Keynotes

Vergleich: Siehe: Terms in Homeopathy

[Stuart Close

Eexplains the real meaning of characteristics and keynotes.

In paragraph 153 of The Organon, Hahnemann says that in comparing the collective symptoms of the natural disease with drug symptoms for the purpose of finding the specific curative remedy,

“the more striking, singular, uncommon and peculiar (characteristic) signs and symptoms of the case are chiefly and almost solely to be kept in view; for it is more particularly these that very similar ones

in the list of symptoms of the selected medicine must correspond to, in order to constitute it the most suitable for effecting the cure. The more general (common) and undefined symptoms; loss of appetite, headache, debility, etc., demand but little attention when of that vague and indefinite character, if they cannot be more accurately described, as symptoms of such a general nature are observed in almost every disease and drug.”

This seems a sufficiently clear description of what Hahnemann meant by “characteristic” symptoms; and yet the term has been the subject of much discussion and many have differed as to what constitutes a “characteristic.” Confusion arose and still exists through the inability on the part of many to reconcile the teaching of this paragraph with the apparently conflicting doctrine of The Totality of the Symptoms as the only basis of a true homœopathic prescription. These have taken refuge either in the mechanical “symptom covering” already referred to, as fulfilling their conception of the “totality” or in what is knows as “keynote prescribing,” which, as they practice it, means prescribing on some single symptom which they (perhaps whimsically) regard as the “keynote” of the case.

The fundamental mistake here has been in the failure to distinguish between the numerical totality and the related or logical totality, as already explained. Both of these misapprehensions should be recognized and corrected.

The real “keynote system,” as taught and practiced by the late Dr. Henry N. Guernsey (but perverted by many) does not conflict with the doctrine of the totality of the symptoms, nor does it fall short of complying with Hahnemann’s injunction to pay most attention to the peculiar and characteristic symptoms of the case. It is, in fact, strictly Hahnemannian. The truth is that Dr. Guernsey simply invented

a new name for the old Hahnemannian idea. A synopsis of Dr. Guernsey’s keynote method will be of value in this connection.

The term “keynote” is merely suggestive as used in this connection. The reference being to the analogy between materia medica and music. This analogy is shown in the use of other musical terms in medicine, as when the patient speaks of being “out of tune,” or the physician speaks of the “‘tone” of the organism. Disease is correctly defined as a loss of harmony in function and sensation.

The keynote in music is defined as “the fundamental note or tone of which the whole piece is accommodated.” In pathology the term “pathognomonic symptom” expresses what might be called the keynote of the disease, or that which differentiates it from other diseases of a similar character.

In comparing the symptoms of medicines we find that each medicine presents peculiar differences from all other medicines. These differences by which one remedy is distinguished from another, are the “keynotes” of the remedy, according to Dr. Guernsey.

It does not mean that the keynote of the case alone is to be met by the keynote of the remedy alone and that the other features of the case or remedy are to be ignored. The keynote is simply the predominating symptom or feature which directs attention to the totality. Its function is merely suggestive. A prescription is not based upon a keynote, considered as one symptom, no matter how “peculiar” it may seem. Its utility lies in this: that when the prescriber has become familiar with these “keynotes” or “characteristics” of remedies he will be able more quickly to find the remedy in a given case because the field of selection has been narrowed. When he recognizes such a keynote in the symptoms of a case it suggests or recalls to mind a medicine, or medicines, having a similar keynote. Reference to the repertory and materia medica will verify and complete the comparison. There is usually something peculiar in the case, some prominent feature or striking combination of symptoms that directs the attention to a certain drug, and this is what Dr. Guernsey called a keynote.

The misunderstanding and abuse of this method has caused it to fall somewhat into discredit. But considering Guernsey’s “keynotes” and Hahnemann’s “characteristics” as synonymous terms, which

they are, and making legitimate use of Guernsey’s method, it has value.

A characteristic or keynote symptom is a generalization drawn from the particular symptoms by logical deduction. Evidently the characteristic or peculiar symptoms of a case cannot be determined until

a complete examination has elicited all the symptoms of the case (the numerical totality) for purposes of comparison. This having been done there are various ways of selecting the characteristic.

