The Patient Was…

The patient was a 60-something-year old male who was the very first patient I recall in detail. He was not my patient, but rather my roommate, along with two other patients in an old-fashioned four-bed ward in a small private hospital where I was recovering from surgery for acute appendicitis. I was thirteen years old, but I remember it well because it was three weeks before my bar mitzvah.

The patient was tall, gaunt, actually cachectic; he looked like he had been starving for weeks. What was most remarkable was that from the moment he was admitted to the ward he had hiccups. Apparently, that was the very reason for his admission to the hospital: persistent, unremitting hiccups. If it sounds funny, it wasn’t. He had been suffering this way for a couple of months, virtually unable to eat or rest or sleep.

Hiccups sound like a simple matter; everybody has them occasionally. They are usually self-limited, but there are also a lot of techniques recommended if they don’t stop on their own. Some are breathing exercises, some involve changing body position, while others involve swallowing sugar, honey, or even plain water. Most of these, if they work, actually do so by manipulating the physiology of the nervous system, and the physiology behind hiccups is not so simple.

In its basic form, a hiccup represents a sudden and involuntary muscular contraction of the diaphragm, the thick muscle that lies between and separates the chest cavity and the abdominal cavity. Like most structures in the body, the diaphragm contains lots of nerve fibers; the major ones that innervate the diaphragm are the phrenic and vagus nerves. These are part of the so-called autonomic nervous system, which means they are not under our voluntary control. They control bodily functions that are largely automatic, like digestion, kidney function, and blood pressure.

In the instance of a hiccup, something stimulates the nerve fibers in the diaphragm. Usually, the stimulus arises in the digestive tract itself, especially the stomach or esophagus which are the digestive structures closest to the diaphragm. Things that distend the stomach, like eating too fast and swallowing air, or drinking carbonated beverages, are common stimuli to the nerves controlling motion of the diaphragm. Chemical irritation, such as the presence of alcohol, can also be a diaphragmatic nerve trigger. And other less common causes of irritation of the nerves of the diaphragm may also be the culprit.

Persistent hiccups, lasting hours, days, weeks, or even months, are quite unusual. And the longer the duration of symptoms, the less frequent the occurrence. So, cases like the patient I remember are really rare.

In a small hospital room, with four patients in their beds, there is really no privacy. The act of pulling curtains or setting up screens around a bed may block sight, but it does not and cannot dampen sound. So, every question, every answer, every word is heard by and shared with everyone else in the room. And as a thirteen-year-old, I was fascinated.

It seems that the patient had been to many doctors over the period of time he had been suffering. Remember, these were the days before CAT scans and MRIs, and fancy diagnostic techniques. Medical technology was in its infancy. As it turns out  —  and here is a bit of a spoiler  —  all the modern technology available today would likely not have helped in this case anyway.

 The doctors he had seen were mostly diligent, from what he said. They had asked a lot of questions, performed thorough physical examinations especially of his abdomen and chest, and did whatever relatively simple tests were available at the time, including a lot of blood tests. But nothing showed up as a cause for the disabling hiccups.

He had now been admitted under the care of a well-known abdominal surgeon, whose plan was to do exploratory surgery to try to find a cause, and hopefully a cure, for what was literally a life-threatening condition by this point.

The young hospital doctor who was examining him on admission to the ward asked a lot of questions, none of the answers to which gave a clue to any possible cause for the persistent hiccups. It was actually funny to me as a youngster to hear the patient try to talk when he hiccupped every few seconds. The physical examination, behind the curtains, was clearly thorough because it took some time. When the doctor finally pulled back the curtains and headed for the door of the ward he suddenly stopped, turned back to the patient (“Columbo style”) and said, “I’ll be right back.”

A few minutes later, he returned with an otoscope, which is a small, hand-held device with a detachable, cone-shaped speculum to focus light within the ear canal. He didn’t bother to close the curtains around the bed to examine the patient’s ears.  After checking both of the ear canals, he inserted a thin, flexible instrument held between his thumb and index finger into the patient’s left ear canal, and made a slight flick of his wrist. A few seconds later, the patient’s hiccups stopped.

The sound of silence was awesome! And that moment has stayed with me through all these years.

So what happened?

It’s no secret, as we have learned through the progress of medical science, that the connections within the human body are more numerous and more complex than ever imagined earlier. Almost every part of human physiology can be affected by activities and processes of other organs and tissues. I learned later, during my professional life, that some doctor had once reported an unusual case of persistent hiccups due to a hair in the ear canal pressing against the tympanic membrane (ear drum). And since then, a few such cases have also been reported.

So, how is the ear drum connected to the diaphragm. (Isn’t there a song lyric in there?) Well, it’s back to nerve supply again. While the nerves that innervate the ear drum and diaphragm are mostly separate and distinct, they share some fibers that arise in the cervical spinal cord (spinal cord of the neck). Thus, something that may stimulate or irritate the ear drum can, in rare instances, send enough nerve signals up toward the brain and then back down to the diaphragm through the phrenic and vagus nerves, which are the main nerves controlling the diaphragm.

The doctor, on his examination of the patient, spotted a stiff hair in the ear canal that seemed to be touching the ear drum. He surmised, or more likely just hoped, that somehow if he moved the hair so it wasn’t touching the ear drum, the hiccups might stop. Nothing ventured, nothing gained. Nothing to lose, right?

Right!

Remember the proverb, “For want of a nail the shoe was lost?” It goes on to say that ultimately a kingdom was lost because of a lost horseshoe nail. It means that small things can lead to unexpected and bigger consequences, and that attention to detail is important.

Who knows what ultimately would have happened to the patient if the enterprising physician had not tried what seemed to be a useless idea. In this circumstance, it worked, and the surgeon lost a patient  —  in the best way possible: He didn’t get to operate.

The patient won by a hair.