Medicine:Vomiting

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Short description: Involuntary, forceful expulsion of stomach contents, typically via the mouth
Vomiting
Other namesEmesis, puking, barfing, spewing, heaving, throwing up, hurling
A Renaissance drawing with vivid colours depicting a woman holding the head of a man, who is bent over and expelling a brownish-red material from his mouth. A second woman stands at the left of the image in the doorway to the room, and appears to offer support. A crude representation of vomiting.
14th-century illustration of vomiting from the Casanatense Tacuinum Sanitatis
SpecialtyGastroenterology
SymptomsNausea
ComplicationsAspiration, electrolyte and water loss, damage to the enamel of the teeth, tear of the esophageal mucosa
Risk factorsHistory of migraine, history of PONV or motion sickness in a child's parent or sibling, better ASA physical status, intense preoperative anxiety, certain ethnicities or surgery types, decreased perioperative fluids, crystalloid versus colloid administration

Vomiting (also known as emesis and throwing up)[lower-alpha 1] is the involuntary, forceful expulsion of the contents of one's stomach through the mouth and sometimes the nose.[1]

Vomiting can be the result of ailments like food poisoning, gastroenteritis, pregnancy, motion sickness, or hangover; or it can be an after effect of diseases such as brain tumors, elevated intracranial pressure, or overexposure to ionizing radiation.[2] The feeling that one is about to vomit is called nausea; it often precedes, but does not always lead to vomiting. Impairment due to alcohol or anesthesia can cause inhalation of vomit. In severe cases, where dehydration develops, intravenous fluid may be required. Antiemetics are sometimes necessary to suppress nausea and vomiting. Self-induced vomiting can be a component of an eating disorder such as bulimia, and is itself now classified as an eating disorder on its own, purging disorder.

Complications

Vomiting

Aspiration

Vomiting is dangerous if gastric content enters the respiratory tract. Under normal circumstances the gag reflex and coughing prevent this from occurring; however, these protective reflexes are compromised in persons who are under the influence of certain substances (including alcohol) or even mildly anesthetized. The individual may choke and asphyxiate[3] or develop aspiration pneumonia.[4]

Dehydration and electrolyte imbalance

Prolonged and excessive vomiting depletes the body of water (dehydration), and may alter the electrolyte status. Gastric vomiting leads to the loss of acid (protons) and chloride directly. Combined with the resulting alkaline tide, this leads to hypochloremic metabolic alkalosis (low chloride levels together with high HCO−3 and CO2 and increased blood pH) and often hypokalemia (potassium depletion). The hypokalemia is an indirect result of the kidney compensating for the loss of acid. With the loss of intake of food the individual may eventually become cachectic. A less frequent occurrence results from a vomiting of intestinal contents, including bile acids and HCO−3.

Mallory–Weiss tear

Repeated or profuse vomiting may cause erosions to the esophagus or small tears in the esophageal mucosa (Mallory–Weiss tear). This may become apparent if fresh red blood is mixed with vomit after several episodes.

Dentistry

Recurrent vomiting, such as observed in bulimia nervosa, may lead to the destruction of the tooth enamel due to the acidity of the vomit. Digestive enzymes can also have a negative effect on oral health, by degrading the tissue of the gums.

Pathophysiology

Receptors on the floor of the fourth ventricle of the brain represent a chemoreceptor trigger zone, known as the area postrema, stimulation of which can lead to vomiting.[2] The area postrema is a circumventricular organ and as such lies outside the blood–brain barrier; it can therefore be stimulated by blood-borne drugs that can stimulate vomiting or inhibit it.[5]

There are various sources of input to the vomiting center:

The vomiting act encompasses three types of outputs initiated by the chemoreceptor trigger zone: Motor, parasympathetic nervous system (PNS), and sympathetic nervous system (SNS). They are as follows:

  • Increased salivation to protect tooth enamel from stomach acids.[12] (Excessive vomiting leads to dental erosion.) This is part of the PNS output.
  • The body takes a deep breath to avoid aspirating vomit.[12]
  • Retroperistalsis starts from the middle of the small intestine and sweeps up digestive tract contents into the stomach, through the relaxed pyloric sphincter.[12]
  • Intrathoracic pressure lowers (by inspiration against a closed glottis), coupled with an increase in abdominal pressure as the abdominal muscles contract, propels stomach contents into the esophagus as the lower esophageal sphincter relaxes.[13] The stomach itself does not contract in the process of vomiting[14] except for at the angular notch, nor is there any retroperistalsis in the esophagus.
  • Vomiting is ordinarily preceded by retching.[12]
  • Vomiting also initiates an SNS response causing both sweating and increased heart rate.[12]

