PRIMARY AND SECONDARY SYMPTOMS OR THE OPPOSITE ACTION OF LARGE AND SMALL DOSES. MUCH confusion exists among medical men for want of a proper comprehension of our subject; and false claims as to principles of selection and the modus operandi of cures are often made when primary and secondary symptoms of drugs are used as guides in determining the seize of the dose.

MUCH confusion exists among medical men for want of a proper comprehension of our subject; and false claims as to principles of selection and the modus operandi of cures are often made when primary and secondary symptoms of drugs are used as guides in determining the seize of the dose.

This is not strange, however, since the terms primary and secondary, as applied to drug-action, are susceptible of different interpretations, and are used with different significations by different authors.

Of the picture of primary and secondary effects of drugs which we find in the works of Old-School writers, and which have been made the basis of the “law of the dose” by some writers of the Homoeopathic School, I quite agree with the late Dr. Dunham’s estimate, that “they 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.”.

Let me rehearse what the writers of the Homoeopathic School have said concerning the subject under consideration.

Hahnemann, in his essay, “Suggestions for Ascertaining the Curative Powers of Drugs,” published in 1796, and which you can read in the Lesser Writings, says: “Most medicines have more than one action; the first a direct action, which generally 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.” He illustrates his meaning thus: “Under Opium a fearless elevation of spirit, a sensation of strength and high courage, an imaginative gaiety are part of the direct primary action of a moderate dose on the system; but after the lapse of eight or twelve hours an opposite state sets in, the indirect secondary action, and there ensue relaxation, dejection, diffidence, peevishness, loss of memory, discomfort, fear.”

It must be noted here, however, that Hahnemann admitted qualifications as to his general statement as to the opposite primary and secondary action of medicines and specified metals and minerals which “continue their primary action uninterruptedly, of the same kind, though always diminishing in degree, until after some time no trace of their action can be detected, and the natural condition of the organism is restored”.

In the preface of the Fragmenta, published in 1805, Hahnemann further 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…..

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, or 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 cases 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 drugs 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 came 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.”.

The illustrate his views he prefixed or appended to the symptomatology of the drugs mentioned in the Fragmenta the following remarks:.

Under Aconite: “Through the whole course of action of this plant, its effect of the first and second order were repeated in short paroxysms two, three or four times before the whole effect ceased. These effects were as follows:.

Coldness of the whole body and dry internal heat; chilliness; sense of heat, first in the hands, then in the whole body, especially in the thorax, without sensible external heat. .

Alternating paroxysms (during the third, fourth and fifth hours), general sense of heat, with red checks 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”.

Under Chamomilla: “The course of its action is run in paroxysms of several hours’ duration being comprising symptoms of each order, free spaces or remissions being interjected, so, nevertheless, that in the earlier paroxysms the symptoms of the first order; in the later, those of the second order, predominate”.

Under Ignatia: “Inconstancy, impatience, vacillation, quarrelsomeness, wonderful mutability of disposition-now prone to laughter, now to tears. These mental symptoms are wont to be repeated at intervals of three or four hours”.

Commenting on these quotations from Hahnemann, Dr. Carroll Dunham has truly said: “In his definition of primary and secondary symptoms, 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”.

Hahnemann pointed out they clearly, however, that there are symptoms in every proving to which there can be no symptoms of an opposite nature. He says: “Our organism always bestirs itself to set up on opposition to the first drug-effect the opposite condition, if such a condition can exist.” In other words, such symptoms as in their nature did not admit of an opposite condition (as, for example, pain, cutaneous eruptions, 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 also recognized symptoms occurring occasionally which he denominated contradictory, which were not secondary, but how to distinguish them from the secondary symptoms we are not told. In the Organon he gives instances of what he regards as secondary symptoms, viz: “the gaiety which follows the use of coffee is a primary symptom; 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 symptom”.

According to the rules laid down in the Organon, we are to use the primary symptoms in prescribing, nerve the secondary.

In the Materia Medica Pura, however, we find Hahnemann to deviate from his definitions and illustrations in the Organon. In the preface to Belladonna he says: “There is no known drug of long action which expresses itself in so manifold (two and three- fold) alternate conditions….Of none of these alternate conditions (Wechselwirkungen) can it be said that they are beyond the primary action.” The symptoms referred to are:.

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.

In the preface to Nux vomica, 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 belong to the primary action of the drug. We call these alternate actions (Wechselwirkungen)”.

Other Nux vomica symptoms referred to, are:.

Anorexia and great appetite.

Constipation with tenesmus, and diarrhoea with desire and tenesmus.

Discharge of mucus from the nose, and dry obstruction of the nose.

Dr. C. Hering, in 1844, rejected Hahnemann’s explanation of primary and secondary symptoms, but admitted that there are in every proving symptoms which appear early and late, and although they may appear opposed to each other, they are all to be made the basis of prescriptions. Indeed, he says the longer lasting, more permanent and more opposed the later symptoms are to the earlier, the more useful they are in practice. He declares that “all symptoms which arise in provings of the higher potencies are similar to the later effects of the lower or so-called stronger doses, and are not like the first effects of strong doses”-and adds that the great characteristics of remedies accompany both the earlier and later symptoms, e.g., the burning of arsenic”.

