You should know, you're a medic

Any cures for Hipo Hik Hoquet?

Diego Kaski investigates

Since the time of Hippocrates, hiccups have intrigued doctors, philosophers, and the public alike. Given their familiarity, it is surprising that their purpose remains largely unknown. In fact, it is commonly believed that hiccups are at best a useless biological quirk, and a nuisance at worst. However, it seems strange that such a complex and impeccably coordinated reflex does not serve a purpose.

Hiccups are experienced by fetuses, children, and adults. In the fetus, they may be present after the eighth week of gestation and tend to persist after birth in premature infants.¹ Brief hiccup episodes are common among healthy children and adults but do not usually require medical intervention. Chronic hiccups, defined as lasting over 48 hours, are rare but can be exceptionally distressing. The record for the longest hiccupping fit is held by an American, Charles Osborne, who began hiccupping in 1922 and continued for 68 years--over 430 million hiccups! ² Prolonged or recurring spells may cause depression, weight loss, insomnia, and exhaustion. Chronic hiccups seem to occur more frequently in men than women. Possible reasons for this remain unclear but there may be a genetic predisposition in some patients. A case of familial intractable hiccup, in which seven members of a patient's family suffered from the same affliction, has been documented.³

What are hiccups?

Hiccups are spasmodic, forceful, contractions of the inspiratory muscles. They involve involuntary lowering of the diaphragm and closure of the glottis--the sound producing folds of the upper throat. This produces the characteristic sound as the breath is drawn in, which gives its name to the phenomenon in most languages. The glottis closes 35 milliseconds after electrical activity in the diaphragm and intercostal muscles rise, preventing inspiration.4 Hiccups are often cyclical phenomena; a single attack predisposes toward a further hiccup, thus sustaining the bout. The reasons underlying this are unknown, but may be the result of the sudden impulse transmitted to the oesophagus. The spontaneous frequency of hiccups varies significantly between individuals, ranging from 2-60 hiccups a minute.

What causes hiccups?

Distension of the stomach--that is, due to overeating--and ingestion of carbonated drinks, spicy, very hot or very cold foods are well established causes of hiccups. Parents of small babies are familiar with the hiccups that frequently follow feeding. Brief episodes may also be caused by a sudden change in temperature, drinking alcohol, excess smoking, or emotional factors, such as laughter, fear, or shock. Persistent hiccups are rare and may represent a serious underlying disease, such as a structural lesion or infection of the central nervous system, trauma, irritation of the diaphragm by a tumour or an inflammatory process, myocardial infarction, or renal failure. In addition, a variety of drugs including barbiturates and other sedatives, as well as general anaesthesia and corticosteroids, have been implicated in causing hiccups.

The function of hiccups

It is generally believed that these short, sharp, sudden inspiratory croaks serve no useful purpose. However, it has been suggested that hiccups represent an essential intrauterine reflex to prepare the fetal respiratory musculature for breathing after birth.⁵ This has led to the suggestion that the presence of hiccups in adults represents the persistence of this primitive reflex.⁸ For some researchers, a hiccup is a digestive reflex, preventing aspiration of amniotic fluid,⁶ or the result of gastric expansion following the ingestion of fluid.⁷ Others believe their function is to transfer food through the oesophagus.

Arguments for a developmental function of hiccups have centred on their universality. Almost everyone seems to get them at some point but a hiccup is no more universal than bedwetting or drooling, which have no function but are indicative of an underdeveloped neuronal control system, or an underlying disease.⁹ It has therefore been suggested that hiccups are similarly biologically useless phenomena. However, based on recent studies by Launois et al, it sseems that in some cases, hiccups may protect the respiratory tract from oesophageal reflux. Indeed, the French have always known that "enfant hoquetant, enfant bien-portant" (a child who hiccups is a healthy child).

Remedies

Most readers will be familiar with methods used to break the hiccup cycle including standing on your head, holding your breath, and startling the sufferer. Clinical trials have endorsed the use of granulated sugar as treatment for hiccups, although the mechanism of action remains a mystery.¹¹ The notorious Hippocratic manoeuvre is thought to produce gagging in addition to sneezing. Startling the sufferer, with a loud and sudden sound, is a preferred and often effective means of abolishing hiccups. It has been shown that sounds at the 70-125 dBA level, in subjects exposed to 1000 Hz acoustic stimuli, are most effective at stopping hiccups.¹² the most innovative form of treatment has been proposed by Peleg and Peleg.¹³ They report a case of drug induced intractable hiccups terminated after sexual intercourse. Recently, smoking marijuana has also been reported to terminate obstinate hiccups,¹⁴ although such treatment carries important ethical and legal considerations. Given the diversity of available remedies, perhaps the true function of hiccups is to fuel the imagination, in a quest to develop the most demanding, ridiculous, or entertaining remedies to cure them.

Chronic hiccups

Although often underestimated by the medical profession, the management of chronic hiccups is of great importance to sufferers. A detailed medical history and thorough examination should form part of management in order to identify possible underlying causes. If non-pharmacological treatment is ineffective, efficient drug remedies include baclofen, chlormazepine, and metoclopramide.

1. Brouillette RT, Thatch BT, Abu-Psba YK, Wilson SL. Hiccups in infants: characteristics and effects on ventilation. J Pediatr 1980; 96:219-225.
2. McFarlane D (ed). Guinness Book of World Records: New York, Sterling Publishing Co., 1990
3. Davis NJ. An experimental study of hiccup. Brain 1970; 93:851-872.
4. Lance JW & Bassil GT. Familial intractable hiccup relieved by baclofen. Lancet 1989; ii:276-277.
5. Fuller GN. Hiccups and human purpose. Nature 1990; 343:420.
6. Miller FC, Gonzales F, Mueller E, McCart D. Foetal hiccups: an associated heart rate pattern. Obstet Gynecol 1983; 62:253-255.
7. Swan HR Hiccups complicating myocardial infarction. N Engl J Med 1952; 247:726-728.
8. Dunn AM. Foetal hiccup. Lancet 1977; ii:505.
9. Golomb B. Hiccup for hiccups Nature 1990; 345:774.
10. Launois S, Bizec JL, Whitelaw WA, Cabane J, Derenne JPh. Hiccup in adults: an overview Eur Respir J 1993; 6:563-575.
11. Engleman EG, Lankton J, Lankton B. Granulated sugar as treatment for hiccups in conscious patients N Engl J Med 1972; 285(26):1489.
12. Stacher G, Schmeierer G, Landgraf M. Tertiary oesophageal contractions evoked by acoustic stimuli Gastroenterology 1979; 77:49-54.
13. Peleg R & Peleg A. Case report: sexual intercourse as potential treatment for intractable hiccup. Can Fam Physician 2000; 46:1631-2.
14. Gilson I, Busalacchi M. Marijuana for intractable hiccups. Lancet 1998; 351:267.
15. Hulbert NG. Hiccoughing (hiccup or singultus) Practitioner 1951; 167:286-289.
16. Brenn E. Sequel on singultus N Engl J Med 1982; 306:1115.
17. Goldenburg IF, Ochi RP, Almquist A, Benditt DG. Cardioversion for intractable hiccups: a frightening cure N Engl J Med 1987; 316:883.
18. Ridell WR. Hippocrates and hiccup Med J Record 1930; 132:40-41.
19. http://www.gerzon.com/resources/hiccup.html