Role of Sū’-i- Mizāj in the Etiopathogenesis of Fawāq (Hiccups)

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Sadaf Ambreen¹ , Nida Sultana² , Ataullah Fahad²

¹Department of IlmulAmraz (Pathology), Faculty of Unani Medicine, Dr.SarvepalliRadhakrishnan and Rajasthan Ayurved University, jodhpur, Rajasthan, India.

²Department of Ilmul-Amraz (Pathology), Faculty of Unani Medicine, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

Corresponding Author Email: ambreensadaf2018@gmail.com

DOI : https://doi.org/10.51470/AMSR.2025.04.01.52

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1. Introduction

In the Unani system of medicine, mizāj (temperament) is a fundamental principle that dictates the structural and functional integrity of the body. Health (Ṣiḥḥat) is considered the result of a balanced mizāj. A deviation from this balance, termed Sū’-i-Mizāj, is the underlying cause of most diseases. Fawāq, commonly known as hiccup or hichkī, is a condition recognized in both unani and modern medicine. Although typically transient, hiccups may signify more serious underlying conditions when prolonged. Unani scholars have extensively discussed Fawāq,attributing its origin to disruptions in the temperament (mizāj) of the stomach and diaphragm. The abnormal temperament (Sū’-i- Mizāj) of these organs stimulates expulsive force(QuwwatDāfia),which acts as a corrective mechanism, attempting to eliminate the source of discomfort and restore physiological ease.

Through the lens of dystemperament (Sū’-i-Mizāj), this paper critically analyzes the etiopathogenesis(ḥudūth al-Maraḍ) of Fawāq (hiccups), including its causative factors (asbāb), pathological basis, symptoms (alamāt), and diagnostic framework (tashkhīṣ).

2. Definition and Classification

According to Unani scholar definitions, Fawāq (hiccup) refers to a sudden, involuntary movement of the diaphragm (ḥijāb-e-ḥājiz), usually triggered by the accumulation of gas or disturbances in the gastric region. This involuntary action is associated with discomfort and the release of air. According to Moalejat-e-Buqratia, hiccups are attributed to the formation of gas in the esophagus, which disrupts the natural digestive process.^{(1)  (2) (10)}  In Firdaus al-Hikmat, hiccup is defined as an involuntary gastric movement that causes the expulsion of air, highlighting its connection to stomach disturbances.^{(3) ( 4)}The Canon of Medicine offers a more detailed explanation, describing hiccup as an abrupt contraction of the esophagus and stomach that may recur in spells. It connects the condition to both gastrointestinal and neurological factors, emphasizing that the temperament (mizāj) of the stomach plays a critical role. Possible causes include excessive dryness, irritation of the diaphragm, or rising vapors (bukhārāt) from the stomach. ^{(6) (7) (9)}   The text also elaborated that an overly intense action of the expulsive faculty(QuwwaDāfia) in the stomach could provoke hiccups, indicating a deviation from normal gastric functioning. In his analysis, hiccup (Fawāq) was not just a symptom but a condition linked to deeper systemic and humoral imbalances ⁽⁶⁾ Kitab al-Hawi expands the scope by linking hiccups to undigested food and emotional triggers such as fear or anger as a contributing factor. ⁽²⁾ZakhiraKhawrazmShahi emphasizes the influence of phlegmatic humor (AkhlātMāliyah) and notes that abnormal humors can irritate the diaphragm and adjacent nerves (Aaṣāb), leading to hiccups.⁽⁹⁾ Finally, Kitab al-Taisir points to extremes in heat (ḥarāratnāriyah), moisture (burūdat), andsevere dryness (yabūsat) within the stomach as contributing causes.⁽⁸⁾