Hering therefore deduces the following law of dose: “Having chosen the remedy, according to the symptoms of a case, from the complete correspondence of the characteristics is disease and drug, we have only to consider whether the symptoms of the case generally have more resemblance to the earlier (primary) symptoms of the drugs, and then we give the lower potencies; or more resemblance to the later (secondary) effects, that is, to the symptoms produced by the higher potencies, and then we give the higher potencies”.

Dr. E.M. Hale, in 1860, expressed the belief, and in 1874 reiterated it, that he had discovered the law of dose. He states that “the proper dose for each case may be selected with as much certainty as the proper remedy.” Assuming that all drugs produce, and all diseases present, two series of symptoms (primary and secondary), and that in one or the other of these classes is embraced every symptom of drug or disease, he lays down the following rule:.

“If the primary symptoms of a disease are present, and we are combating them with a remedy whose primary symptoms correspond, we must make the dose the smallest compatible with reason; and if we are treating the secondary symptoms of a malady with a remedy whose secondary symptoms correspond, we must use as large a dose as we can with safety”.

Von Grauvogl, in his Lehrbuch der Homoeopathic, says:.

“In ignorance of the law of proportional oscillation, some have sought to generalize these motions, and to call primary effect that which we bring to pass, and secondary effect that which, is the reflex action of the organism after the effect is complete. In this another mistake was made, viz.:that it was generally thought that the secondary effect could always be considered and looked for as the opposite of the primary effect, and hereupon indications were to be built up.

This could only come to pass by the cotemporaneous but impractical further division of this alternation of phenomena into chemical and dynamical, of which the latter were held to be the more enduring. For example: primary effect of Quinine, swelling of the spleen; secondary effect, atrophy of the same; or, primary effect of Ipecac, nausea, convulsive cough, etc.: secondary effects, relaxation of the musculature, etc.

As the same time, the secondary effect was sometimes considered as only an intermediate stage, form which recovery might and should proceed; as for example, from Alcohol, first excitement, then bodily malaise (Katzenjammer), finally the normal condition again. And while, with the so-called dynamic remedies, the primary effect was to form the indication, it was to consist, with regard to chemical remedies, in the waiting for the secondary effect; e.g., with Arsenic, primary effect, paralysis and emaciation; secondary effect, convulsions, gain in flesh and invigoration of the body, and other similar arbitrary divisions, which, however, are not taken from practical life.

That the whole question of primary and secondary effects turns upon the dose, not upon the question whether substances operate chemically or dynamically, is easy to demonstrate. But first, we must have decided whether, in this question, we will set out from the large dose of the physiological school, or from the small Homoeopathic dose, since in both cases, there are primary and secondary effects.

Sulphur, for instance, in the Allopathic dose of the physiological school, produces at first watery diarrhoea, as a local effect upon the intestinal canal, according to the law of causation; but not always in the Homoeopathic dose, because it lacks this local effect according to the succession of cause and effect, for it brings the Sulphur first, not into the intestinal canal, but into the blood.

Soon, however, diarrhoea is produced by Sulphur even in a Homoeopathic dose, but not in consequence of accelerated secretion of the inner wall of the intestine, irritated by the Sulphur, but in consequence of increased formation of bile and of its discharge into the intestines. For this reason the diarrhoea produced by the large dose of Sulphur is, at first, not bilious, though this is the effect of the small dose.

The secondary effect, however, in both cases, as soon as no more Sulphur is given, is precisely the same, to wit, obstruction. But this obstruction is no longer the effect of Sulphur, whether given in an Allopathic or a Homoeopathic dose, but phoronomic, the result of the proportional oscillation of the organic activities.

If we take Sulphur in Homoeopathy dose only, then we have a series of phoronomic changes, according to the law of reciprocal action, by which always two symptoms, the one following the other, show that, in the interior of the organism, movements have arisen, of which the preceding is always the cause of the succeeding. In this instance we should not, and strictly speaking, cannot speak any more of primary and secondary effects, and for the reason that here the primary effect can be no longer established according to the individuality, since in one case, cough with mucous expectoration, is the first thing noticeable, in another, palpitation of the heart, in the third, a haemorrhoidal flow.

For the sake of curing, we must thus, in many cases, commit such a penetrating remedy as Sulphur in a minimal dose (often after one single dose), for some time to the counter-actions and reciprocal actions of the organism, and if the indication has been correct, the result cannot fail, and all the same whether we had to give the Sulphur for some kind of eruptions, an irregular menstruation, or a case of gout, etc., in accordance with the concomitant circumstances…..

Hence the cure of such diseases by Sulphur is effected not in consequence of a secondary effect, according to the law of proportional oscillation, as warmth succeeds the coldness of the hand which has been in cold water, but in consequence of reciprocal effects induced by it and propagating themselves from part to part, within the organism, whereby the Sulphur taken (by the organism) may have been removed therefrom long ago.