Dr. Adolph Lippe illustrated his method in this way: “In many cases,” he says, “the characteristic symptoms will consist in the result obtained by deducting all the symptoms generally pertaining to the disease with which the patient suffers, from those elicited by a thorough examination of the case.” In other words the characteristic symptoms are the symptoms peculiar to the individual patient, rather than the symptoms common to the disease.

He illustrated this by a case, as follows: The patient was attacked by cholera. All the characteristic symptoms of cholera were present; but in this individual case there was (1) an unusual noise in the intestines, as if a fluid were being emptied out of a bottle. (2) The discharge came away with a gush. Of what pathological value these symptoms were we know not. Still they formed part of the totality which we must cover. Deducting from the (numerical) totality of the symptoms those common to the disease, we were in possession of the characteristic symptoms of the patient.

“We found that those two symptoms are also characteristic of Jatropha Curcas, and that this remedy, at the same time, has caused symptoms corresponding with the general pathological condition.” Jatropha promptly cured the case.

The selection of a curative remedy in this case, therefore, was governed by two symptoms of no known pathological value, and of seemingly trifling character. Yet these two symptoms were what gave

the case its individuality, and unerringly pointed out the curative remedy.

This case is a beautiful example of the kind of work for which Dr. Lippe was famous. It illustrates the necessity of being familiar with the natural history, symptomatology and diagnosis of disease.

Dr. Lippe could not have decided that these two symptoms were peculiar and characteristic if he had been unfamiliar with the symptoms of cholera. Neither could he have selected these two symptoms

as peculiar if he had not had the rest of the symptoms before him for comparison. The mistake of arbitrarily picking out some “freak” symptom, and giving a remedy which has a corresponding symptom, should be avoided. Dr. Guernsey did not teach prescribing on a single symptom.

In the preface to the first edition of his great work on Obstetrics Dr. Guernsey presents the subject of “keynote prescribing” in another way. He says: The plan of treatment may seem to some rather novel, and perhaps on its first view, objectionable, inasmuch as it may seem like prescribing for single symptoms, whereas such is not the fact. It is only meant to state some strong characteristic symptom, which will often be found the governing symptom, and on referring to the Symptomen Codex or Materia Medica all the others will be there if this one is.

“There must be a head to everything; so in symptomatology; if the most interior or peculiar symptom, or keynote, is discernible, it will (usually) be found that all the other symptoms of the case will be also found under that remedy which produces this peculiar one, if the remedy be well proven. It will be necessary, in order to prescribe, efficiently, to discover in every case that which characterizes one remedy above another in every combination of symptoms that exist. There is certainly that in every, case of illness which pre-eminently characterizes that case, or causes it to differ from every other. So in the remedy to be selected, there is and must be a peculiar combination of symptoms, a characteristic or keynote. Strike that and all the others are easily touched, attuned or sounded. There is only one keynote to any piece of music, however complicated, and that note governs all the others in the various parts, no matter how many variations, trills, accompaniments, etc.”

If it is understood that the “keynote” to a case may and often does exist in, or consist of, a “peculiar combination,” as Dr. Guernsey puts it, and that it is not merely some peculiar, single, possibly incomplete symptom which the tyro is always mistakenly looking for, the subject is cleared of part of its obscurity. Dr. Guernsey might have summed up the whole matter in one word-Generalization, which ha a been discussed at length in the chapters on the logic of homœopathy.

Dr. Lippe, discussing characteristic symptoms, wrote as follows: “When medicines are submitted- to provings upon the healthy they develop a variety of symptoms in a variety of provers. Each prover

has his own peculiar, characteristic individuality affected by the medicine in a peculiar, manner; other differently constituted individuals experience different, yet similar, peculiar symptoms from the same medicine. There is a similarity and a difference evident upon close comparison. In like manner diseases and all other external influences affect different individualities differently, yet similarly.

The physiological school and its followers accept in disease only what is general (common) to all those affected by it; in medicinal provings in the same manner they accept only that which has been experienced alike by many. In both cases they simply (sic) generalize. The homœopathic school reverses this order. Accepting all the symptoms experienced by the differently constituted provers, they consider as peculiarly characteristic the individual symptoms of the patient; those not generally experienced by others suffering from a similar form of disease.”