Although traditional Unani literature does not formally classifyhiccups (Fawāq) in a structured manner, a careful examination of key texts reveals a recurring connection between this condition and dysfunctions in specific anatomical areas, severity, and etiology, which can be logically inferred from the descriptions provided by esteemed Unani physicians. In terms of location,  Kitab al-Hawipoints out that hiccups can arise from inflammation, irritation, or the buildup of morbid substances affecting the stomach(mi’da), chest area(sadr), or nervous system(Nizām-e-Aṣāb).^{(2) (10)(18)}SimilarlyAlQanun fi-al-Tibb, identifies hiccups(Fawāq) as stemming from disturbances in the stomach, diaphragm (ḥijāb-e-ḥājiz) or brain (dimāgh),  depending on the root cause and humoral imbalance.⁽⁶⁾ ZakhiraKhawrazmShahialso mentions different origins of Fawāq , attributing it to gastric issues, diaphragmatic spasms, or cerebral factors.^{(9) (18)} From these descriptions, a classification based on location can be reasonably inferred encompassing gastric, diaphragmatic, and neurological types of Fawāq.

The classification based on severity is determined by the duration and impact of the symptoms. Kitab al-HawiandZakhiraKhawrazmShahiexpress similar concerns, noting that prolonged hiccups(Fawāq) can result in complications such as insomnia(sahar) difficulty breathing(zauf-e-tanaffuz) or even loss of consciousness(ghashi).^{(2) ( 9)(16) (18)}Al Qanun fi-al-Tibb, distinguishes between mild hiccups caused by dietary issues or a cold temperament and more severe, persistent hiccups that suggest significant internal problems.^{(6 )(7)} Therefore, hiccups can be classified as mild, moderate or severe depending on their frequency, duration, and associated systemic symptoms.

From an etiological standpoint, Unani physicians attribute Fawāq to factors such as poor digestion, ingestion of inappropriate foods, emotional turmoil or an imbalance of humours (dam, balghām, safrā, sawdā) specifically balghām(phlegm) and safrā (yellow bile). ^{(6) (7) (9) (10)}According to Al Qanun fi-al-TibbandZakhiraKhawrazmShahisecondary causes may include conditions like fever (humma), pneumonia (zaturriya) or cereberal disturbances (ikhtilal-e-Dimagh). This leads to a classification that distinguishes between primary (idiopathic) and secondary (symptomatic) Fawāq. Further categorization is based on the predominant humor involved. This inferred classification not only enhances clinical insight but also aligns with the diagnostic and therapeutic framework of Unani medicine, effectively bridging classical concepts with methodical clinical reasoning.

3. FawāqEtiology (Asbāb)

• Extrinsic Factors
• Intrinsic factor :-Sū’-i- MizājSāda(HarSāda, BaridSāda, RatabSāda) and Sū’-i- MizājMāddi (Sū’-i- MizājBalghm, SafrāandSawdā )
•  Involvement of Liver(kabid) and stomach(mi’da)

4. Etiopathogenesis of Fawāq(Hudūth al-Maraḍ)

In Unani medicine, hiccups (Fawāq) are attributed to both extrinsic (external) and intrinsic (internal) factors. These influences disturb the natural temperament (Mizāj) and functioning of the stomach (Miʿda), resulting in the abnormal formation and expulsion of gas (Riyāḥ), which leads to hiccups. The imbalance of bodily heat (Harārat), moisture (Rutūbat) and wind (Riyāḥ) plays a central role in the pathophysiology of hiccups.

4.1 Extrinsic (External) Factors

Extrinsic causes refer to environmental or lifestyle factors that disrupt the stomach’s temperament and provoke diaphragmatic spasms. These include: 1) Consumption of extremely hot (Har), dry (yabis), or cold (barid) foods: Such dietary extremes alter the stomach’s Mizāj, irritating the diaphragm (ḥijāb-e-ḥājiz) and inducing hiccups. 2) Hasty eating or overeating: Rapid ingestion or excessive food intake leads to gastric distension, which can stimulate hiccup (Fawāq) reflexes. 3)Inhalation of cold air: Sudden exposure to cold air irritates the respiratory passages and diaphragm, initiating spasms (tashannuj).4)Abrupt changes in posture: Quick transitions from lying to sitting or vice versa may displace internal organs, leading to hiccups (Fawāq).5)Use of specific medications: Drugs with a hot and dry temperament, including certain purgatives or stimulants, can irritate the stomach and ḥijāb-e-ḥājiz.These external factors disturb the physiological equilibrium, often leading to excessive internal heat, dryness, or gas accumulation that manifests as hiccups.^{(2) (5) (6) (9) (18) (12) (14)}

