Concomitants: the symptom that has no business being there

The fourth part of a symptom

The classical anatomy of a complete symptom has four parts: location, sensation, modality, concomitant.

Students collect the first three with reasonable reliability. The fourth is collected almost never, largely because nobody asks the question that produces it.

A concomitant is a symptom that accompanies the main complaint without being caused by it.

• A headache accompanied by profuse, pale urination.
• A cough accompanied by involuntary weeping.
• Joint pain accompanied by a sudden craving for salt.
• A fever accompanied by complete absence of thirst.

None of those pairs has a pathological connection. That is exactly what makes them valuable: the disease does not explain the pairing, so the pairing belongs to the patient. It is the strange, rare and peculiar principle in its most usable form.

Why Bönninghausen built a method on it

Kent's repertory is organised by complete, located symptoms — you look up the head chapter for a head symptom. That works when the Materia Medica happens to record the exact combination you are looking at, and fails when it does not.

Bönninghausen's Therapeutic Pocket-Book takes a different approach. It treats sensations, modalities and concomitants as generalisable across the body: if a remedy produces a burning pain in one location and a characteristic modality in another, those characteristics are held to belong to the remedy rather than only to the location where they happened to be observed.

That makes concomitants first-class data rather than incidental notes, and it is why the Pocket-Book handles a sparse or awkward case better than a location-first repertory does. It is also why the two repertories disagree, and why the disagreement is useful — there is more in Kent vs Bönninghausen.

A practical note: the Pocket-Book uses a four-degree grading rather than three. Software that silently flattens it to three throws away Bönninghausen's highest-confidence marks, which is the opposite of what you want when you are relying on his method.

How to ask for one

There is essentially one question, and it works because it is not about the complaint:

"What else was happening at the same time?"

Then, when the first answer runs out — and it will, because patients assume you only want the relevant material:

"Anything at all, even if it seems completely unconnected?"

The permission is the important part. Patients filter hard. They have decided in advance that their headache is the medical fact and the odd thirstlessness that came with it is irrelevant, so they do not mention it. The phrase "even if it seems unconnected" is what unlocks it.

Two more that reach the same material from different angles:

• "When this comes on, is there anything else you notice about yourself?"
• "Does anything change in your appetite, sleep or mood when it is bad?"

The trap: coincidence versus concomitant

Not everything that happens at the same time is a concomitant. Two checks before you use one.

Is it reliably paired? A concomitant recurs with the complaint. If the patient had a strange craving once, during one episode, it is an anecdote. If the craving arrives every time the headache does, it is a symptom. Ask directly: "Does that happen every time, or just that once?"

Is it caused by the complaint after all? Nausea with a severe headache is common enough to be explained by the headache. Nausea with a knee pain is not. The concomitant that is worth having is the one with no plausible connection — which is precisely what makes it individualising.

What it does to the analysis

A good concomitant is often the highest-weighted rubric in the case, above the chief complaint.

That feels wrong the first few times. The patient came about the headache; the analysis ends up resting on the urination that accompanies it. But this is the same logic as everything else in individualised prescribing: the chief complaint is shared with thousands of other patients, and the pairing is not.

In a shortlist of four to eight rubrics, one or two concomitants earn their place ahead of a second or third rubric describing the same complaint from a slightly different angle. Adding more rubrics about the chief complaint adds almost no information; adding a concomitant adds a great deal. That arithmetic is worked through in why fewer, better rubrics wins.

Classic examples worth knowing

These are worth recognising because they are frequently present and frequently unrecorded:

• Thirstlessness during fever — fevers cause thirst, so its absence is a genuine concomitant rather than a negative finding.
• Profuse pale urine with headache.
• Weeping with a complaint the patient describes as purely physical.
• Chill without subsequent heat, or heat without preceding chill, where the sequence is broken.
• A marked change in a general — appetite, sleep, thermal state — arriving with a local complaint.

Each of these is a small observation that is easy to lose and difficult to reconstruct later.

The habit

Add one line to your case record, under every complaint:

Accompanied by:

Leave it blank if there is genuinely nothing. But the heading has to exist on the page, because the question does not get asked otherwise — not from ignorance, but because at minute thirty of a consultation you are thinking about the analysis rather than about the form.

A printed heading asks the question for you.