Primary & Secondary Symptoms in Determining Dose



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.

Carroll Dunham
Dr. Carroll Dunham M.D. (1828-1877)
Dr. Dunham graduated from Columbia University with Honours in 1847. In 1850 he received M.D. degree at the College of Physicians and Surgeons of New York. While in Dublin, he received a dissecting wound that nearly killed him, but with the aid of homoeopathy he cured himself with Lachesis. He visited various homoeopathic hospitals in Europe and then went to Munster where he stayed with Dr. Boenninghausen and studied the methods of that great master. His works include 'Lectures on Materia Medica' and 'Homoeopathy - Science of Therapeutics'.