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Chronic hiccups may be a problem of great significance to the affected patient. A 62-year-old man with severe heartburn and persistent hiccups despite numerous diagnostic tests and therapeutic drug trials presented to our clinic. Esophageal motility and intraluminal pH studies demonstrated decreases in intraesophageal pressure during hiccups and acid exposure during 68% of the measured time. The patient underwent Nissen fundoplication, which improved his heartburn but not his hiccups. The association between gastroesophageal reflux and hiccups is discussed. Our experience suggests that the presence of hiccups and gastroesophageal reflux in the same patient may be coincidental rather than having a cause-and-effect relationship.

Hiccups result from a wide variety of conditions that act on the supraspinal hiccup center or that stimulate or disinhibit the limbs of its reflex arc. While scores of hiccup remedies have been reported over the centuries, no single "cure" stands out as being the most effective. Measures that stimulate the uvula or pharynx or disrupt diaphragmatic (respiratory) rhythm are simple to use and often help to speed the end of a bout of otherwise benign, self-limited hiccups. Such manueuvers may also terminate persistent hiccups. Drug therapy usually becomes necessary for more intractable hiccups; chlorpromazine and metoclopramide being two of the most widely employed agents for this purpose. Physical disruption of the phrenic nerve, hypnosis, and acupuncture are other modes of therapy that have been used in severe cases. Because so many reports of hiccup "cures" are based on anecdotal experience rather than controlled clinical studies, I review the available treatments to provide a rational approach for the management of hiccups.

A patient who developed hiccups after laparotomy was treated with numerous drugs with limited success. A left phrenic nerve crush was eventually successful. A review of published work showed that the drugs most likely to succeed were chlorpromazine and metoclopramide, and that phrenic nerve injection and crush should be considered if these failed.

The authors implanted a diaphragm pacer in a 71-year-old man who had suffered for two years from continuous hiccup of unknown cause with resulting insomnia. Preoperative transcutaneous stimulation of the phrenic nerves in the neck resulted in diaphragm contractions but did not affect his hiccup. Postoperatively, the patient was free of symptoms for two weeks. Electrophrenic stimulation was then initiated and after three days his hiccup disappeared again. After a ten day period without stimulation his hiccup recurred. For ten months the patient has suffered from hiccup only in the day time during which time he has also used the pacer. With a few exceptions he has been free of symptoms and without pacing during the night, which enables him to sleep normally. The effect of phrenic nerve stimulation on hiccup could be due to interference with the abnormal activation of the phrenic nerve, whatever its cause.

The Authors, after studying hiccup in 30 patients aged 7-70, submitted them to acupuncture therapy. After short exposition on etiopathogenesis of hiccup, the Authors explain acupuncture therapy used in 10 cases before treated with different therapies with negative results and in 40 not treated cases, exposing the obtained results.

This article provides a comprehensive review of the literature regarding nonmedical approaches to the understanding and treatment of intractable hiccups. The author provides a rationale for an interactional view and presents a case in which post-surgical hiccups were successfully treated, using principles developed by the Mental Research Institute. Of particular interest is the manner in which the therapist managed a system that included the victim's wife, a physician, and other medical personnel who were all trying to eliminate the hiccups. Interventions were designed primarily to alter meanings attributed to the hiccups and, thus, to intervene in the system that was maintaining the problem. This article is presented as a response to Weakland's call for research and practice in family somatics.

Toward the goal of comfort and quality of life, symptom management is utmost in importance and requires constant reassessment of the patient. Before launching a medication program, each set of symptoms should be assessed by history, physical examination, and laboratory tests. When symptoms can be understood in the context of the disease without correctable, specific causes, the physician can carefully prescribe treatments to alleviate the misery and suffering. The most common symptoms in terminally ill cancer patients are anxiety and depression (80 to 90 per cent); pain (66 per cent); nausea, vomiting, and constipation (50 per cent); and respiratory symptoms (30 to 40 per cent). Medical attention to these discomforts will help the patient and family to cope better with the dying process.