THE CHIEF COMPLAINT AND THE AUXILIARY SYMPTOMS IN THEIR RELATION TO THE CASE by H.A. Roberts
Dr. Robert’s guide on which symptoms should be taken during case taking….
*** ALMOST every case that comes to the attention of the physician presents two distinct phases, two separate pars, as it were: the part comprising the symptoms of which the patient complains, those which are most annoying to him and most outstanding in his recognition; and secondly, those symptoms which he does not recognize as symptoms or which he does not consider worth reporting or does not consider as having any relationship to the case.
The chief complaint has a psychological value out of all proportion to its value in homoeopathic prescribing: it brings the patient to the physician, and if the physician responds and by careful questioning draws out the history of other symptoms, the patient feels as satisfaction and confidence that the physician is not treating his case as of no consequence.
Now the chief complaint is a very necessary part of every case; some of our colleges are giving the chief complaint of every case much consideration. The young physician places much dependence upon this part of the case; it is close to his training along diagnostic lines. The older prescriber, while giving due weight to the chief symptoms, feels that in prescribing he must consider the totality of the symptoms and in order to do so he must give more weight to the other part, probably unexpressed without some encouragement on the part of the physician, which is an even more necessary part of the case than the chief complaint, because it is that part which manifests more clearly the individuality of the patient and indicates most clearly the individuality of the remedy to cover the case -the totality of the symptoms, if you prefer.
The chief complaint, as presented by the patient, may be altogether different in value from the symptoms discovered and illuminated by the physician’s analysis of the case. The chief complaint is often a pathological state, or an approach toward a pathological state, in the functional sphere.
The chief complaint, or the leading symptoms, may be defined as those symptoms for which there is clear pathological foundation or the symptoms that are most prominent and clearly recognizable; or the symptoms which first attract the attention of the patient or physician; or which cause the most suffering or which indicate definitely the seat and nature of the morbid process; which form the “:warp of the fabric”, as if has been expressed.
The auxiliary or concomitant symptom or group of symptoms seldom has any definite relationship to the leading symptoms from the standpoint of theoretical pathology these are the symptoms which the pathologist would exclude as accidental and meaningless, but they have actually a definite relationship to the case, because they occur in the same patient, and at the same time or in definite relationship of time, as the other symptoms which are considered the chief complaint. If they do not fit into the theories of pathology, they have an even greater individual value in the case; those symptoms which can be explained are of little help in selecting the homoeopathic remedy, but it is this group of auxiliary or concomitant symptoms which limit the choice of the *simillimum.
That group of which the patient complaints most, almost without exception cannot be relied upon for the definite selection of the remedy; it is the concomitant group of symptoms which, taken in conjunction with the major group of symptoms, makes possible the definite selection of the remedy by greatly reducing the number of remedies indicated in such conditions, and upon a closer analysis we can pick the *simillimum unerringly from this small group.
For instance, when we find a case where the patient gives as her chief complaint ovarian pain, we cannot instantly pick the remedy from consideration of this symptom alone; the homoeopathic materia medica has over fifty remedies that have this symptom. Cerebral congestion may be met with any of 150 or more remedies; and so with many single symptom pictures. We might numerous complaints where the chief complaint would lead us into a morass of remedies, any one of which *might give relief to the patient, but only one of which would cure.
At times the chief complaint seems contradictory to the auxiliary group of symptoms brought out by the physician’s questioning; the patient may have, within the course of a day, an exceedingly dry mouth, and then complain of its excessive moisture. The patient may complain of diarrhoea, but a careful taking of the case may reveal an alternation of diarrhoea and constipation. Or there may be a complete alternation of symptoms at different seasons of the year, as rheumatic conditions at one time, and gastric disturbances at another time; rheumatic pains in the limbs during one attack, and perhaps rheumatic iritis at another time. The physician will find many such alternating symptom groups, any one of which may be the chief complaint. Only the thoughtless physician will tell the patient that the present symptoms group is the one to be considered at the present time, a nd when the other symptom group appears it will be plenty of time to consider that group. Such an attitude in the part of the physician may seem logical, but the thoughtful student of homoeopathy realizes that many remedies in our material medica have alternating group symptoms, and he cannot ignore any symptoms which the patient may recite.
Much has been said of keynote prescribing; many at the present time use a repertory simply as a means of seeking a key to unlock the case through the peculiar and unusual symptom.. this has a certain value, if we are so fortunate as to find the *simillimum by some outstandingly peculiar symptom; but most often this is not enough, and it has little more value than selecting at random any one remedy from a group known to have a certain symptoms in the provings. *We must not fail to recognize the value of the totality of the symptoms; and this must take into consideration the chief complaints, those of which the patient most often complains plus the peculiar characteristics of the patient. If both these elements are present, we may be sure we are on the right track.
Let us consider a few cases.