Phases

The vomiting act has two phases. In the retching phase, the abdominal muscles undergo a few rounds of coordinated contractions together with the diaphragm and the muscles used in respiratory inspiration. For this reason, an individual may confuse this phase with an episode of violent hiccups. In this retching phase, nothing has yet been expelled. In the next phase, also termed the expulsive phase, intense pressure is formed in the stomach brought about by enormous shifts in both the diaphragm and the abdomen. These shifts are, in essence, vigorous contractions of these muscles that last for extended periods of time—much longer than a normal period of muscular contraction. The pressure is then suddenly released when the upper esophageal sphincter relaxes resulting in the expulsion of gastric contents. As the mouth and nasal cavity are connected via the back of the throat, particularly forceful vomiting, or producing large quantities of vomit may result in material being ejected through the nostrils in addition to the mouth. Individuals who do not regularly exercise their abdominal muscles may experience pain in those muscles for a few days. The decrease in pressure and the release of endorphins into the bloodstream after the expulsion causes the vomiter to feel relief almost immediately after vomiting.[15]

Contents

Partially digested food, with a rubber glove for scale

Gastric secretions and likewise vomit are highly acidic. Recent food intake appears in the gastric vomit. Irrespective of the content, vomit tends to be malodorous.[citation needed]

The content of the vomitus (vomit) may be of medical interest. Fresh blood in the vomit is termed hematemesis ("blood vomiting"). Altered blood bears resemblance to coffee grounds (as the iron in the blood is oxidized) and, when this matter is identified, the term coffee-ground vomiting is used. Bile can enter the vomit during subsequent heaves due to duodenal contraction if the vomiting is severe. Fecal vomiting is often a consequence of intestinal obstruction or a gastrocolic fistula and is treated as a warning sign of this potentially serious problem (signum mali ominis).[citation needed]

If the vomiting reflex continues for an extended period with no appreciable vomitus, the condition is known as non-productive emesis or "dry heaves", which can be painful and debilitating.[citation needed]

Color of vomit[16]
  • Bright red in the vomit suggests bleeding from the esophagus
  • Dark red vomit with liver-like clots suggests profuse bleeding in the stomach, such as from a perforated ulcer
  • Coffee-ground-like vomit suggests less severe bleeding in the stomach because the gastric acid has had time to change the composition of the blood
  • Yellow vomit suggests bile, indicating that the pyloric valve is open and bile is flowing into the stomach from the duodenum (this is more common in older people)

Causes

Vomiting may be due to a large number of causes, and protracted vomiting has a long differential diagnosis.[citation needed]

Digestive tract

Causes in the digestive tract

Sensory system and brain

Causes in the sensory system:[citation needed]

Causes in the brain:[citation needed]

Metabolic disturbances (these may irritate both the stomach and the parts of the brain that coordinate vomiting):[citation needed]

Pregnancy:[20]

Drug reaction (vomiting may occur as an acute somatic response to):[citation needed]

High altitude:

Illness (sometimes colloquially known as "stomach flu"—a broad name that refers to gastric inflammation caused by a range of viruses and bacteria):[citation needed]

Psychiatric/behavioral:

Emetics

An emetic, such as syrup of ipecac, is a substance that induces vomiting when administered orally or by injection. An emetic is used medically when a substance has been ingested and must be expelled from the body immediately. (For this reason, many toxic and easily digestible products such as rat poison contain an emetic.[23] This presents no problem for the effectiveness of the rodenticide as rodents are unable to vomit.)[24] Inducing vomiting can remove the substance before it is absorbed into the body. Emetics can be divided into two categories, those which produce their effect by acting on the vomiting center in the medulla, and those which act directly on the stomach itself. Some emetics, such as ipecac, fall into both categories; they initially act directly on the stomach, while their further and more vigorous effect occurs by stimulation of the medullary center.[23]

Salt water and mustard water, which act directly on the stomach, have been used since ancient times as emetics.[25] Care must be taken with salt, as excessive intake can potentially be harmful.[26][27] Copper sulfate was also used in the past as an emetic.[28][29] It is now considered too toxic for this use.[30]

Hydrogen peroxide is used as an emetic in veterinary practice.[31][32]

Self-induced

  • Eating disorders (anorexia nervosa or bulimia nervosa)
  • To eliminate an ingested poison (some poisons should not be vomited as they may be more toxic when inhaled or aspirated; it is better to ask for help before inducing vomiting)
  • Some people who engage in binge drinking induce vomiting to make room in their stomachs for more alcohol consumption.
  • Participants in milk chugging typically end up vomiting most of the milk they consume, as proteins in the ingested milk (such as casein) rapidly denature and unravel on contact with gastric acid and protease enzymes, rapidly filling the stomach. Once the stomach becomes full, stretch receptors in the stomach wall trigger signals to vomit to expel any further liquid the participant ingests.
  • People suffering from nausea may induce vomiting in hopes of feeling better.