4.2 Intrinsic (Internal) Factors

Intrinsic factors originate within the body and directly affect the stomach, diaphragm, or nervous system. Key internal causes include gastric irritation due to indigestion (Zoʿf-e-Hazm) accumulation of gas (Riyāḥ) in the stomach, emotional stress or nervous tension, which may impact diaphragmatic control, disturbances in temperament (Sūʾ-i-Mizāj) affecting the stomach and diaphragm.

A. Sūʾ-i-MizājSāda (Non-Material Dystemperament)

These conditions arise without the presence of morbid humors but involve imbalances in the body’s intrinsic qualities:

HarSāda(Hot Simple Dystemperament): Excessive internal heat leads to vapor formation and frequent Hiccups (Fawāq).^{(4) (5)}

BaridSāda(Cold Simple Dystemperament):In Firdaus al-Hikmatit is written that cold temperament impairs digestion, which causes distress to the stomach and due to this distress  the expulsive force (QuwwatDāfia) of the stomach is triggered and becomes excessively active, resulting in hiccups. Sometimes, this type also occurs due to sneezing and it is most  commonly seen in elderly individuals, as coldness in coldness in their stomach tends to be greater.³ There are three causes of Sū’-i- MizājBarid (ColdDystemperament) in the stomach.

1) When Sūʾ-i-Mizāj Barad occurs in the stomach, the process of digestion is not completed properly. In such cases, the stomach becomes diseased, and when coldness enters the stomach, it leads to an imbalance. This causes irritation, which in turn stimulate the stomach’s natural expulsive force, attempting to expel the foreign or irritating matter.^{(4) (12)}

2) Secondly, it occurs when the stomach becomes overly cold, leading to irritation and the subsequent activation of the body natural mechanism (like hiccups), and the system attempts to remove the foreign substance from the stomach.⁽⁴⁾⁽⁶⁾

3) Thirdly, it happens due to the abnormal expulsion of matter from the stomach. In this case, some material from the stomach that was supposed to remain is expelled. This imbalance can result in various disorders such as hiccups, nausea, vomiting, especially in individuals with weak gastric heat.^{(4)(6)(12)(18)}

RatabSāda(Simple phlegmatic Dystemperament)This condition is caused by the accumulation of excessive moisture in the stomach. These excess fluids are either non benificial or decomposed. When this moisture becomes excessive in the stomach,it irritates the stomach lining. In an attempt to expel it, the stomach activates its natural expulsive mechanism, often resulting in Hiccups.^{(3)(10)(12)(14)}

YābisSāda(Dry Simple Dystemperament)regarding this,inAkseerAzamandTib-e-Akber it is written that excess dryness in the stomach causes stiffness, due to which the natural movement of the stomach is disrupted, and blockages occur. This can result from excessive heat (intense or dry), dryness, and lack of moisture, which causes the stomach to shrink and become tight. This ultimately disrupts its function. This dryness can be so severe that the stomach becomes unable to expel harmful materials, leading to digestive issues. The imbalance can also affect the lymph nodes and surrounding tissues, as they rely on the stomach’s moisture. The disorder arises from a deficiency of moisture.^{(4)(5)(12)(13)}

B. Sūʾ-i-MizājMāddī (Material Dystemperament)

These involve the accumulation of abnormal humors (Akhlāṭ) within the body that interfere with stomach function:

