Concomitant Symptom Opinion of Stalwarts and Clinical Practice

Dr Mohan Giri

Concomitant Symptom of Boenninghausen, Opinion Of Other Stalwarts and Its Importance in Clinical Practise

INTRODUCTION: –The father of medicine Hippocrates taught some 2000 years back that “not the disease but the diseased individual” and recognition of the individual symptoms in every case of illness. It was Master Hahnemann who put forward the wisdom of Hippo crates and his individualities concept in the treatment of the sick. 

Individualization is the keynote of homoeopathic prescribing and healing the sickness of whole man to health is our mission. Section 153 of Organon of Medicine is the clue of artistic prescribing. There Master Hahnemann writes “In this search for a homeopathic specific remedy … the more striking, singular uncommon and peculiar (characteristics) signs and symptoms ….c hiefly and most solely to be kept in view.”

Boenninghausen was a close follower of Hahnemann and was gifted with a keen analytical mind. He accepted the following fundamental as pronounced by Hahnemann: —

• Nothing can be known of a disease except through symptoms.
• It is the patient who is sick not his parts.
• Symptoms are the only unfailing guide to the selection of the remedy.
• Homoeopathic selection of medicine should be based on totality of the case.

To Boenninghausen, therefore, totality is the true diagnosis of the disease, and at the same time diagnosis of the remedy. He proceeded on the hypothesis that this totality was not only the sum total of symptoms, but was itself one grand symptoms — the symptoms of the patient. Such totality of the case, according to Boenninghausen practically consists of the totality of complete symptoms. He asserted that a symptom would be considered as complete when it is studies in relation to the following factors: —

• Location
• Sensation
• Modality
• Concomitant

DEFINITION OF CONCOMITANT SYMPTOMS
The word “Concomitant” is derived from a Latin word “Concomitory”. “Con” means cum with “Com” means together with, in combination, or union, also altogether, completely and “Comitant” means present.

Gould medical dictionary defines Concomitant symptoms as accessory phenomena occurring in connection with the essential phenomena of a disease.

We may define Concomitant symptoms as:

A symptom which co-exists with the main symptoms without having any pathological and Physiological relation and only relation is time association.

A symptom, which rarely appear in connection with the leading disease, hence peculiar.

A peculiar symptom, which occur in the same patient with the leading symptoms either at the same tine or having some definite relation to the time.

A symptom, which neither has separate existence nor has any cause for their existence.

Such a peculiar and striking phenomena we term “Concomitant symptoms”.

It is often asked that if two symptoms are occurring together then which one is the Concomitant?

Suppose headache and backache occurring simultaneously, in such conditions the problem may be salved from the following observation: —

Duration: – Time of occurrence of the both should be inquired. One may either proceeds or follows the other.

Relation: – Is there any relation between headache and backache, which one affects the other? Whether headache is felt more when backaches get aggravated or vise-versa. There must be some time relation if one is the Concomitant. Both can not be Concomitant to each other.

Troublesome: – We may ask the patient which complaint is most troublesome, to you? As it has been frequently observed that Concomitant symptoms are rarely troublesome because they are non-pathological, and represent the individualistic feature of a case.

Disappearance: – Concomitant symptoms are bound to disappear with the disappearance of the main symptoms. If one group of symptom is removed and other remained after administration of remedy it indicate that they are not Concomitant symptoms rather two different complaints which has no relationship to each other.

VALUE of CONCOMITANT SYMPTOMS

According to Hahnemann:-   Common / General   Uncommon / peculiar

According to Boenninghausen: –   Primary / Typical,   Secondary / concomitant

Location  Sensation   Modalities, Symptoms belong to   the individual, Concomitant   of the disease symptoms

Hence they are always characteristics and deals with individualistic feature of patient as well as the totality of the disease.

In the lesser writing Dr. Boenninghausen had said- “First of all, those symptoms which are found in almost all disease may be left out at our count unless they manifest themselves in a striking manner.

On the other hand, those entire attendant symptoms should be carefully noted which:

(i):- Rarely appear in connection with the leading disease, and are therefore, also found rarely among the proving.

(ii):- Those, which belong to another sphere of disease than the chief ailment.

(iii):-Lastly, those, which have more or less of the characteristic signs of one of the medicines.

Such a symptoms would be included among those which Hahnemann calls “More striking, singular, uncommon and peculiar (Characteristic), signs”, because they predominantly give to the whole disease in its individual Character.

