Unusual Cause of Dysarthria in a Patient With Cerebrovascular Disease difficulty in speech with impaired articulation and pronunciation has been termed dysarthria. Although the list of neurological causes of dysarthria is long, an elderly patient with acute dysarthria associated with myocardial infarction would often be presumed to have had a stroke. We were asked to evaluate a patient with stroke who had an unexpected mechanical cause for dysarthria. A 67-year-old woman with diabetes awoke with jaw pain, right arm pain and numbness, and difficulty speaking and swallowing. She wrote a barely legible note saying "take me to the hospital." Five days earlier she had a brief episode of headache and right arm numbness associated with difficulty finding the right word and speak- Motor ing intelligibly. Electrocardiogram showed acute myocardial infarc- tion and she was treated with tissue-type plasminogen activator. The pain in the right arm and in the jaw, as well as the right arm numbness, resolved, but her speech and swallowing difficulties persisted. She was alert and followed 3-step commands. Speech was slurred and poorly articulated, although her tongue had normal strength and mobility. She was able to repea, phrases and had no difficulty finding words. Her jaw hung open and she was unable to close her mouth, nor could it be closed by the examiner, and the mandible ap¬ peared to have an unusual configuration. Other cranial nerve function appeared normal. She had good strength in all extremities except for questionable slight weak¬ ness in the right arm. The muscle stretch reflexes were present and symmetric in the upper extremities, but ab¬ sent in the lower extremities. She had an extensor re¬ sponse on the right to plantar stimulation. Coordina¬ tion was normal. Computed tomography of the brain showed a nonacute left putamen lacunar infarct. Angiography showed moderate stenosis of the left internal carotid artery. Elec¬ troencephalogram showed slight slowing over the left hemisphere. Panorex view of the mandible showed bi¬ lateral anterior condylar dislocation (Figure). Reduc- Panorex view of the mandible shows bilateral condylar dislocation without fracture. tion of the mandibular dislocation resulted in complete resolution of the dysarthria. The clinical characteristics of acute anterior man¬ dibular dislocation include dysarthria, dysphagia, drool¬ ing, pain anterior to the ear, inability to close the mouth, jaw protrusion, and inability to approximate the teeth anteriorly.1"3 Mandibular dislocation may be caused by trauma or by extreme mouth opening (man¬ dibular hyperextension), such as during dental or anes¬ thetic procedures, laughing, oral sex, yawning, vomit¬ ing, or taking a large bite of food.1·4 It may occur during an epileptic seizure or from abnormal jaw movements in movement disorders or dystonic drug reactions.5·6 Diagnosis is easily accomplished by a panoramic view of the mandible. This patient had no history of trauma and had no idea how her jaw became dislocated. The initial clinical impression of symptomatic cerebrovascular disease was correct, but did not explain her dysarthria. Dysarthria and dysphagia are not usually found in anterior circulation ischemie events unless the infarct is very large, and their presence typically suggests brain-stem dysfunction. How¬ ever, she had no other signs or symptoms of brain-stem dysfunction to suggest a posterior circulation event, nor evidence for cortical language disturbance. Although the dysphagia and dysarthria were typical for mandibular dis¬ location, the presentation was misleading, especially the Downloaded From: http://archneur.jamanetwork.com/ by a New York University User on 06/02/2015 absence of a known precipitating event and lack of pain as a prominent feature, resulting in delayed diagnosis and treatment. Clinicians must keep in mind that dysarthria and dysphagia may result from mechanical or traumatic causes, as well as the anticipated or usual acute and chronic neurological disorders. 2. Cohen JS, Fihn SD, Boyko EJ, Jonsen AR, Wood RW. Attitudes toward assisted suicide and euthanasia among physicians in Washington State. N Engl J Med. 1994;331:89-94. 3. van der Maas PJ, van der Wal G, Haverkate I, et al. Euthanasia, physician- assisted suicide, and other medical practices involving the end of life in the Netherlands, 1990-1995. N Engl J Med. 1996;335:1699-1705. Cynthia L. Coulter, MD Department of Neurology Creighton University Medical School 601 N 30th St Suite 5300 Omaha, NE 68131 Alan M. Kaneshige, MD Tulsa, Okla William M. Wyatt, DDS Omaha 1. Luyk NH, Larsen PE. The diagnosis and treatment of the dislocated man- dible. Am J Emerg Med. 1989;7:329-335. 