An adolescent ward.

Abstract

503papers dealing with treatment are unhelpful to the clinician seeking guidance for a plan of management. For this reason we have drawn up the following protocol based on our own observations and on our review of previous work:Respiratory function tests should be performed before attempts to paralyse the phrenic nerve. The left side should be blocked with bupivacaine first to test the effect on hiccup and respiratory function. Left-sided diaphragmatic contraction is more distressing to the patient, and an attack on this side is usually successful.19 If it succeeds phrenic crush should be performed. If this fails the right phrenic nerve should be blocked and crushed, provided respiratory reserve is adequate. Hiccup may persist even after bilateral phrenic nerve crush, in which case muscle relaxation and positive-pressure ventilation with 5°o carbon dioxide should be considered.Hiccups may diminish in frequency over hours or days in response to treatment, rather than stopping immediately.39 For this reason regular recording of the frequency and intensity of hiccup is essential in assessing the effect of any therapeutic agent.We thank Mr T Hamilton for permission to publish the case report, and for helpful advice and criticism. ReferencesFriedgood, C E, Ripstein, C B,journal of the American Medical Association, 1955, 157, 309. 2Mon, P L, and Chen, C H, British Journal of Psychiatry, 1973, 122, 185. 3Concro, R, and Wilder, R, American Journal of Psychiatry, 1970, 127, 368. 4Ikram, H, Orchard, R T, and Read, S E C, British Medical Journal, 1971, 2, 504. 5 Salkind, M R, Practitioner, 1971, 206, 535. 6 Catalono, F, Acta Neurologica, 1973, 28, 466. 12 Gibbs, A E, Practitioner, 1963, 191, 646.