This is individualizing with a vengeance! In aspersing the process of what he calls generalizing Dr. Lippe traduces the very instrument he is apparently unconsciously using, but misusing the word.

One is the traditional pathological-diagnostic method based upon an arbitrary and artificial classification of only the common or gross phenomena of disease; the other is the homœopathic natural or inductive method of modern science, based upon all the phenomena of the case, but paying particular attention to the uncommon and peculiar features, never forgetting that we always have an individual patient to treat and cure.

Dr. P.P. Wells says: “Characteristic symptoms are those which individualize both the disease and the drug. That which distinguishes the individual case of disease to be treated from other members of

its class is to find its resemblance among those effects of the drug which distinguish it from other drugs. This is what we mean when we say that with these the law of cure has chiefly to do. When we

say ‘like cures like’ this is the ‘like’ we mean.”

Characteristics may sometimes be symptoms observed only as a result of the closest scrutiny, like the apparently trifling clues in a mysterious murder case which the ordinary detective overlooks or ignores, but which a Sherlock Holmes pounces upon and utilizes with amazing logical acumen to clear up what is otherwise impossible of solution. Their value depends upon who is using them. An Agassiz or a Leidy, placed in possession of a fragment of bone, or the scale of a fish, found in the remains of some pre-glacial geologic period, will reconstruct for us not only the animal or fish from which it came, but unfold a whole chapter of natural history, picture the scene and repeople a forgotten period of earth’s history before our delighted eyes.

Dr. Charles G. Raue pointed out that scarcely one of the “keynotes” or characteristic symptoms belongs exclusively to a single remedy, and cautioned us not to diagnose a remedy on one symptom only, be it ever so characteristic. “While in some cases,” he says, “it may point exactly to the remedy, it cannot do so in every case as it is not rational to suppose that the whole sphere of action of a remedy, which is often extensive and complex, should find its unerring expression and indication in one symptom. But such characteristics are of great aid in the selection of the remedy, as they define the circle of remedies out of which we must select.”

Dr. Hering, in his quaint fashion, years before the “keynote system” was ever heard of, said: “Every stool must have at least three legs, if it is to stand alone.” He advised selecting at least three characteristic symptoms as the basis of prescribing.

A milking stool will stand upon one leg-if you sit on it and thus provide your own two legs as the other necessary props; but even then, as every farmer’s boy knows by bitter experience, a vicious kick,

or a “corkscrew swat” from the old cow’s tail may upset the youthful milker and his pail of milk and bring him to grief.

It is wise to always give the symptomatic milk-stool as broad a base and as many legs as possible. The youthful prescriber will get many a vicious kick from refractory cases. He may be knocked sprawling and lose his pail of milk a few times, but he will be able to avoid this when he has learned the peculiarities of his patient as well as I learned the peculiarities of my bovine kicker when I was a boy.

The Totality is an ideal not always to be realized. As a matter of fact, in practical experience, it is often impossible to complete every symptom, or even a large part of the symptoms. Patients have not observed, or cannot state all these points. They will give fragments; the location of a sensation which they cannot describe, or a sensation which they cannot locate; or they wilt give a sensation, properly located, but without being able, through ignorance, stupidity, failure to observe or forgetfulness, to state the conditions of time and circumstances under which it appeared. Sometimes no amount of questioning will succeed in bringing out the missing elements of some of the symptoms.

What is to be done under such circumstances? Make a guess at the remedy? Give two or three remedies, in alternation? Give a combination tablet? Or “dope” the patient with quinine or morphine? Rather than do any of these things, follow the advice of my old preceptor, Dr. P. P. Wells. Sometimes, when I approached him with a difficult case, he would assume a quizzical expression and ask, “Don’t you know what to do?” On being answered in the negative he would say, “if you don’t know what to do, do nothing – until you do know;” emphasizing the injunction with a characteristic downward stroke of his right forefinger. Then he would go over the case and show what should be done and how to do it.