Miscellaneous

Other types

  • Projectile vomiting is vomiting that ejects the gastric contents with great force.[33] It is a classic symptom of infantile hypertrophic pyloric stenosis, in which it typically follows feeding and can be so forceful that some material exits through the nose.[34]

Treatment

An antiemetic is a drug that is effective against vomiting and nausea. Antiemetics are typically used to treat motion sickness and the side effects of medications such as opioids and chemotherapy.

Antiemetics act by inhibiting the receptor sites associated with emesis. Hence, anticholinergics, antihistamines, dopamine antagonists, serotonin antagonists, and cannabinoids are used as antiemetics.[35]

Evidence to support the use of antiemetics for nausea and vomiting among adults in the emergency department is poor.[36] It is unclear if any medication is better than another or better than no active treatment.[36]

Epidemiology

Nausea and/or vomiting are the main complaints in 1.6% of visits to family physicians in Australia.[37]

Society and culture

Herodotus, writing on the culture of the ancient Persians and highlighting the differences with those of the Ancient Greece , notes that to vomit in the presence of others is prohibited among Persians.[38][39]

Social cues

A drunk man vomiting, while a young slave is holding his forehead. Brygos Painter, 500–470 BC

It is quite common that, when one person vomits, others nearby become nauseated, particularly when smelling the vomit of others, and often to the point of vomiting themselves. It is believed that this is an evolved trait among primates. Many primates in the wild tend to browse for food in small groups. Should one member of the party react adversely to some ingested food, it may be advantageous (in a survival sense) for other members of the party to also vomit. This tendency in human populations has been observed at drinking parties, where excessive consumption of alcoholic beverages may cause a number of party members to vomit nearly simultaneously, this being triggered by the initial vomiting of a single member of the party. This phenomenon has been touched on in popular culture: notorious instances appear in the films Monty Python's The Meaning of Life (1983) and Stand By Me (1986).[40]

Intense vomiting in ayahuasca ceremonies is a common phenomenon. However, people who experience "la purga" after drinking ayahuasca, in general, regard the practise as both a physical and spiritual cleanse and often come to welcome it.[41] It has been suggested that the consistent emetic effects of ayahuasca—in addition to its many other therapeutic properties—was of medicinal benefit to indigenous peoples of the Amazon, in helping to clear parasites from the gastrointestinal system.[42]

There have also been documented cases of a single ill and vomiting individual inadvertently causing others to vomit, when they are especially fearful of also becoming ill, through a form of mass hysteria.[citation needed]

Special bags are often supplied on boats for sick passengers to vomit into.

Most people try to contain their vomit by vomiting into a sink, toilet, or trash can, as vomit is difficult and unpleasant to clean. On airplanes and boats, special bags are supplied for sick passengers to vomit into. A special disposable bag (leakproof, puncture-resistant, odorless) containing absorbent material that solidifies the vomit quickly is also available, making it convenient and safe to store until there is an opportunity to dispose of it conveniently.[citation needed]

People who vomit chronically (e.g., as part of an eating disorder such as bulimia nervosa) may devise various ways to hide this disorder.[citation needed]

An online study of people's responses to "horrible sounds" found vomiting "the most disgusting". Professor Trevor Cox of the University of Salford's Acoustic Research Centre said, "We are pre-programmed to be repulsed by horrible things such as vomiting, as it is fundamental to staying alive to avoid nasty stuff." It is thought that disgust is triggered by the sound of vomiting to protect those nearby from possibly diseased food.[43]

Psychology

Emetophilia is sexual arousal from vomiting, or watching others vomit.[44] Emetophobia is a phobia that causes overwhelming, intense anxiety pertaining to vomiting.

See also

Notes

  1. ↑ informally known as (chiefly U.S.) puking, barfing, and (chiefly Brit.) being sick or getting sick

