Installment 7 of a series on case analysis
© Will Taylor, MD 2001 (bio)
of the Totality of Symptoms:
and the Concept of Keynotes
Sections: 1 | 2
What are the characteristic features of a keynote?
First, a keynote must be a strongly-expressed symptom of a remedy, one that is seen strongly-marked with considerable consistency in provings and in the clinical settings calling for the remedy as simillimum. Second, 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 (1)a relatively strongly-marked remedy, in (2)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 Lilium tigrinum, Murex, Platina, Sabina, 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, worse lying (especially 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, & 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 to bed, 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)
Here is a standard repertorization, weighted for number of symptoms x degree:
Sulphur, Lycopodium, Phosphorus, Graphites, 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 for Small Rubrics
Weighting the repertorization for small rubrics will selectively weight those rubrics that are more highly characterizing due to the rarity of the symptom (& hence 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 - alternating with - pain; rheumatic: (2) 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.
1 H.N. Guernsey, preface to Application of Principles of Homeopathy to Obstetrics
2 S. Hahnemann, Organon of the Medical Art, 5th / 6th edition, Dudgeon/Boericke translation
Sections: 1 | 2