CRITERIA FOR THE SELECTION OF CONCOMITANT SYMPTOMS
There are certain criteria which can be considered as the selection of the Concomitant symptoms, this means, it may occur in same patients either, with, before, during or after the main complaints / conditions i.e. —

Coexistence of a symptom with the main symptoms / disease / Condition.

• Lachrymator with pain in other parts of body.
• Cough with pain in distant part.
• Eructation when pressing painful parts.
• Emptiness in Stomach menses before.
• Ineffectual urging for urination during perspiration.
• Headache after pressing the stool.
• Vertigo coition after. (Condition)
• Appetite, ravenous, epilepsy, before. (Disease)

A common place or well known accompaniment, can be taken as Concomitant if they occur in an extraordinary degree or in a singular manner i.e.-

Fever with thirst is a common accompaniment, but fever with thirst for small quantity of water at frequent interval is extraordinary, hence become Concomitant

Common symptoms when occur in unusual combination i.e.

• Inflammation without pain.
• Fever with coldness of body.

Two common symptoms become uncommon when they have definite relationship i.e.

• Coryza with polyurea.
• Coryza ending in diarrhoea.
• Sudden stopping catarrh of respiratory tract followed by diarrhoea.
• Cough ends in sneezing.

CONCOMITANT AND ASSOCIATED SYMPTOMS DO THEY BEAR SAME MEANING
There is some difference of opinion regarding Concomitant and associated symptoms. In broader sense both represent accompanying symptoms, but Concomitant symptoms is non pathological hence peculiar where as associated symptoms have got pathological relationship with the main symptoms – hence common and less important

EVOLUTION Of CONCEPT Of CONCOMITANT IN HOMEOPATHY
It has been found that the word Concomitant was used in the various writing of Master Hahnemann but the purpose was different which is unrelated to the literally meaning of Concomitant. This may be different translator’s wording according to their language consciousness.

The concept of Concomitant is owned by Dr. Boenninghausen who has given a new dimension to Concomitant symptoms. He used these words to explain uncommon phenomena accompanying the main trouble. He was the first to notice that the certain symptoms are opting to appear in-group. He further observed that these symptoms have no other relationship to the group of chief symptoms than their time association, thus giving individuality to the picture and help to differentiate it from similar picture. In other words these represent the characteristic differentiating features.

He further observed in the materia medica that certain medicine has greater propensity to produce Concomitant symptoms. He thus started collecting the concomitant symptoms and placed them in his Therapeutic Pocket Book in a generalized form in relation to the particular affection.

In homeopathic concept of concomitant symptoms we do not found any logical cause but it has a deep meaning in every case of disease as well as the medicines and related to the constitutional differences and tends to remain constant with patient, irrespective of the nature of the disease.

HOW HE APPLIED “ANALOGY” ON CONCOMITANT SYMPTOMS?
AND WHAT MADE HIM TO DECLARE THAT HIS REPERTORY IS BASED ON CONCOMITANT:-
Being convinced of the importance of Concomitant symptoms he started collecting them whatever present in the Materia Medica Pura and experienced of him and other could provide. Eventually the numbers increases so incredibly that it was impossible to write individually all the Concomitant symptoms in relation to that particular area.

Boenninghausen thought if he would go on writing the concomitant symptoms individually in relation to the particular affection then the repertory would become very voluminous.

Hence instead of writing them individually, he deduces a general rule with the help of Doctrine of Analogy and presented a separate general rubric on Concomitant.

In this way Boenninghausen has kept several general rubrics on concomitant whenever relevant i.e:-

MIND:-Drugs which have Concomitant of mental symptoms.

NOSE:-accompanying symptoms of nasal discharge.

STOOL: – Trouble before during and after stool.

MICTURITION:-

• Before
• At the beginning of
• During
• At the close of and
• After micturition.

MENSTRUATION:-

• Before menstruation
• At the beginning of menstruation.
• During menstruation.
• After menstruation.

LEUCORRHOEA;-Accompanying trouble of, leucorrhoea,

RESPIRATION:- Accompanying trouble.

COUGH:-Trouble associated with cough.

YAWNING: – Associated trouble.

SLEEP:-Associated symptoms.

FEVER:-Heat stage and associated symptoms

SWEAT: – with associated symptoms.

COMPOUND FEVER: – during, before and after.

These all representation made Boenninghausen to declare that his repertory is based on doctrine of Concomitant.

OPINION OF OTHER STALWARTS REGARDING CONCOMITANT
The concept of Concomitant varies from person to person, according to his own opinion, moreover there are many stalwarts who totally oppose and criticized it.