It was he who taught me Bœnninghausen’s method of dealing with such cases. And I thought the more of it because he had known Bœnninghausen and had received instruction and treatment from the Grand Old Man personally, while travelling in Europe.

[Will Taylor, MD 2001 (bio)

Characterizing Dimensions of the Totality of Symptoms: H.N. Guernsey and the Concept of Keynotes

"It was in the year 1827 when I made my debut in the practice of Homoeopathy, at a time when the only resources at our command were the Materia Medica Pura of the founder of our school and a few cures reported in Stapf's "Archiv," and in the "Praktischen Mittheilungen" (Practical Communications.) With these scanty means we had to get along as well as we could, and, by a diligent and attentive study of the drugs with whose pathogeneses we had become acquainted at that time, familiarize ourselves with the characteristic symptoms of each drug and its special indications, in order to avail ourselves of them for therapeutic purposes in such case as might present themselves for treatment. This was no small task, which could never have been accomplished, if the Materia Medica of that time

had contained the large number of drugs that are offered at the present time to the beginner in homoeopathic practice.

But since the number of drugs known at that time, did not exceed sixty, and among these only twenty had been proved with exhaustive perseverance and correctness, we had it in our power to study them thoroughly without too much trouble ... At this time such a careful study of our Materia Medica is unfortunately no longer possible to the beginner in Homoeopathy. Overwhelmed by the accumulated mass of drugs and clinical observations, he scarcely knows which way to turn for at least one ray of light in the chaos spread out before him ..."

- G.H.G. Jahr, Forty Years Practice

I recall several years ago sitting down with a capable and seasoned homeopathic practitioner, showing off my brand-new copy of Franz Vermeulen's Concordant Materia Medica. He looked it over briefly, handed it back, and said "I don't know what to do with the material in here - I find it overwhelming." We have today something on the order of 800 reasonably-characterized remedies, and perhaps as many more with some narrowly-defined spheres of usefulness. Some have thousands of recorded symptoms. How can we possibly organize and work with such an "accumulated mass of drugs and clinical observations"? Where does one turn for a "ray of light in the chaos spread out" before one in our voluminous materia medica?

Early on in the development of our art and science, Hahnemann recognized this need and called for a symptom-index to organize our knowledge of the materia medica. Boenninghausen's inspiration to break symptoms down into component dimensions allowed the creation of this, in the form of our historical and modern homeopathic repertories. Boenninghausen's use of symptom-dimensionality in case analysis - as discussed in previous installments in this series - introduced some order to the chaos inherent in our voluminous materia medica. Historical and contemporary innovators in our tradition - such notables as J.T. Kent, George Vithoulkas, Rajan Sankaran, Paul Herscu, and others - have introduced a number of ways of organizing the information of our materia medica to make it more accessible and useable in the determination of similitude, approaches I will address in future installments in this series. One of the earliest innovations in this direction was H.N. Guernsey's concept of remedy Keynotes.

Henry Newell Guernsey was born in Rochester, Vermont in 1817. He earned his medical degree from New York University in 1842, and in 1856 moved to Philadelphia and subsequently became professor of Obstetrics at the Homeopathic Medical College of Pennsylvania (which merged with the Hahnemann Medical College in 1869). His writings include The Application of the Principles and Practice of Homoeopathy to Obstetrics, and Keynotes to the Materia Medica.

Collections of Keynote symptoms of the homeopathic materia medica include several classical texts:

H.N. Guernsey, Keynotes of the Materia Medica

A. Von Lippe, Keynotes of the Homoeopathic Materia Medica

A. Von Lippe, Keynotes and Red-Line Symptoms of the Materia Medica

C.M. Boger, Boenninghausen's Characteristics

C.M. Boger, A Synoptic Key of the Materia Medica

H.C. Allen, Keynotes and Characteristics with Comparisons

J.H. Clarke, Grand Characteristics of the Materia Medica

Along with some excellent contemporary compilations:

R. Morrison, Desktop Guide to Keynotes and Confirmatory Symptoms

S.R. Phatak, Materia Medica of Homeopathic Medicines

As with any interesting or useful innovation, the use of Keynotes has been trivialized and misapplied by many, both in & since the days of Guernsey. We have all perhaps met homeopaths describing themselves as "Keynote Prescribers" -"he's a Sulfur type- hot & messy;" "I just took one look at the cracks in the corners of his mouth and gave him Nitric acid;" etc. Guernsey's inspiration is sadly trivialized by this approach, to near-uselessness. Yet some attention to what Guernsey really intended, can offer us a robust tool to add to our kit-bag of case-analysis strategies.

