 Nearly everybody has experienced hiccups, but what exactly are they? The idea that a hiccup is just a simple muscle spasm of the diaphragm was apparently disproved over 40 years ago, and instead involves a complex orchestrated pattern of muscle contractions. But why? It may be a leftover from the womb. During fetal life, hiccups are universally present, their incidents peaking in the third trimester suggesting hiccups might represent a necessary and vital primitive reflex that would permit in the womb training of the breathing muscles without choking on the amniotic fluid. In adulthood, nearly anything can trigger hiccups. Case in point, 19-year-old woman with persistent hiccups, physical exam was normal, except there was an ant crawling on her eardrum. The ant was removed, and the hiccups stopped. And there appear to be as many cures as there are causes, as the famous Dr. Mayo put it. The less we know about something, the more treatments we seem to have for it, and perhaps no disease had more forms of treatment than the persistent hiccup. There's drugs, of course, there's always lots of drugs, from thorazine to apomorphine, but there's also a whole slew of non-pharmacological approaches from breathing into a paper bag and drinking from the foreside of a glass to smearing mustard onto your tummy. You'll note many of these quote-unquote remedies have not been tested. Some appeared to have been invented purely for the amusement of the patient's friends. This first one here, forcible traction of the tongue, which means pulling on someone's tongue, attributed to the great Dr. Osler, the first chief physician at Johns Hopkins. But the therapy dates back earlier to perhaps not surprisingly French origins. Another trick that might work is a modified Heimlich maneuver with just moderate pressure, three thrusts, and the hiccups were gone. In general, though, treatments are disappointing. Hundreds of remedies have been tried, but none have been found to be regularly curative. You know doctors are getting desperate when they start suggesting things like chilling of the earlobe, and you know doctors are really getting desperate when they have to tack on to the end prayer. This is the paper that started me down the hiccup rabbit hole. I was reviewing the latest research on vinegar and stumbled across this. After the failure of common treatments for hiccups, the patient was given a sip of vinegar and his hiccups stopped after just a single sip. More tastes such as vinegar and lemon have evidently been used to treat hiccups since the 1930s, but non-pharmacological remedies such as vinegar fell out of favor with the widespread use of drugs. After all, how much can you charge for a sip of vinegar? Worst comes the worst, there's surgery, the phrenic nerve crush, which is as bad as it sounds. But before you go down that route, you'd be surprised how many patients with hiccups respond to digital compression of the eyeballs, digit as in finger, as in like pushing your thumbs into someone's eyeballs as a counter irritation measure. That'll get their mind off of their hiccups, and if that doesn't distract them enough, there's always digital rectal massage. A 27-year-old man presents to the ER with intractable hiccups. They try massaging other places. They try the digital eyeball compression. Nothing really seemed to do it, so bend over. Digital rectal massage was then attempted using a slow circumferential motion, and it worked. So, before giving people drugs, maybe we should be giving patients a massage. It's easy to perform, and maybe less dangerous than sticking your fingers into people's eye sockets, which if you're a medical school don't have to memorize all these stupid names. It's known as the Dagnini Ashtner Maneuver. Medicine loves its eponyms. Speaking of maneuvers, how's this for a pickup line? Hey, what, to help cure my hiccups? On the fourth day of continuous hiccubing, with spousal help, the patients' hiccups vanished at the point of climax. It's unclear, the doctor wrote, whether orgasm in women leads to a similar resolution. An issue, he said, would have to be investigated further, and it was back in 1845, in an infamous, disturbing case report amounting to effectively bragging about sexual assault. Published in what was to become the New England Journal of Medicine, a young religious woman with intractable hiccups fell into the hands of a Dr. George Dexter, who first attempted the best modern medicine could offer, bloodletting. She still hiccups, though, until he pressed his hand on her genitals for a few minutes, and it apparently worked. This went on for month after month, frequently calling upon his colleagues to exhibit to them this singular phenomena. Who was this guy? Although his interaction with a young female patient would not meet today's ethical standards, you could say that again. His medical observation was considered valid, though rectal massage and sexual stimulation may help. This kind of recommendation should probably be reserved. This research review continues, concluded for carefully selected patients.