These are, therefore, no secondary effects, but series of effects which themselves again have become the causes of other effects, and if we allow these series of effects, or to speak scientifically, these reciprocal actions, to run their course, undisturbed, them we may again designate this only as “permitting the remedy to expend its force,” in direct contrast with the so-called secondary effects.

If we were harboring the delusion that we had to produce, or wait for these secondary effects in order to attain a cure, would we thus establish indications, that we first had to disturb the self-activity of the organism so that we might afterward restore its equilibrium again, then we should with such senseless indications, which at best, could be thought of only by the worshippers of the vis medicatrix naturae, have effected nothing but superfluous torture; for, to what would it lead, to give laxatives, that constipation might follow; or to hasten menstruation with Cuprum, Pulsatilla, etc., that it might afterward remit; to irritate or paralyze the functions of the organism to the very verge of their capability of resistance, that they might be able to help themselves?.

In other to bring to a decision in a practical way the contending opinion relative to primary and secondary effects of drugs, let us adduce an example of phoronomic motion.

If we take several times a day a few drops of tincture of Belladonna, our organism experience in various, but specific directions, an accelerated exchange, and in other directions a retarded exchange.

When first taking this drug in small doses, and for some days thereafter, there is evidently a greater quantity of carbonic acid excreted by the lungs, while during the action of stronger doses a smaller quantity is excreted. In general after the use of Belladonna the excretion of the infusible salts in the urine is diminished; on the country, the urea, the vesical mucus, the fusible salts, and the extractive matter are increased.

At first the pulse is retarded two or three beats in the minute, while as the same time an accelerated, i.c., an increased exertion from the mucous membrane of the organs of deglutition takes place. If we persist in the use of the drug, injection and inflammation of the same parts take place, but now with acceleration of the pulse, four or five beats in the minute, and thus beyond the usual individual frequency. Hence, if the capillary vessels in any part are overfilled, the beat of the heart is correspondingly retarded; but, if inflammation and swelling take place, then the pulsations are increased again, and remain at this height for three or four days even, without any more Belladonna having been taken.

These are clearly the specific effects of Belladonna, and specific counter-effects of the organism, because these occurrences as often as they are reproduced, must inevitably return in the same manner, and this, as long as the power of resistance of the organism against the influence of the Belladonna is not exhausted, or the movements of the Belladonna are not removed by those of some other substance.

If, for instance, during those inflammatory swellings in the organs of deglutition we take some drug retarding interchange, such as Coffee, in repeated doses, then the affections in the throat experience, of once, a marked alleviation, and on the second day have already disappeared, while the pulsation of the heart returns at the same time to its individual frequency, and thus much sooner than if these Belladonna affections had been left to themselves.

Coffee accelerates, indeed, the frequency of the pulse, but decreases its force manifestly, and the pulse afterwards is retarded below the individual (normal) frequency, and is small and weak. This increase of the pulse, however, is not accompanied by an increased excretion of carbonic acid from the lungs, as usually occurs in a proving of Belladonna.

Coffee not only diminished the exhaled carbonic acid for the moment, but constantly more and more, the longer it is taken, and thereby only the excretion of the solid substances of the urine, the urea, the uric acid, and urates, is diminished Although Coffee at first accelerates the movements of the bowels, it yet retards them afterward, more and more; in the blood, the solid substances the serum, the albumen, and the blood-cells, are increased, and the latter become even melanotic, as after the use of Belladonna, but they increase so that they manifestly diminish the reception of oxygen, and the exertion of carbonic acid, which again, is not the case after the use of small doses of Belladonna, when they are rapidly turned to bile in the liver, and are no more brought into the circulation.

But if, after the use of Belladonna we take Coffee in large quantities, then the inflammatory process induced by the action of the Belladonna is brought suddenly to a pause, and even the increased secretion of bile produced by the Belladonna is suddenly suppressed, with, at the same time, an increased frequency of the pulse. With Coffee, moreover, the augmented frequency of the pulse (a substitute in the motions of the central circulatory system for the stagnation of the blood in the peripheric system) constantly increases, and without any inflammatory condition being associated therewith (as is the case with Belladonna), this substitution is gradually weakened and finally lost entirely.

Here, we thus find not the least ground for the division of the symptoms of Belladonna or of Coffee into a primary and secondary effect; in both cases we saw, on the contrary, reciprocal actions in a specific manner, and varying only according to the dose. A contrary effect, however, we saw only between the action of Belladonna and that of Coffee following it, since the latter opposed the motions of the former.

Just as the so-called secondary effects must become known by the art of observation, by the differential diagnosis between the amount of motion of morbid substances and curative substances, just so it must be in the case of all drugs as regards the repetition of the dose. If we intend, for instance, in the scheme of Belladonna, nothing but lasting depression of the pulse, then it is self-evident that, when this depression is once reached, and not before, the does which produced this effect ought not to be repeated till a pause, or rather the proportionally too early restoration of the frequency of the pulse, or its renewed increase, announces itself; moreover, if we continue to administer the remedy without regarding, this, we got, at once, other Belladonna symptoms for which we did not seek-difficulty of swallowing, dilation of the pupils, etc.

Charles Mohr