In the introduction to Application of Principles of Homeopathy to Obstetrics, Guernsey stated:

"The plan of treatment may seem to some rather novel, and, perhaps, on its first view, as objectionable, inasmuch as it may seem like prescribing for single symptoms; whereas such is not the fact.

It is only meant to state some strong characteristic symptom, which will often be found the governing symptom, and on referring to the Symptomen Codex, all the others will surely be there if this one is."

How does focused attention on a single (Keynote) symptom differ from prescribing for single symptoms?

Let's assign you the task of telling someone how to identify Meg Ryan, a moviestar, out of the crowd at a train station. You could arm them with a list of 6 or ten "Meg Ryan" rubrics from the

movie-star repertory:

Stature: feet, less than 6', 5' to 5'4"

Eyes: blue

Hair: blond

Hair: short

Face: smile, nice

Affect: feminine

Voice: inflection, rising, on word "love" when saying "I love you"

And you might have some success. Likely, though, your instructee would come back with 57 possibilities - and these might not even include Meg! (recall, her hair was long in Sleepless; and

variably blond, black, brown or red in Joe vs the Volcano; and she was pretty Butch in Courage under Fire).

So how can we lend some order to the chaos of the crowd at the train station, and to Meg's variable appearance, for a ray of light to aid us in our search?

Guernsey reminds us:

"There is certainly that, in every case of illness, which preeminently characterizes that case or causes it to differ from every other."

And for Meg, we can find such a Keynote characteristic: in the peculiar expressiveness of the corners of her mouth.

Will she be the only person in the train station with this characteristic? Probably not. But armed with this particularly characteristic feature to look for, our greeter will likely come back with only

4 or 5 possibilities:

One male

One speaking Croatian

One lovely overweight, grey-haired woman from Michigan with pictures of her grandchildren

One 17 year-old kid saying "whatever…"

And one with a reasonable fit to the rubrics in the original list - Meg herself. With that smile.

(OK, OK … might as well admit, my other obsession is chocolate …)

We do not really have any Keynotes that are specific for a given remedy, that can define a remedy in isolation. Arum-t. has cracks at mucocutaneous junctions, as well as Nitric acid. Not everyone who is pathologically messy needs Sulfur. The rubric in Kent for bearing-down pains of the uterus does list Sepia - along with 73 other remedies (92 in the Full Synthesis). Keynotes are not specific to a remedy, but they are those symptoms where the greatest weight resides in differentiating remedies - Meg Ryan's smile, Richard Nixon's jowls, Dorothy's ruby slippers, Sheryl Deaver's fingernails.

The full characterization of a remedy requires a greater totality of symptoms, and this greater totality is required to assign similitude to a case - but these Keynote symptoms are the symptoms within the totality that most strongly declare the individuality of our medicinal agents.

Guernsey's work with keynotes derived out of a series of lectures delivered to the students of the Hahnemann Medical College of Philadelphia between 1871 & 1873. About these lectures, he wrote,

"To give the Materia Medica, with anywhere near all the symptoms of each remedy, would require at least three consecutive courses of lectures - each course to be not less than six months long." He intended instead to present the leading characteristics of remedies, "to turn the student's mind, when he should engage in practice, in the direction of the proper remedy, when prescribing for the sick."

Guernsey's described keynotes in the following manner: "There is certainly that, in every case of illness, which preeminently characterizes that case or causes it to differ from every other. So in the remedy to be selected, there is or must be a combination of symptoms, a peculiar combination, characteristic or, more strikingly, key-note. Strike that and all the others are easily touched, attuned or sounded."

