The larynx must be examined with special instruments. The bronchi and lungs present pain in the side, chest cough, difficult breathing, and expectoration. Difficult breathing and dyspnea may be due to either lung or heart affection. It may be reflex; if so, any of the organs may cause it.

Cough may be lung cough, or it may be reflex.

Respiration and pulse normally have a ratio of about one to five.

Cheyne-Stokes respiration belongs to cerebral or meningeal lesions, At first it is rapid and superficial, and gradually becomes more profound. This is followed by a diminution, with a final arrest; then a short period, followed by short, shallow breathing, gradually becoming faster, with a repetition of the former sounds.

Diabetic coma is characterized by abrupt and deep inspiration, followed by a pause; then a quick expiration, and a pause. These types of breathing are due to medullary derangement-possibly toxin poisoning.

Rales are of three types:

Dry or sonorous rales are called rattling when they have a grave pitch; sibilant when acute. They indicate bronchial inflammation or catarrh.

Crepitant rale is like rubbing a lock of hair between the thumb and finger close to the ear. It means pneumonia.

Moist rale has a bubbling sound. When high, it indicates tuberculosis, when of fine bubbles, capillary involvement.

A blowing sound, when heard between the shoulders, indicates bronchitis. It is tubal when it has a slightly metallic or whistling character. The pleuritic murmur has the sound of "i" spoken in a whisper through the closed fist as an ear trumpet. The sound will be modified in keeping with the amount of effusion.

In empyema (pus in the pleura) the percussion dullness will be flat like the liver sound. If the patient will count "one, two, three," while the ear is placed on the chest, the sound conveyed will be far distant-removed; whereas the voice will come to the ear when there is no accumulation.

Egophony

While the patient is speaking, if the voice comes to the ear with a tremulous murmur, this is called egophony, and is indicative of pleurisy or splenopneumonia.