Dr. Hering and Dr. Kent criticized Boenninghausen for to broad an application of the concept of Concomitant.

Dr. Jugal kishore emphasized that Boenninghausen has generalized entire Concomitant and associated symptoms, and their exists no distinction between the peculiarities of the remedy.

Moreover Dr.Kenthas badly criticized the concept of Concomitant of Boenninghausen but if we go through Dr. B.K.Sarkar book “Essential of Homoeopathic Philosophy” – He writes thatKenthas substituted Concomitant with peculiar symptoms in his repertory.

Dr. H.A.Robert has used the word auxiliary symptoms in place of Concomitant symptoms. There may be bit different in word meaning but no different in the concept of Concomitant what Boenninghausen has established.

He himself, while giving value to the Concomitant symptoms in Introduction to Boenninghausen Therapeutic Pocket Book writes, – “Concomitant symptom is to the totality what the condition of aggravation and amelioration is to the single symptom’.

All the other stalwarts in the field of homeopathy have described concomitant by own way and wording but concept of Concomitant remained unchanged till today.

IMPORTANCE OF CONCOMITANT SYMPTOMS IN CLINICAL PRACTICE
As it has been well established that Concomitant symptom is the Characteristic as well as the totality of the case, so without Concomitant symptoms any prescription can not be made homoeopathically.

Here I would like to cite some cases which are showing the importance of Concomitant symptoms in clinical practice.

CASE No –1
Mr. DS/M/H , aged about 50 years, came to me  on 11.12.2001 with a various neurological manifestation. The case has been diagnosed  as “Cerebellar disorder syndrome”. There was all the classical presentation of Cerebellar diseases. After careful study of the case the following characteristics have obtained,-

• Trembling of whole body, specially outstretching hand < when asked the patient to act > by rest.
• Trembling speech.
• Encysted swelling on forehead and back which is soft and pliable.
• H/O Convulsive disease in the childhood.
• Tendency to delayed healing of wound.
• T/R – Heat intolerance but patient is ambithermal.
• Hunger intolerable in the morning.
• Craving – Sour, Salt++, fish, meat.
• Aversion – sweet.
• Intolerance – egg, produce nausea after eating.
• Salivation during sleep, which is stringy.
• Urge for urination when seeing running water and while bathing.
• Mild and yielding disposition.
• Desires Company.
• Consolation > symptoms.
• Fear of water.

ANALYSIS AND EVALUATION OF SYMPTOMS

• Mild and yielding disposition.
• Desires company.
• Consolation > symptoms.
• Fear of water.
• Craving salt++, fish.
• Aversion sweet.
• Intolerance egg-produce nausea
• Salivation during sleep, which is stringy.
• Urge for urination when seeing running water and while bathing.
• Hunger intolerable.
• Trembling of whole body, specially outstretching hand < when asked the patient to act > by rest.
• Trembling speech.

MIASMATIC ANALYSIS
Psora:  (points in favour of):-

• History of convulsive disease in childhood without any known cause
• Fear of crowed when passing through
• Desire company
• Hunger intolerable
• Trembling of whole body specially outstretched hand
• Trembling of speech

Sycosis: (points in favour of):-

• Dreams of daily business
• Encysted swelling on fore head and back which is of soft and pliable
• Tendency of delayed healing of wound

Syphilis: (points in favour of):-

• Thermal reaction — Ambithermal
• Perspiration offensive
• Salivation during sleep which is stringy in character
• Interrupted speech

MIASMATIC DIAGNOSIS: –Mixed miasmatic state with predominant of psora

TOTALITY OF SYMPTOMS:

Causation: – Mixed miasmatic state with predominant of psora

Characteristic Mental Generals:

• Mild and yielding disposition
• Desire Company
• Fear of water.

Characteristic Physical Generals:

• Hunger intolerable
• Perspiration offensive
• Salivation during sleep
• Urge for urination when seeing running water and while   bathing
• Craving salt ++
• Aversion sweet
• Intolerance  — egg, produce nausea

Characteristic Particulars:

• Trembling speech
• Trembling of outstretched hand

Important Physical Findings:

• Dysdiadokokinesia – Left side more than right
• Intention tremor
• Brisk knee jerk
• Titubation

REPERTORISATION:-Repertorisation done with the help of Hompath Classic (Kent Repertory)  on the basis of totality of symptoms.

REPERTORIAL SELECTION WITH REASONS:;-After proper Repertorisation, it has been found that Phos. Covered 9 symptoms out of 12 symptoms and scored maximum 20 marks

So, Repertorial selection for this case is Phosphorus.

