190 THE LARYNX, BRONCHI AND OESOPHAGUS
severely disturbed patient will make very little effort to project the voice. One
can almost imagine her deliberately making no attempt to use any throat or
chest muscles in the act of voice production. The condition is most .common
in young females with love or work problems. On the rarer occasions when it
occurs in males the cause is usually to be found in promotional difficulties at
work or staff incompatibilities.
One of the most helpful diagnostic features is the effort involved in creating
the symptom. Mention has already been made of the associated lack of
volume of the whisper. Examination shows not only that the cords are in
abduction but where adduction does occur it is incoordinated—as if the patient
is trying to suppress the normal reflex adduction of gagging. The single most
important diagnostic feature, however, is that no matter how aphonic the
patient is for speech she will always produce a good cough when asked to,
showing that normal adduction of the cords can occur.
TREATMENT. This lies outwith the field of otolaryngology. In suitable
patients, quackery, such as the subcutaneous injection of sterile water
accompanied by appropriate reassurances, is occasionally rewarding. In the
vast majority of cases, however, the patient requires some form of psycho-
therapy, whether from her family doctor, a speech therapist or a psychiatrist.
The otolaryngologist should limit himself to diagnosis and an explanation of
the psychosomatic nature of the condition.