J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.51.1.161 on 1 January 1988. Downloaded from

Matters arising 161 neuromuscular transmission. Our experi- essential and, as implied by Corbin 5 Hartman DE, Aronson AE. Clinical ence, like that of Martinez and Jimenez, and Williams, other disorders of move- investigations of intermittent breathy dys- Hear Disord indicates that these patients may never dem- ment.2 8 phonia. J Speech of 1981;46:428-32. onstrate clinical manifestations Co-occurring impairment of one or more 6 Marsden CD, Sheehy MP. Spastic dysphonia, myasthenia gravis, thus therapeutic deci- of the other components of motor speech, Meige disease, and torsion . Neur- sions should be made based on the clinical namely articulation, resonation, respiration, ology 1 982;32: 1202-3. findings, rather than EMG abnormalities. and prosody (speech rhythm) is consistent 7 Hartman DE, Abbs JH. The Dysarthrias of DONALD B SANDERS with dysarthria rather than a focal laryngeal Movement Disorders. In: Jankovic J, Tolsa JAMES F HOWARD, JR disorder.2 79 E, eds. Facial Dyskinesias: Advances in Neur- Division ofNeurology, The response of spastic dysphonia to ology. New York: Raven Press (in press). Duke University Medical Center, treatment seems to depend upon aetiology, 8 Hartman DE. Neurogenic dysphonia. Ann Otol Rhinol Laryngol 1984;93:57-64. Box 3403, type of disorder (adductor, abductory, 9 Darley FL, Aronson AE, Brown JR. Motor Durham, mixed), and mode of therapy.47 Speech Disorders. Philadelphia: WB North Carolina 27710, USA, For those types of spastic dysphonia for Saunders, 1975. and Department of , which a recognisable aetiology cannot be University of North Carolina, identified, the term "idiopathic spastic dys- Chapel Hill, North Carolina 27514, USA. phonia" has been recommended along with Corbin and Williams reply: regular follow-up, which may eventually Sir: Dr Hartman reminds us of the possible reveal an underlying substrate for the mechanisms of vocal cord dysfunction in disorder.2 -4 spasmodic dysphonia; however, in our final the need dystonia phases of Parkinson's DAVID E HARTMAN paragraph' we sought to emphasise Stridor during Department ofNeurology, for clinicians to consider dystonia as a cause disease Gundersen Clinic, of what may otherwise be an enigmatic dis- refer not only to some cases of Sir: Doctors Corbin and Williams' report of 1836 South Avenue, order; we co-occurring with limb La Crosse, spasmodic dysphonia but also to problems respiratory stridor Wisconsin 54601, USA. such as piano-player's dystonia and the and orofacial dystonia in two patients with occupational .2 Many such cases idiopathic Parkinson's disease is note- were previously classified as hysterical. Dr Protected by copyright. worthy.1 However, their statement that "... Hartman's policy of accepting that some spasmodic dysphonia is now recognised as References cases of spasmodic dysphonia lack recog- being a form of focal dystonia of the laryn- nisable aetiology is safer in that it does not geal muscles" (p. 821) needs clarification. I Corbin DOC, Williams HC. Stridor during deny the possible existence of an organic The cardinal signs of spastic (spasmodic) dystonic phases of Parkinson's disease. J dysphonia, principally (1) intermittent or Neurol Neurosurg Psychiatry 1987;50:82 1. cause. regular adductor voice arrests secondary to 2 Aronson AE. Clinical Voice Disorders. 2nd ed. hyperadduction, (2) New York: Thieme Inc, 1985. References vocal fold/laryngeal 3 Hartman DE, Abbs JH. Clinical investigations moments of strained, effortful vocal quality of adductor spastic dysphonia. Ann Otol I Corbin DOC, Williams AC. Stridor during interspersed within apparent normal pho- Rhinol Laryngol (in press). dystonic phases of Parkinson's disease. J nation, and (3) intermittent or regular 4 Aronson AE, Hartman DE. Adductor spastic Neurol Neurosurg Psychiatry 1987;50:821-2. breathy moments secondary to abductory dysphonia as a sign of essential (voice) 2 Lees AJ. Tics and Related Disorders. London: glottal arrests may represent psychogenicity, tremor. J Speech Hear Disord 1981;46:52-8. Churchill Livingstone, 1985:166.

when, but why, a particular agent should be disorders. Inevitably the particular biases of

Book reviews prescribed. the authors are revealed and not everyone http://jnnp.bmj.com/ The initial chapter is a review of the will agree with their suggestion that steroids actions of drugs on the nervous system and have a role in ischaemic stroke. Indeed the Neurological Disorders. (Treatment in briefly considers the role of the blood brain authors seem somewhat uncertain them- Clinical Medicine series.) By D Parkes, barrier. It contains useful tables of drugs selves in that on one page they state "it may P Jenner, D Rushton, C David Marsden. (Pp which are agonists and antagonists for the therefore be beneficial to treat focal oedema 227; £38-00.) London: Springer-Verlag, various neuro-transmittor receptors and around an infarct using osmotic diuretics or 1987. examples of compounds which act upon steroids" and on the next page "post- specific receptor sub-types. There follow infarction oedema does not respond to This is the fifth monograph in a series on chapters on each of the common neu- steroids". on September 25, 2021 by guest. management and treatment in specialities in rological disorders with the appropriate In the chapter on infections it would have medicine and serves as a perfect riposte to therapy and, where known, a summary of been useful to have a suggestion as to the those who would believe that the neurologist their mode of action. The authors' own most reasonable combination therapy in the has a major role in diagnosis but only a interest and expertise in the treatment of infant, adult or aged patient presenting with minor role in therapy. It contains a practical movement disorders and sleep disorders is a presumed but unidentified or partially approach to major neurological disorders apparent in these, the best, chapters in the treated bacterial rather than the which is spiced by the pharmacological book and the whole provides a useful prac- bald statement that therapy "depends on expertise of Dr Jenner in explaining not only tical guide to logical therapy in neurological isolation of the causative organism". No