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
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
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