1 Note that Guernsey's Keynotes can be viewed as the characteristic symptoms of a remedy that correspond rather directly to the " striking, singular, uncommon and peculiar (characteristic) signs and symptoms" of disease that Hahnemann discusses in aphorism 153 of the Organon:

"In this search for a homoeopathic specific remedy, that is to say, in this comparison of the collective symptoms of the natural disease with the list of symptoms of known medicines, in order to find

among these an artificial morbific agent corresponding by similarity to the disease to be cured, the more striking, singular, uncommon and peculiar (characteristic) signs and symptoms (1) of the case of disease are chiefly and most solely to be kept in view; for it is more particularly these that very similar ones in the list of symptoms of the selected medicine must correspond to, in order to constitute it

the most suitable for effecting the cure.

The more general and undefined symptoms: loss of appetite, headache, debility, restless sleep, discomfort, and so forth, demand but little attention when of that vague and indefinite character, if they cannot be more accurately described, as symptoms of such a general nature are observed in almost every disease and from almost every drug."

What are the characteristic features of a keynote?

1^st a keynote must be a strongly-expressed symptom, one that is seen strongly-marked with considerable consistency in provings and in the clinical settings calling for the remedy as simillimum.

2^nd a keynote must be a somewhat peculiar symptom, one not shared with many other remedies.

The symptom "Bearing down pain in the pelvis, as if the pelvic organs would fall out" can be considered a keynote for Sepia, as it is strongly marked for Sepia, being seen frequently in the provings,

and frequently in cases where Sepia is called for [certainly though not in all Sepia cases - but when uterine discomfort is present in a Sepia case, it is dominantly of this nature]; and it is shared

prominently by only a few other remedies.

These two features translate into a repertory presence of this symptom as a relatively strongly-marked remedy, in a relatively small rubric.

I wish to re-emphasize, as did Guernsey, that one cannot accurately prescribe merely "on a keynote." If one were to prescribe Sepia purely on the keynote symptom of bearing-down pains of the uterus,

one would give a great deal of Sepia inappropriately to patients needing Lil-t. Murx. Plat. Sab. etc.

Rather, Guernsey suggested that the Keynote be used to rapidly focus on a small constellation of remedies bearing this symptom - as a most centrally important, potentially highly characterizing feature

of the case and of the remedy bearing similitude to the case.

In practice, Keynotes may be recognized and used in case analysis in several ways. Perhaps it is best to demonstrate this in the context of a brief case.

A 38 year-old woman presented with the diagnosis of gastrointestinal reflex. She reported "risings" in the area behind the zyphoid process and lower sternum, with sour taste in the mouth, < lying

(at night; she would only rarely lie down at other times, but if she did, the same symptoms would appear, especially if she had recently eaten). She felt as if a good belch would relieve her symptoms,

but could rarely belch, and if did, felt no relief of the seeming need to. The pressure in the zyphoid region made it difficult to breath when she was lying down. She would wake about 2 hours after

retiring, feeling unable to get a good breath, with diffuse unexplainable anxiety, and a gnawing hunger in the stomach. She described a constant sensation, pointing to the zyphoid process, as "it feels

like I swallowed a hard-boiled egg that just stuck right here."

I took the following rubrics for her case (the number in parentheses is the number of remedies in the rubric, using the Quantum view of Synthesis vers. 8):

STOMACH - ERUCTATIONS; TYPE OF - sour (166)

STOMACH - ERUCTATIONS - ineffectual and incomplete (80)

STOMACH - ERUCTATIONS - lying - agg. (5)

RESPIRATION - DIFFICULT - lying - while (107)

GENERALS - EATING - after (189)

STOMACH - EGG; sensation as if swallowed an (1)

SLEEP - DISTURBED - hunger, by (10)

MIND - ANXIETY - night - midnight - before (36)

Sulph. Lyc. Phos. Graph. etc. lead the numerical repertorization, but all of these are missing the most striking, peculiar, 'auffallend' symptom of the case - the sensation of a hard-boiled egg lodged

behind the zyphoid.

