to a pathogenesis on a single individual, than the composition of an artist which has the mountains of Ecuador covered with the forests of Oregon and decked with the flowers of Java presents to a faithful landscape from nature.
Most of the provers of Tellurium taking the 3d trit, had, on the first and subsequent days, symptoms of the general sensibility, of sweat, of the skin, of the bladder, etc., etc. But one prover who took the 4th trit. had no symptoms at all until the fourteenth or fifteenth day, when cutaneous symptoms affecting the ear appeared and were very persistent and troublesome. Were these symptoms secondary because they came later than other symptoms in other provers? And secondary to what? How can John’s lumbago be secondary to James’s toothache? But during the second month this same prover, his ear symptoms having vanished, had symptoms referred to the dorsal spine. Were these secondary to the ear symptoms because they came later? Certainly as regards time they were secondary, because later. But being in nature wholly unrelated, neither opposite nor similar, they cannot be called secondary as regards nature nor as regards rank or values. Both have been repeatedly verified in practice.
Again, we are told (1 “The Dose,” by E.M. ale, M.D., N.A.J., ix.265) that coldness, a condition corresponding to the chilly stage of fevers, is the
primary effect of Aconite, and that a state corresponding to the hot stage of fever is the secondary effect of that drug. Let us hear Hahnemann. In the introduction to Aconite (1 Mat, Med, 1st ed) he says: “Aconite is one of a few drugs whose primary action consists in several alternating conditions of chill or coldness and heat.” And now let us study the day-books of the Austrian provers of Aconite.
Rothausl took tincture of Aconite in doses regularly increasing from six drops daily to fifteen drops daily for nine days, when, feeling powerful effects, he ceased taking it and noted his symptoms.
From the second to the eighth day inclusive, he had the following constantly recurring symptoms: restlessness at night; bad dreams; unnatural heat of body; rawness and increased secretion in the larynx; cough; vertigo; headache. On the ninth day, after midnight, severe chill in paroxysms of shivering, starting from the praecordia, lasting two hours, followed by burning, dry heat, with frequent, feverish pulse; and this followed by moderate sweat.
For the next six days he has various troublesome symptoms affecting the chest and limbs, and on the sixteenth day of the proving he had again, at night, a febrile paroxysm consisting of chill, heat and sweat, the first less severe, the last more abundant than on the ninth day.
On the seventeenth day, at night, a similar febrile paroxysm. Then for seven days symptoms of increasing severity in the head and chest, ending with haemoptysis on the nineteenth day, and finally, on the twenty-fourth day, a very severe and well marked and defined neuralgic head and face ache.
How can be ingenuity of the most ambitious law giver find a pretext for dividing the symptoms (especially the febrile symptoms) of this excellent proving into primary and secondary? A febrile paroxysm occurred on the ninth, the sixteenth and the seventeenth days’ before it and after it were well-marked symptoms of the chest and extremities. Which shall be primary and which secondary if date of occurrence determine the question? Which, if nature or if rank determine it?
Certainly, if lateness of occurrence stamp a symptom as secondary, then the neuralgic head and face ache, the very last symptom reported by Rothausl, must be classed as secondary. Not so fast, however? In the proving of Aconite by Zlatorovish with the second decimal, which he took in increasing and very large doses for seven days without effect, the very first symptom was a violent neuralgic head and face ache, almost identical with that described by Rothausl on his twenty-fourth day.
It appears, then, that Rothausl’s last symptoms was Zlatarovich’s first. If the time of occurrence determines the class, we must rank Rothausl’s headache among the secondary, and Zlatarovich’s identical headache among the primary, and thus we have the same symptom in each class, which is a reductio ad absurdum.