FawāqSafrāwī(Choleric Hiccups)This type arises due to an excess or abnormal accumulation of yellow bile (Safrā), which is characterized by its hot and dry temperament, and a sharp, irritative quality. When Safrā increases beyond normal limits, it tends to move towards the stomach, irritating its lining and creating a sensation of heat or burning. This irritation stimulates the stomach’s sensitivity, provoking spasmodic contractions of the diaphragm, which result in hiccups. Patients often experience accompanying symptoms such as a bitter taste in the mouth, restlessness, and a feeling of internal heat.^{(4) (9) (11) (10)}FawāqBalghamī(Phlegmatic Hiccups)This form is associated with the predominance of phlegm (Balgham), which is cold and moist in nature. When this humor becomes excessive, it slows down the digestive process and leads to the accumulation of undigested food or gas within the gastrointestinal tract. This results in bloating, distension, and pressure against the diaphragm, thereby triggering hiccups. Individuals with Balghamī hiccups often feel heaviness, lethargy, and may present with other signs of a cold temperament, such as pallor or a sluggish digestive system.^{(4) (9) (11) (10)}FawāqSawdāwī(Melancholic)This type is caused by an excess of black bile (Sawdā), which is inherently dry and thick. When Sawdā accumulates in the digestive tract, it causes stiffness and rigidity in the stomach and surrounding tissues. This leads to reduced elasticity and function of the diaphragm and stomach, resulting in persistent or chronic hiccups. Patients with melancholic hiccups may also display signs such as anxiety, dryness, constipation, or a sense of constriction in the chest or abdomen.^{(1) (12) (14)}

4.3 Combined Organ Involvement: Miʿda (Stomach) and Jigar (Liver)

When both the stomach and liver are affected, especially in inflammatory conditions, If hot swelling occurs in the liver it causes inflammation of stomach or if cold swelling occurs in the liver it pulls the ligament (doriyan) of the liver, due to which it also pulls the memberane (ghisha) that lies between the oesophagus (Mari) and stomach (mi’da) known as diaphragm (ḥijāb-e-ḥājiz). As a result of this breathlessness (Zaki-ul-nifs) occur and to get rid of this tabiyat activates the quwwatDafiā which ultimately results in Hiccups.^{(1) (12)}

5.Mechanism of Hiccups

Unani Scholar states that this is a movement of the stomach’s natural actions, in which parts of the stomach move towards the esophagus. For this reason, the movement of the stomach is called ‘Qar’ā-e-Mi’da’ and this movement is termed as Fawāq (Hiccups). In the book Tib-e-Akberit is written that it is composed of contraction (inqebāz) and expansion(inbesāt) of the diaphragm (ḥijāb-e-ḥājiz)and the respiratory system in such a way that it causes a sound due to the sudden movement of gaseous material from the stomach to the esophagus. It is a pathological condition in Unani medicine that occurs due to excessive moisture and wind in the stomach.⁽¹²⁾It is characterized by spasmodic interruptions of respiration, sometimes accompanied by pain, nausea, belching, or discomfort in the epigastrium.⁽¹²⁾

6. Symptoms (Alamāt) of Hiccups according to Types of Sū’-i- Mizāj(Dystemperament)

In the context of Unani medicine, hiccups are interpreted through the lens of dystemperament (Sū’-i- Mizāj). The symptoms vary depending on the nature of the underlying dystemperament. Below is a categorized description based on classical Unani texts: Table-2

