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.