“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
Henry GuernseyHenry 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 Comfirmatory 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 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″
Face: smile, nice
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.” 1
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 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 triphyllum 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.” 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:
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):
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:
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:
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