MY EXPERIENCE WITH KEYNOTE PRESCRIBING IN A CASE OF PARKINSONISM PLUS SYNDROME Dr. Gyandas G. Wadhwani Senior Medical Officer (Homoeopathy) Homoeopathic Wing, Directorate of ISM & Homoeopathy

You've probably read in People that I'm a nice guy - but when the doctor first told me I had Parkinson's, I wanted to kill him. Parkinson's is my toughest fight.

Parkinsonism is a motor syndrome whose main symptoms are tremors (resting), rigidity, bradykinesia and postural instability. Parkinsonism can be divided into four subtypes according to the origin Primary or idiopathic Secondary or acquired Hereditary parkinsonism and Parkinson plus syndromes or Multiple system degeneration

Parkinsonism-plus syndromes are primarily parkinsonisms which present additional features viz. Multiple system atrophy Progressive supranuclear palsy Corticobasal degeneration and Dementia with Lewy bodies etc.

Clinical features of Parkinsonism plus syndrome Lack of response to dopamine agonists in the early stages of the disease Early onset of dementia Early onset of postural instability Early onset of hallucinations or psychosis with low doses of dopamine agonists Ocular signs, such as impaired vertical gaze, blinking on saccade, square-wave jerks, nystagmus, blepharospasm, and apraxia of eyelid opening or closure Pyramidal tract signs not explained by previous stroke or spinal cord lesions Autonomic symptoms such as postural hypotension and incontinence early in the course of the disease Prominent motor apraxia Alien-limb phenomenon Marked symmetry of signs in early stages of the disease Truncal symptoms more prominent than appendicular symptoms Absence of structural etiology such as a normal-pressure hydrocephalus (NPH) Etc.

The Parkinson-plus syndromes are usually more rapidly progressive and less likely to respond to more popular anti- parkinsonian medication than Parkinson's disease.

Homoeopathy offers numerous remedies for Parkinsonism. The vast symptomatology detailed in accurately observed phenomena of Human Pathogenetic Trial (more popularly known as Drug Proving) gives a unique edge to this system of medicine in withstanding the any new (or old) medical challenge.

My Clinical Experience

I was asked to visit a 75 years old gentleman, in October 2009.

On observation - average height but stooped - thin built - sharp features - arcus senilis - rigid - restlessness- constantly asking family members and attendants to help him move - WOULD NOT LET GO OF SOMEONE’S HAND

His main complaints were: - Inability to walk stand or sit without support - Speech had deteriorated - Stooping - Restlessness - Tremors All these complaints had developed over last 2 months. On the advice of a neuro-physician levodopa had been started but he reacted poorly to it and it was discontinued.

Past history - Tuberculosis in mid 30’s Family history: N.S. Personal history Non-vegetarian, non-alcoholic, non-smoker. Widower for last 2 years. After retirement from Govt job, he was working as a librarian till 2 months back.

Generals Appetite: Poor for last 2months Thirst: Increased, wanted 3/4 th cup of water frequently Sleep: Disturbed by his restlessness T/R: Chilly

Mind and disposition - Irritable by nature - Abusive when angry - Anguish; Restlessness - Impatient

Life & circumstances Born and brought up in lower middle class family. Always been bright and intelligent in studies. Passion for music, which he learned under Bade Ghulam Ali Khan Sahib (extremely distressed that he could not even speak clearly now). Though a Sikh, he was attracted to Sai Baba.. Composed and sang numerous Bhajans for him. Govt job was satisfactory. Children are settled.

Analysis The most striking (§153) feature of the case was his constant desire to hold someone’s hand, which is a well known Keynote symptom of Bismuth.

(No) Corroboration from Repertory Paralysis agitans Agar, alum, ant-t, aran, aran-ix, arg-met, Arg n, arn, Ars, aur, Aur-s, aven, bar-c, bar-m, bell, bufo, buth-a, Camph-br, Camph-mbr, cann-i, Carb-v, Caust, chin….. Merc….. Rhus-t….. Zinc… old people, in: aven

Corroboration from Hering’s Guiding Symptoms (Bismuth): Nerves –Restless, moving about; anxiety –All muscles of body, particularly those of legs, from toes to thighs, spasmodically contracted. –Constant tremor

Prescription He was prescribed Bismuth in LM potencies

Follow up

Follow up

Follow up

Improvement so far can be summed up thus: - His speech has been restored; he is now able to sing fluently as can be seen in the last recorded video - With the return of his capability to sing, his passion for life has also returned - He can now walk with minimal support - His tremors have almost vanished He is still being followed..

Some words about keynote prescribing..

"…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….”

…The life-work of the student of homoeopathic Materia Medica is one of constant comparison an differentiation. He must compare the pathogenesis of a remedy with the recorded anamnesis of the patient; he must differentiate the apparently similar symptoms of two or more medical agents in order to select the simillimum….. he must have as a basis for comparison, some knowledge of the individuality of the remedy; something that is peculiar, uncommon, or sufficiently characteristic in the confirmed pathogenesis of a polychrest remedy that may be used as a pivotal point of comparison….

……It may be a so-called "KEYNOTE," a "CHARACTERISTIC," the "red strand of the rope," ….. The object of this work is to aid the student to master that which is guiding and characteristic in the individuality of each remedy and thus utilize more readily the symptomatology of the Homoeopathic Materia Medica …

The word ‘keynote’ means Prime or crucial element or an underlying or prevailing tone, spirit or idea. The reference to keynote in the realm of homoeopathy draws from the analogy between Materia Medica and Music.

In the remedy (& patient) 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.

A characteristic or keynote symptom is a generalization drawn from the particular symptoms by logical deduction. Stuart Close

The keynote system of prescribing is a skillful art mastered with an in-depth study of Materia Medica and learnt in close association with the Masters.

The misunderstanding of this method has caused it to fall somewhat into discredit (through disuse/ abuse).

K. Souter, in his article, Heuristics and bias in Homeopathy, has also defined Keynote prescribing as an empirical approach leading to cognitive bias in prescribing, the abstract of which is reproduced as under:

..The practice of Homeopathy ought to be strictly logical. In the Organon Samuel Hahnemann gives the impression that the unprejudiced observer should be able to follow an algorithmic route to the simillimum in every case…

..Judgment and Decision Research, however, indicates that when people grapple with complex systems like homeopathy they are more likely to use heuristics or empirical rules to help them reach a solution. Thus Hahnemann's concept of the unprejudiced observer is virtually impossible to attain. There is inevitable bias in both case-taking and remedy selection…

Keynote (characteristic) prescribing, which demands from the physician, nothing else but earnest study of Materia Medica and sincere case taking (perceiving) has fallen out of favor due to lack of thorough knowledge.

We need to reprise the spirits of Hahnemann, Guernsey, Allen, Lippe etc. and devote ourselves at the altar of this truthful way of prescribing!