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O P Kapoor
Hon. Visiting Physician, Jaslok Hospital and Bombay Hospital, Mumbai,
Ex. Hon. Prof. of Medicine, Grant Medical College and JJ Hospital, Mumbai 400 008.

Patients having hiccups are quite often seen in private practice. The laymenís knowledge is that hiccup is a serious condition and is complained of only by a patient who is seriously ill. An average doctor has been taught in the medical college that in a patient having hiccups, always look for and investigate for any pathological causes above and below the diaphragm which are the usual causes of hiccup. They have been also taught that if the imaging results are normal, renal failure is then the common cause of hiccup. Most of the practitioners give a small dose of drugs like Buscopan or Largactil (Chlorpromazine) and the patients continue to get hiccups and go on changing the doctors.

In my private practice of nearly 40 years, I have confirmed off and on that the commonest cause of hiccup is idiopathic. It is just that the diaphragm becomes irritable and starts involuntary contractions. And why not? In these days when the oesophagus, stomach, colon, rectum, heart and brain are all getting irritable, why canít the diaphragm become irritable? Therefore, the standard principle should be first to convince the patient and the relations that there is nothing seriously wrong with the patient and that the hiccups will subside.

Half the time the patient is already better by hearing this. The next procedure which is most useful is to advise the family to prepare 1/2 a cup of "malai" (cream from the top of boiled milk) or white raddish juice. Either of these solutionsshould be sipped by the patient in a very small quantity of 1/2 - 1 ml every 30-60 seconds. It should take 5-10 minutes to finish that much quantity. If the "malai" does not work, it should be followed by raddish juice or vice versa. Only if nothing is available, sipping of plain water may be done though it is much less effective. There are some patients who will still not respond. If the patient or the relations are very anxious and excited, one injection of 100 mg of chlorpromazine may be given IV and the patient should be told to lie down in bed for 1-2 hours. The dose of the injection is important. The patient usually goes to sleep and gets up in 1-2 hours without any hiccups. Chlorpromazine does not cause fall of blood pressure and was given in the past in IV drip upto 500-1000 mg over 24 hours in patients suffering from tetanus.

Very rarely you will see a patient who has got "status hiccupus". This is the terminology coined by me to compare it to status asthmaticus, status epilepticus and status coitus (which I have described in the past). This condition is due to marked irritability of the diaphragm equivalent to diaphragmatic flutter. Such patients go on continuing hiccuping and could be really choked since they cannot breath in between. The very sight of the patient frightens the relations and the doctor. Such patients should be invariably given IV Chlorpromazine followed by a maintenance dose of 50 mg tablets orally three times a day along with Buscopan.

Fortunately, upto now there was not a single occasion in my private practice when my patient was resistant to the above treatment and needed a local injection of lignocaine in the phrenic nerve inthe neck (to paralyse the diaphragm). It is not a very difficult procedure and may be required to be performed on both the sides. In the literature even phrenic nerve crush surgery has been advocated in very resistant cases.

In the end, I will stress that the commonest cause of hiccup is idiopathic and possibly less consumption of fluids during any illness. Do not manipulate your diagnosis or blame the shadow above and below the diaphragm "including benign gall stonesí or a fatty liver, etc. or slightly raised blood level of urea or creatinine (which only means that dehydration is the cause).

I have advocated malai (milk cream) and raddish juice which is really speaking non-allopathic treatment. But certainly in private practice any alternative or complimentary medicine could be freely used - e.g. ginger is very effective for managing nausea when your allopathic drugs do not work!

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