2. Meldon SW, Bonadio WA. An unusual cause of acute dysphagia and trismus in a child. Pediatr Emerg Care. 1994;10:163-165. 3. Cope MR, Lawlor MG. An unusual mandibular dislocation. BrJ Oral Max- illofac Surg. 1985;23:112-117. 4. Sosis M, Lazar S. Jaw dislocation during general anaesthesia. Can J Anaesth. 1987;34:407-408. 5. Bradshaw RB. Perphenazine dystonia presenting as recurrent dislocation of the jaw. J Laryngol Otol. 1969;83:79-82. 6. Merrill RG. Habitual subluxation and recurrent dislocation in a patient with Parkinson's disease: report of case. J Oral Surg. 1968;26:473-477. Physician-Assisted Suicide Physician-assisted suicide goes against the traditional healing role of the physician and, as pointed out by Bernat,1 is likely to undermine the patient\x=req-\ physician relationship. It is clear that physicians, as a group, are divided in their willingness to assist suicide: 375 (40%) of 938 physicians in Washington State were willing to assist a patient to commit suicide, but 366 (39%) of 938 held that assisted suicide is never ethically justified.2 With the reports3 from the Netherlands that involuntary euthanasia has followed the legalization of voluntary euthanasia, concern will increase among patients as to what would happen to them if they became too ill to participate in end-of-life decisions. Physicians are unlikely to discuss their ethical views with patients, but patients will increasingly want to know their physicians' stand on euthanasia and assisted suicide. One way to address this is for physicians to document their stand on euthanasia and assisted suicide and have this accessible for public review. I have set up a Web site to determine whether physicians who are against as¬ sisted suicide and euthanasia are interested in jointly docu¬ menting their position on these issues (http:// www.wp.com/JMV/Anti-Euthanasia). Patrick Pullicino, MD, PhD Department of Neurology Buffalo General Hospital 100 High St Buffalo, NY 14203 1. Bernat JL. Physician-assisted suicide should not be legalized. Arch Neurol. 1996; 53:1183-1184. To Be or Not to Be? That Is the Question Facing Many Neurology Residency Programs than half of neurology residency positions currently filled by graduates of US medical schools. The clinical emphasis in neurology has Less are switched from the inpatient to the outpatient arena. Most hospitals are experiencing strong financial pressures to reduce residency positions. Recent changes in federal health care requirements for payments to teaching physicians have decreased the advantage of seeing patients with residents. These factors may evoke a sense of pessimism regarding the future of academic neurology and should make many neurology residency programs question the necessity for and viability of their existence. Indeed, many graduate medical education programs in neurology are unlikely to survive long into the 21st century unless some change occurs. The magnitude of change necessary to allow the survival of many of these programs may be smaller than expected. First, any notion regarding a critical mass of neurology resi- dents should be discarded. Quality, not quantity, should be the "gold standard" for residency review committees making accreditation decisions. A residency program that produces 1 quality neurologist every 2 or 3 years should be considered adequate. Second, neurol¬ ogy residency programs with limited numbers of neu¬ rology residents must be allowed to give up their inpa¬ tient ward service without risk of losing their accreditation. Appropriate resident coverage of neurol¬ ogy inpatient beds is not possible when there might only be 1 or 2 residents in an entire program at any par¬ ticular time. Neurology residents can learn the appro¬ priate and necessary clinical skills in the outpatient clinics and on an inpatient neurology consult service. These 2 changes would allow the 50% to 75% less com¬ petitive neurology residency programs to survive. With¬ out these 2 changes, many neurology residency pro¬ grams will die. Should less competitive neurology residency pro¬ grams survive? Absolutely. Neurology residents are an essential ingredient in maintaining a true academic spirit within neurology departments at university medical centers. The loss of a large number of aca¬ demic departments of neurology at many of this nation's university medical centers would ultimately have a significant detrimental impact on the patient populations that they serve. The downsizing of many neurology residency programs is necessary in our cur¬ rent health care environment, should be encouraged Downloaded From: http://archneur.jamanetwork.com/ by a New York University User on 06/02/2015