Using RADAR, a symptom such as this one can be emphasized in any one of several ways:

Weighting the repertorization for small rubrics will selectively weight those rubrics that are more highly characterizing due to the rarity of the symptom (so the smallness of the rubric):

Perhaps the best weighting scheme to bring out the keynote symptoms of an analysis is the Prominence weighting scheme in RADAR. Weighting for prominence will upgrade the most prominent

remedies in each rubric - by applying a formula to bring forward the remedies that stand out in the analysis by being more highly marked in smaller, more unique symptoms:

Weighting for a Keynote

If a symptom is recognized during your analysis as bearing Keynote status, you can weight it by underlining it when it is selected, or later on, after your collection of rubrics is assembled in the rubrics clipboard.

To weight the hard-boiled egg symptom in this case, when the rubric is selected in the repertory, use the + command to move it to the rubrics clipboard, followed by a 3 or 4 to represent 3 or 4 underlines

in your analysis:

Changing the Weighting

If the rubric has already been selected without weighting, weighting can be changed by selecting the rubric in the clipboard, pressing Return, and selecting the weighting in the Intensity of Interrogation box of the Take Edit Options window:

The repertorization now will reflect the weight you have chosen to give this particular symptom:

Elimination Based on a Keynote

Finally, if a symptom is recognized during your analysis as bearing Keynote status, you could choose to eliminate on the basis of this single symptom (or 2 or 3 Keynote symptoms). This is done in the Take Edit Options window, as above, by checking Elimination in the Qualifications box:

It is rare that you'll be using a single-remedy rubric in this manner, as I have above. This serves to highlight a risk inherent in using elimination on a Keynote as an analysis strategy. Although I would really like to see this symptom belong to remedy I select for this case, I am left in this eliminative repertorization with no other remedies to consider in the final stages of analysis - the stage where one goes to the Materia Medica for a differential study of the leading remedies. Elimination particularly excludes smaller remedies that might be forgiven for "going missing" in any particular rubric, if they nicely fit the remaining symptoms of the case.

This case also risks the principle error made in attending to Keynotes in case analysis. When this patient described the sensation of "a hard-boiled egg" lodged at the pyloric cardia, I had difficulty remaining in my seat - having long-before learned this to be one of the most outstanding Keynote symptoms of our materia medica, as a highly characteristic symptom of Abies nigra.

Although this keynote catapults Abies nigra into the lead in the analyses above, it was still necessary to confirm its similitude to the totality of symptoms of the case - albeit a totality heavily weighted by this uniquely characterizing symptom. Finding Abies nigra also in the rubrics [RESPIRATION - DIFFICULT - lying - while], [GENERALS - EATING - after] and [SLEEP - DISTURBED - hunger, by] confirmed the fit of this remedy to the totality of the case. I felt OK about its going missing in the other 4 rubrics taken for the case, as it is a rather "small" remedy, represented in only 97 rubrics in the Full Synthesis Repertory, compared to over 9,000 rubrics for each of the leading remedies of the straight repertorization. Reviewing the primary and clinical materia medica of Abies nigra, along with that of other leading remedies falling out of the analysis - the essential final step of case analysis - confirmed this remedy as the simillimum for the case.

Keynotes may involve single symptoms, as in the example above; but they may also involve a characteristic concomitance or alternation of symptoms that serves as a more complex keynote.

Examples of this include the concomitance of rheumatic complaints, neuralgic pains, and uterine complaints of Cimicifuga; the alternation of rheumatic complaints with cardiac/endocardial symptoms of Kalmia; and the alternation of asthmatic respiration with rheumatic pain of Dulcamara. Many of these characteristic complex keynotes are recorded directly as rubrics in our repertories - e.g., [RESPIRATION - ASTHMATIC # pain; rheumatic: dulc. Med.] - and can be incorporated into an analysis as described above for a simple keynote.

Keynotes can serve as valuable symptoms to help us discover at least "one ray of light in the chaos spread out before us" in finding a simillimum to match the totality of symptoms of a case. When relying on Keynotes in analysis however, it is essential to keep foremost in one's mind that this is merely a strategy to aid in appreciating the totality of symptoms in a rich and full way - and not a means of side-stepping around the need to address that great inevitability, the totality of symptoms, in each and every case.

Vorwort/Suche. Zeichen/Abkürzungen Impressum