a) Sū’-i- MizājSadā:a) Sū’-i- MizājHar (Hot Simple Dystemperament) is marked by an internal heat imbalance. Patients commonly report a burning sensation in the stomach (Mi’da), accompanied by an increased tendency to crave cold substances. There is also a notable rise in thirst and preference for warm items.^{(1) (10) (15)}b) Sū’-i–MizājBarid (Cold Simple Dystemperament) is characterized by a sensation of coldness in the stomach, inclination towards hot and dry substance, thirst is decrease and these symptoms are predominantly observed in both children and adults.^{(1) (12)}c)Sū’-i–MizājRatab (Moist Simple Dystemperament) is characterized by along with hiccups there is accumulation of moisture within the mouth and a constant sensation of movement in the stomach with digestive issues.^{(1) (10) (12)}d) Sū’-i- MizājYabis (Dry Simple Dystemperament)  Regarding this Ghina Mina said that this condition typically emerges following disease onset, chronic constipation, or significant dehydration especially after episodes of severe diarrhea. Clinically, it is associated with pronounced fever (Humma), severe faintness (ghashi) along with the symptoms of inflammation of liver and stomach, and clear indicators of gastric dryness.⁽¹³⁾

b) Sū’-i- MizājMaddi (Material Dystemperament)

This type is caused by the presence of morbid humoral material, particularly yellow bile (Safrā), within the gastrointestinal tract. Clinical features include recurrent hiccups, aninclination towards cold food and beverages. As this morbid matter undergoes internal digestion, patients may exhibit hiccups, which is intensifiedwith gastric heat. Along with this, the stomach often becomes inflamed and the severity depends upon the amount of matter (madda).In FawāqSafrawi, the taste of mouth is bitter and yellow bile is present in the vomitus and in FawāqSawdawitaste of the mouth is sour, vomitus will be black and foul smelling along with this there is a burning sensation in the stomach (mi’da). ^{(1) (12)}

7. Diagnosis

In Unani medicine, the diagnostic approach to hiccups (Shahīqa) involves a detailed assessment of gastrointestinal and systemic symptoms, as well as the identification of underlying causative factors based on the concept of mizāj (temperament).According to classical Unani practitioners, if signs of inflammation or internal heat are observed in the stomach or intestines—especially when triggered by the intake of warm and irritating substances such a condition is regarded as the primary cause of the disorder. In the absence of these heat-related symptoms, physicians are instructed to investigate alternative etiologies, including weak digestion (Zo‘f-e-Hazm), frequent vomiting, hematemesis (Qai-al-Dam), diarrhea, loss of appetite, or dominance of bile (Ghalba-e-Safra).The presence of one or more of these symptoms, particularly when accompanied by elevated gastric heat, guides the physician toward a specific causative factor. For example, excessive intake of hot substances may lead to gastric inflammation (Waram-e-Mi‘da), which is then considered a direct contributor to the onset of the disease. This diagnostic process is rooted in both clinical observation and an understanding of the humoral and temperamental imbalances affecting the gastrointestinal system.^{(4) (5)}

 

8. Conclusion

The Unani perspective on Fawāq (hiccups) offers a profound and integrative understanding of this seemingly benign yet potentially indicative condition. Rooted in the principle of mizāj (temperament), Unani scholars have long recognized that disturbances in the balance of heat, cold, moisture, and dryness—whether due to external influences like diet and environment or internal factors such as digestive inefficiencies, emotional stress, or humoral imbalances—can lead to the development of hiccups. The classification of Sū’-i-Mizāj into Sada (simple) and Maddi (material) types provides a pronounced framework for diagnosis and treatment, emphasizing the importance of identifying the root cause of the disorder rather than merely addressing its symptoms.^{(3)(4) (6) (7) (9) (10) (12)}

Moreover, the involvement of organs like the stomach (Miʿda) and liver (Jigar) in the pathogenesis of hiccups underscores the interconnectedness of body systems in Unani thought.^{(1) (12)} By focusing on restoring the natural balance of temperament and humors, Unani medicine presents a holistic and individualized approach to managing hiccups, highlighting the relevance of classical knowledge in contemporary healthcare. This understanding not only enriches the therapeutic landscape but also advocates for preventive strategies rooted in lifestyle moderation and temperament awareness. Hiccup (Fawāq) as described in Unani medicine is not a mere mechanical phenomenon but a reflection of deeper temperamental disturbances. Identifying the specific type of Sū’-i- Mizājhelps in delivering personalized and effective treatment.^{(4) (5)}

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