Intractable hiccups

I have observed in my practice that spraying ethyl chloride along
the strenomastoid muscles on both the sides terminated hiccups instantly.
The literature related to this measure put forward a hypothesis that the
phrenic nerve conduction was hampered by cooling effect of ethyl chloride
and thus the conduction along the nerve was diminished which in turn
terminated hiccups.

I would like to have the readers responses if any one has tried such
a measure.

Bakul P. Dhruva, MD

Competing interests:
None declared

Nine years ago, my husband suffered from violent, intractable hiccups
for several days,so much so, that he was unable to eat, sleep, and had
trouble breathing. He went into the emergency room, and was treated with
Thorazine, promptly going into seizure. The hiccups did stop, and we found
the cause was a volvulus of his stomach, with his intestines out of place,
as well. This was subsequently repaired.

Two years ago, he again had
intractable hiccups. This time, we knew Thorazine was out of the question
as a treatment. The medical professionals were at a loss, having rarely
seen this condition. I stumbled upon baclofen, as a treatment, on the
Internet, and suggested this to his doctors. About five days of baclofen,
10 mg, 3 times a day, did the trick. THIS time, the culprit was a
cigarette-pack sized pocket of s rare bacteria called a nocardia
asteroidis near his diaphram caused the hiccups. It was treated with
Bactrim for about a year.

A week ago, he got the hiccups once again. Two
days of Baclofen seemed to have done the trick; We don't yet know the
cause. My point is, that intractable hiccups may have many causes
(including brain lesions and AIDS), and that although our first goal is to
stop the hiccups, we must always look further to find its cause, and treat
that!

To the editor,

I read with enjoyment the novel and successful method for curing
hiccups described by Dr Macdonald (1) and would like to offer a few
thoughts on nomenclature and treatment.

The term “hiccup” is derived from the sound of the event. The medical
term “Singultus” is thought to have originated from the Latin singult,
which can be roughly translated as "the act of catching one's breath while
sobbing" and aptly describes the affect of most sufferers. Although 10
days duration may seem forever, the term “intractable” is reserved for
attacks of longer than one month. A hiccup “bout” is any episode lasting
more than a few minutes and those longer than 48 hrs they are considered
to be “persistent” or “protracted”. The longest recorded attack is six
decades and is surely not to be intentionally bettered.

As for cures, the Oxford Textbook is correct in that no single
treatment has been effective but is misleading in that benzodiazepines as
a group may exacerbate or precipitate hiccups. The patient's observation
of the benefit of a full stomach should be added to the theories of
Hippocrates and Celsus who believed that hiccups were due to inflammation
of the liver and similar conditions, Galen who attributed them to violent
emotions erupting from the stomach and more modern "cures" such as passage
of naso-gastric tubes, induced emesis and iced gastric lavage.
Alternatively it may have been the stimulation of the nasopharynx (the
basis behind swallowing granulated sugar and drinking from the far side of
a glass of water) or the (sufferers by now firm) hope and belief in a cure
that produced the effect. Mental distraction, fright and hypnosis are all
equally effective (2). No doubt the patient preferred the treatment to
that described by Fesmire (3).

Regardless of the mechanism it is pleasing to see this doctor and
patient has affirmed yet another successful "treatment" unlike one poor
sufferer who, after eight years and over 60,000 suggested treatments,
prayed to St Jude, the Catholic saint of lost causes and, finally, was
cured!

Dr Garry J Wilkes MBBS, FACEM

Director, Trauma and Retrieval Services

Sir Charles Gairdner Hospital
Perth, Western Australia.

References:

1. Macdonald J. Intractable hiccups. BMJ. 1999 Oct 9;319(7215):976

2. Wilkes GJ. Hiccups. Emergency Medicine. Boston Medical Publishing Corp;
www.emedicine.com/emerg/topic252.htm On line from October 1997.

3. Fesmire FM. Termination of intractable hiccups with digital rectal
massage.
Ann Emerg Med. 1988 Aug;17(8):872