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described on page 445), and sometimes breathing becomes periodic (Cheyne-Stokes) Amyotrophic lateral sclerosis is the main condition in which the signs of spastic and atrophic bulbar palsy are combined When the dominant frontal operculum is damaged, speech may be dysarthric, usually without impairment in emotional control In the beginning, with vascular lesions, the patient may be mute; but with recovery or in mild degrees of the same condition, speech is notably slow, thick, and indistinct, much like that of partial bulbar paralysis Magnetic stimulation of the cortex in these cases reveals a delay in corticobulbar conduction The terms cortical dysarthria and anarthria, among many others, have been applied to this disorder, which is more closely related to mild forms of Broca s aphasia than to the dysarthrias being considered in this section (see Pure Word Mutism, page 422) Also, in many cases of partially recovered Broca s aphasia and in the mini-Broca syndrome, the patient is left with a dysarthria that may be dif cult to distinguish from a pure articulatory defect Careful testing of other language functions, especially writing, will in this instance reveal the aphasic aspect of the defect A severe dysarthria that is dif cult to classify but resembles that of cerebellar disease may occur with a left hemiplegia, usually the result of capsular or right opercular infarction It tends to improve over several weeks but initially may be so severe as to make speech incomprehensible (Ropper) Rigid (Extrapyramidal) Dysarthria In Parkinson and other extrapyramidal diseases associated with rigidity of muscles, one observes a rather different disturbance of articulation, characterized by rapid mumbling and cluttered utterance and slurring of words and syllables with trailing off in volume at the ends of sentences The voice is low-pitched and monotonous, lacking both in ection and volume (hypophonia) The words are spoken hastily and run together in a pattern that is almost the opposite of the slowed pattern of spastic dysarthria In advanced cases, speech is almost unintelligible; only whispering is possible It may happen that the patient nds it impossible to talk while walking but can speak better if standing still, sitting, or lying down The terms hypokinetic and festinating have been applied to these aspects of parkinsonian speech Curiously, in the extrapyramidal disorder of progressive supranuclear palsy, the dysarthria and dysphonia tend to be spastic in nature With chorea and myoclonus, speech may also be affected in a highly characteristic way The speech is loud, harsh, improperly stressed or accented, and poorly coordinated with breathing (hyperkinetic dysarthria) Unlike the defect of pseudobulbar palsy or Parkinson disease, chorea and myoclonus cause abrupt interruptions of the words by superimposition of involuntary movements of bulbar muscles The latter abnormality is best described as hiccup speech, in that the breaks are unexpected, as in singultation Grimacing and other characteristic movement abnormalities must be depended upon for diagnosis The Tourette syndrome of multiple motor and vocal tics is characterized both by startling vocalizations (barking noises, squeals, shrieks, grunting, snif ng, snorting) and by speech disturbances, notably stuttering and the involuntary utterance of obscenities (coprolalia) Elements of both corticobulbar (spastic) and extrapyramidal speech disturbances may be combined in Wilson disease, in Hallervorden-Spatz disease, and in the form of cerebral palsy called double athetosis The speech is loud, slow, and labored; it is poorly coordinated with breathing and accompanied by facial contortions.

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and athetotic accesses of tone in other muscles In diffuse cerebral diseases such as general paresis, slurred, tremulous speech is one of the cardinal signs Ataxic Dysarthria This condition is characteristic of acute and chronic cerebellar lesions It may be observed in multiple sclerosis and various degenerative disorders involving the cerebellum or its peduncles, or as a sequel of anoxic encephalopathy and rarely of heat stroke The principal abnormalities are slowness of speech, slurring, monotony, and unnatural separation of the syllables of words (scanning) The coordination of speech and respiration is disordered There may not be enough breath to utter certain words or syllables, and others are expressed with greater force than intended (explosive speech) Scanning dysarthria, speaking metronomically as if scanning poetry for meter (see page 77), is another cerebellar pattern distinctive and is due most often to mesencephalic lesions involving the brachium conjunctivum However, in some cases of cerebellar disease, especially if there is an element of spastic weakness of the tongue from corticobulbar tract involvement, there may be only a slurring dysarthria, and it is not possible to predict the anatomy of the lesions from analysis of speech alone Myoclonic jerks involving the speech musculature may be superimposed on cerebellar ataxia in a number of diseases Acquired Stuttering This abnormality, characterized by interruptions of the normal rhythm of speech by involuntary repetition and prolongation or arrest of uttered letters or syllables, is a common developmental disorder, discussed in Chap 38 But as pointed out by Rosenbek et al and by Helm and colleagues, it may appear in patients who are recovering from aphasic disorders and who had never stuttered in childhood This acquired stuttering in adults resembles the developmental type in that the repetitions, prolongations, and blocks are restricted to the initial syllables of words, and there is no adaptation However, it involves grammatical as well as substantive words and is generally unaccompanied by grimacing and associated movements In many instances, acquired stuttering is transitory; if it is permanent, according to Helm and associates, bilateral cerebral lesions are present Nevertheless we have observed some cases in which only a left-sided, predominantly motor aphasia provided the background for stuttering, and others in which stuttering was an early sign of cerebral glioma originating in the left parietal region Benson also cites patients in whom stuttering accompanied uent aphasia Noteworthy is the fact that stuttering differs from palilalia, in which there is repetition of a word or phrase with increasing rapidity, and from echolalia, in which there is an obligate repetition of words or phrases The causative lesion in acquired stuttering may be subcortical and even, as in an exceptional case described by Ciabarra and colleagues, located in the pons The treatment of Parkinson disease with L-dopa and, occasionally, an acquired cerebral lesion may reactivate developmental stuttering The latter may explain the emergence of stuttering with oddly situated lesions, such as the aforementioned pontine infarct.

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Finally, a few points should be made concerning the fourth group of speech disorders, ie, those due to disturbances of phonation In adolescence there may be a persistence of the unstable change of voice normally seen in boys during puberty As though by habit, the patient speaks part of the time in falsetto, and the condition may persist into adult life Its basis is unknown Probably the larynx

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