Involuntary movements may be due to organic disease of the central nervous system, particularly when the extrapyramidal system is involved (see p. 216). Disorders of movement may also result from primary disease elsewhere (see Table 2.4).

The 'flapping tremor' of encephalopathy due to hepatic failure may only be apparent when the patient's arms are

TABLE 2.4 Some abnormal movements



Increase in physiological tremor

Anxiety Thyrotoxicosis

Beta agonists (e.g. salbufamol)

Twitching and myoclonic jerks whiie falling asleep

Chronic renal failure with uraemia Respiratory failure with carbon monoxide retention

Flapping tremor

Hepatic encephalopathy

Flapping Tremor
Fig. 2.4 Hand and arm position for observing the 'flapping tremor' of hepatic encephalopathy.

outstretched with the hands dorsiflexed (see Fig. 2.4). The sign consists of" irregular jerky movements of the hands due to flexion and extension of the wrists and fingers.


Normal speech depends upon the tongue, lips, palate and nose, the integrity of die mucosa, muscles and nerve supply of the larynx and the ability to expel sufficient air from the lungs.

The neurological abnormalities which cause disturbances of voice and speech are described on page 194. Many of the other causes can be recognised by inspection, for example a cleft palate, nasal obstruction, loose dentures or a dry mouth. Hoarseness of the voice may be neurological in origin, due to laryngitis or the result of excessive smoking. The voice in myxoedema may be so characteristic that the diagnosis can be made over the telephone without seeing the patient. The normal inflections of tone disappear, speech is low-pitched, slow and deliberate, and seems to require more effort than normal; it sounds 'thick". Many of these changes are due to myxoedematous infiltration of the tissues concerned in voice production.

Several other types of abnormal sound may be heard. Wheezing, rattling or stridor (p. 123) may help in the differentiation of dyspnoea. The character of a cough may be revealing (p. 189). Witnesses may give an account of a whoop suggestive of pertussis or the cry of an epileptic fit. Audible noises of cardiovascular and alimentary origin are described in the appropriate chapters.


The body normally produces an odour. This largely arises from apocrine sweat contaminated by diphtheroid bacteria and may be reduced by deodorants or concealed with perfume, Excessive sweating causes an increase in body odour, which becomes pungent. Poor personal hygiene results in an exaggeration of this smell, which may be compounded by the odour of dirty and soiled clothing and the smell of dried-out urine. Where washing and toilet facilities are available, malodour usually occurs only in:

• Ihe very elderly and infirm

• those with a physical disability that prevents normal toileting

■ subjects with severe learning difficulties or personality disorders

• those with dementia and other causes of progressive brain disorders.

Some odours are sufficiently characteristic to be diagnostic;

• the sickly 'fetor hepaticus' of liver failure

• the sweetness of the breath in diabetic or starvation ketoacidosis, obvious to some observers but not appreciated by others

• the smell of wounds or ulcers Infected by Pseudomtmas aeruginosa

• she characteristic smell of wet gangrene, chronic suppuration, necrotic tumours or some skin disorders.

Halitosis or malodorous breath is often unrecognised by the patient but offensive to others. Sometimes, halitosis occurs without any obvious explanation. It may be caused by decomposing food wedged between the teeth, gingivitis, stomatitis, atrophic rhinitis and tumours of the nasal passages, as well as pulmonary suppuration. Bronchiectasis may be associated with offensive breath and. in some cases, the patient may notice that expectorated sputum tastes foul. In patients with gastric outlet obstruction from scarring or carcinoma of Ihe stomach, foul-smelling eructations may occur, but probably the most offensive odour of this type is associated with a gastrocolic fistula caused by the faecal contents of the stomach.

Tobacco has a characteristic lingering smell which pervades clothing. Marijuana can also be identified by smell. Its presence and that of alcohol should prompt the doctor to ask appropriate questions from tile patient and, if necessary, from others about the subject's habits. If alcohol can be detected in the breath before midday, there is a high probability that the patient has a significant drink problem.

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Essentials of Human Physiology

Essentials of Human Physiology

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