FINAL SELECTION OF MEDICINE:- Points in favour)

• Nausea after egg eating.
• Urging for urination when seeing running water and while bathing.

Finally after proper study of a case and consulting the materia medica the drug Lysine has been prescribed from M1 to M16 potency with marked improvement of case in all respect. The other physical generals and mental symptom even they are not under the sphere of the disease process has improved remarkably.

The case has been presented in front of modern science physicians and they are highly satisfied with our treatment and recommended that homoeopathy is better mode of treatment for neurological disorder.

Within this period of treatment patient was totally symptoms free.

Case No II
Mr. SM/M/M, aged 25 years came to me with the complaints of haematemesis, excessive flatulence and convulsive manifestation. This is known case of grand-mal epilepsy and had been taken anticonvulsive drugs for long time. The C.T. Scan was normal and E.E.G.  was showing +ve neuronal events. After careful study of the case following symptoms has been obtain:-

• Excessive flatulence < at evening, < eating after > by eructation.
• Recurrent attach of bleeding from mouth for last 3 years.
• Heaviness on nape of neck < exertion after,> by rest.
• Ravenous hunger, can not tolerate hunger.
• Craving-Meat+, Fish++, Cold food.
• Epileptic convulsion occurs during chilliness.
• Stool-alternate hard and soft, regular, occasional. Mucoid.
• T/R-chilly patient.
• Thirst- profuse, small quantity at a time.
• Perspiration- profuse mainly on spine.
• Violent irritability, use to beat his wife.
• Fear of death.
• Desire Company.
• Memory weak.
• F/H-of epilepsy and haemorrhagic tendency.

ANALYSIS AND EVALUATION.

• Violent irritability, use to beat his wife.
• Desire Company.
• Fear of death.
• Memory weak.
• T/R-Chilly patient.
• Hunger intolerable.
• Thirst profuse but small quantity at a time.
• Craving fish++.
• Recurrent attach of bleeding from mouth.
• Heaviness at the nape of neck < on exertion.
• Flatulence-excessive.
• Epileptic convulsion occurs during chilliness.

MIASMATIC ANALYSIS:
Psora: — (Points in Flavour)

• Family history of epilepsy.
• T/R-chilly patient.
• Desire fish, meat.
• Hunger intolerable.
• Thirst profuse but small quantity at a time.

Sycosis: — (Points in favour)

•  T/R-chilly patient.
• . Heaviness at the nape of neck.

Syphilis:  — (points in favour)

• Desire cold food.
• Recurrent attach of haemorrhage from mouth.

MIASMATIC DIAGNOSIS: -Mixed miasmatic case with predominance of psora.

TOTALITY OF THE SYMPTOMS
Causation:– Mixed miasmatic case with predominance of psora.

Characteristic Mental General.

• Violent irritability, use to beat his wife.
• Desires Company.
• Fear of death.

Characteristic Physical General.

• T/R-chilly patient
• Hunger intolerable
• Epileptic convulsion occurs during chilliness.
• Thirst profuse, but small quantity at a time.
• Craving fish++.

Characteristic Particulars.

• Recurrent attach of bleeding from mouth.
• Heaviness at the nape of neck.
• Flatulence-excessive.  .

Important Laboratory Finding.

• E. E. G. showing epileptic foci.
• C. T. scan of brain was normal.

REPERTORISATION. – Repertorisation done with the help of Hompath Classic (Kent Repertory)  on the basis of totality of symptoms.

REPERTORIAL SELECTION WITH REASIONS.-After proper Repertorisation it has been found that PHOS. Covered 11 symptoms and scored highest 25 points.

So, Repertorial selection for the case is PHOS.

FINAL SELECTION OF MEDICINE:-
(Points in favour):-

• Epileptic convulsion occurs with chilliness.
• Solitude intolerable.
• Mixed miasmatic case with predominance of Psora.

Finally after proper study of a case and consulting the materia medica the drug Arsenic-Album has been prescribed from M1 to M20 potency with marked improvement of case in all respect. The other physical generals and mental symptom even they are not under the sphere of the disease process was also improved.

After starting the treatment the patients stop the anticonvulsive drug and during the course of treatment there was not a single convulsive attack. Within this period of treatment patient was totally symptoms free.

Bibliography 

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Dr.Mohan giri. B.Sc (hons) bhms (hons) m.d (hom).nih.
Lecturer deppt of practice of medicine.mbhmch..howrah..
Ex-research fellow.NIH, Ex-lecturer nshmch.bhopal