A young woman complains of tension, stiffness and lameness through the muscles of her back, particularly between the shoulders and in the nape of the neck, the stiffness causing a pulling sensation of the muscles even into the cheeks. She cannot turn her head without distress; bending the body or raising the arms, especially the left, aggravates the condition. How many remedies and what remedies flash through your mind as possibly covering these symptoms? However, you feel the need of more careful questioning to elicit more characteristic symptoms, for this symptoms group, although it is the chief complaint is not enough on which to base your prescription if you wish to be sure of curing your patient.
It develops upon further inquiry that she also has a leucorrhoea. This symptoms also might come into a number of remedies that you have already hastily considered as applicable to the case,. but in itself it has no value as a differentiating symptom. Upon careful questioning, the patient volunteered that her leucorrhoea comes on only when sitting; she is absolutely free from it as soon as she gets up on her feet, either standing or walking. Here is a truly auxiliary symptom that has a unique value: *Leucorrhoea only when sitting.
So far as I have been able to determine, there is only one remedy which in the provings has developed this characteristic symptom, and that is *Fagopyrum. Lest we be accused of keynote prescribing, let us look over the symptoms of this remedy in their relationship to the chief complaint.
We find the muscular tension and drawing, especially between the shoulders and in the nape. We find other symptoms of which the patient complained, less characteristic of any remedy in particular than those mentioned and then we find the outstanding symptom, characteristic and peculiar, which is perhaps the most characteristic and peculiar symptom of *Fagopyrum, the Leucorrhoea only while sitting; and we know beyond any question that we have found the *simillimum.
In this case the chief complaint was the tension of the muscles, the lameness; but the outstanding concomitant symptom that apparently bore no relationship to the chief complaint was the leucorrhoea better while standing or walking, worse sitting. It was the concomitant symptom which, taken in conjunction with the other more common symptoms defined the choice of the remedy.
A case of chronic asthma complaints of the characteristic wheezing, suffocative sensation and other symptoms which we call asthma. How can we prescribe on these symptoms? How many remedies have these symptoms? Of course, the answer is that the chief complaint here is of use merely as a background upon which to depict the individual peculiarities in the case. His cough is worse at night; he is better after expectoration; his hands and feet are icy cold. These symptoms may limit the number of remedies that we consider, but still there is nothing that definitely points the way the selection of the remedy,. He adds that he has an attack come on after he becomes angry, or the attack is worse after anger; worse after eating; he is fearful, especially at night. Our search narrows still more; then he adds the most enlightening symptom yet related: it seems as if there was a choking sensation rising up from his stomach into his throat and suffocating him, which brings on the attack. There are but two remedies to be thought of with this symptom, *Sepia and *Mancinella. The provings of *Mancinella have brought out this symptom phrased by the provers exactly as the patient described it, while *Sepia has close counterpart. A comparison of the two remedies in relationship to the totality of the symptoms leaves us in no doubt but the remedy is *Mancinella.
Boenninghausen once offered a prize for a “treatise” concerning the greater or lesser (characteristic) value of the symptoms occurring in a disease, to aid as a norm or basis in the therapeutical selection of the remedy”. After three years of silence on the part of the homoeopathic world, Boenninghausen himself attempted to give what he considered a somewhat adequate answer. His reply was founded on Hahnemann’s instructions in Paragraph 153 of the fifth edition of the *Organon; or, as Boenninghausen puts it, this paragraph “contains the proper, true kernel of the answer….. and deserves to be first premised.”
In seeking for the specific homoeopathic remedy, i.e. in this juxtaposition of the phenomena of the natural disease and the list of the symptoms of the medicines, in order to discover a morbid potency corresponding in similitude to the evil to be cured, the more striking, particular, unusual and peculiar (characteristic) signs and symptoms of the case should be especially and almost solely kept in view; for there must especially be some symptoms in the list of the medicine sought for corresponding to this, if the remedy should be the one most suitable to effect the cure. The more general and indefinite symptoms, such as lack of appetite, headache, weariness, disturbed sleep, uncomfortableness, etc., in their generalness and undefinedness deserve but little attention, unless they are more especially pronounced as something of a general nature is seen in almost every disease and in almost every medicine.
After this quotation from the *Organon, Boenninghausen continues:
It is seen, however, that it is here left to the physician to judge what is understood by the *more striking, particular, unusual and peculiar symptoms, and it might, indeed, be difficult too furnish a commentary to this definition, which would not be too diffuse and therefore easily understood, and on the other hand would be complete enough to be properly applied to all these cases…..
It is obvious that Hahnemann never intended his directions to be taken that we do keynote prescribing; while his instructions were not give undue weight to the most general or symptoms it is to be remembered that Hahnemann never slighted any of a case in making a prescription. He had the genius of giving each symptom its true place in the picture without distorting the totality. While it is inconceivable that Hahnemann ever did keynote prescribing, it is also beyond our knowledge of Hahnemann’s thorough mind that he eliminated the chief complaints in building up the symptom-image.
Our way, too, must lie in the golden mean between these two points, the one two general and the other too individual to assure us to a true totality. If we can find a remedy that has the “more striking, particular, unusual and peculiar (characteristic) signs and symptoms of the case” and in addition covers the chief complaint as well, we may consider ourselves as having a sound basis for the prescription of the *simillimum.