References

  1. ↑ Tintinalli, Judith E. (2010). Emergency Medicine: A Comprehensive Study Guide (Emergency Medicine (Tintinalli)). New York: McGraw-Hill Companies. p. 830. ISBN 978-0-07-148480-0. 
  2. ↑ 2.0 2.1 Hauser, Joshua M.; Azzam, Joseph S.; Kasi, Anup (2022-09-26). "Antiemetic Medications". StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532303/. 
  3. ↑ Robson, Philip (1999). Forbidden Drugs (2nd ed.). New York: Oxford University Press. p. 49. ISBN 0-19-262955-7. https://books.google.com/books?id=fFgA5NzT-BwC&pg=PA49. Retrieved August 9, 2021. 
  4. ↑ Chambers, David; Huang, Christopher; Matthews, Gareth (January 15, 2015). Basic Physiology for Anaesthetists. Cambridge, United Kingdom: Cambridge University Press. p. 277. ISBN 978-1-107-63782-5. https://books.google.com/books?id=5ma8BQAAQBAJ&dq=vomit+alcohol+%22aspiration+pneumonia%22+inpublisher:university+inpublisher:press&pg=PA277. Retrieved August 9, 2021. 
  5. ↑ Holland, James F.; Kufe, Donald W.; Weichselbaum, Ralph R.; Pollock, Raphael E.; Frei III, Emil; Gansler, Ted S.; Bast Jr., Robert C. (2003). Cancer medicine (6. [ed.]. ed.). Hamilton, Ontario [u.a.]: Decker. ISBN 978-1-55009-213-4. https://archive.org/details/cancermedicine60002unse. 
  6. ↑ Hornby, PJ (2001). "Central neurocircuitry associated with emesis". The American Journal of Medicine 111 Suppl 8A (8): 106S–112S. doi:10.1016/S0002-9343(01)00849-X. PMID 11749934. 
  7. ↑ Naylor, RJ; Inall, FC (January 1994). "The physiology and pharmacology of postoperative nausea and vomiting.". Anaesthesia 49 Suppl: 2–5. doi:10.1111/j.1365-2044.1994.tb03575.x. PMID 8129158. 
  8. ↑ Matsuoka, I; Ito, J; Takahashi, H; Sasa, M; Takaori, S (1984). "Experimental vestibular pharmacology: a minireview with special reference to neuroactive substances and antivertigo drugs.". Acta Oto-Laryngologica Supplementum 419: 62–70. PMID 6399658. 
  9. ↑ Li–gui, Huang; En–tong, Wang; Wei, Chen; Wei–xi, Gong (June 2011). "Role of Histamine H1 Receptors in Vestibular Nucleus in Motion Sickness". Journal of Otology 6 (1): 20–25. doi:10.1016/S1672-2930(11)50003-0. 
  10. ↑ Ray Andrew P.; Chebolu Seetha; Ramirez Juan; Darmani Nissar A (2009). "Ablation of Least Shrew Central Neurokinin NK1 Receptors Reduces GR73632-Induced Vomiting". Behavioral Neuroscience 123 (3): 701–706. doi:10.1037/a0015733. PMID 19485577. 
  11. ↑ "What is nausea? A historical analysis of changing views". Autonomic Neuroscience 202: 5–17. January 2017. doi:10.1016/j.autneu.2016.07.003. PMID 27450627. 
  12. ↑ 12.0 12.1 12.2 12.3 12.4 Anthony L. Kovac (March 29, 2016). "2: Mechanisms of nausea and vomiting". in Tong Joo Gan; Habib, Ashraf S.. Postoperative Nausea and Vomiting: A Practical Guide. Cambridge, United Kingdom: Cambridge University Press. p. 13. ISBN 978-1-107-46519-0. https://books.google.com/books?id=-6qxCwAAQBAJ&dq=retroperistalsis+inpublisher:university+inpublisher:press&pg=PA13. Retrieved August 8, 2021. 
  13. ↑ Boarder, Michael; Dixon, Jane; Newby, David; Navti, Phyllis; Zetterström, Tyra (2017). Pharmacology for Pharmacy and the Health Sciences: A Patient-Centred Approach (2nd ed.). New York, NY: Oxford University Press. p. 317. ISBN 978-0-19-107072-3. https://books.google.com/books?id=eAaTDQAAQBAJ&dq=vomiting+abdominal+muscles+contract+inpublisher:university+inpublisher:press&pg=PA317. Retrieved August 8, 2021. 
  14. ↑ Koshi, Rachel (August 24, 2017). Cunningham's Manual of Practical Anatomy: Volume 2, Thorax and Abdomen (16th ed.). New York, NY: Oxford University Press. p. 300. ISBN 978-0-19-251647-3. https://books.google.com/books?id=tn8yDwAAQBAJ&dq=vomiting+abdominal+muscles+contract+inpublisher:university+inpublisher:press&pg=PT310. Retrieved August 8, 2021. 
  15. ↑ Lembke, Anna (November 15, 2016). Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, and Why It's So Hard to Stop. Baltimore, Maryland: Johns Hopkins University Press. p. 137. ISBN 978-1-4214-2140-7. https://books.google.com/books?id=FqfhDAAAQBAJ&dq=vomiting+endorphins+inpublisher:university+inpublisher:press&pg=PA137. Retrieved August 9, 2021. 
  16. ↑ W. S., CRAIG (1961). "Vomiting in the early days of life.". Archives of Disease in Childhood 36 (188): 455. doi:10.1136/adc.36.188.451. PMID 13696216. 
  17. ↑ K.L., Koch (2000). "Unexplained nausea and vomiting". Current Treatment Options in Gastroenterology 3 (4): 303–313. doi:10.1007/s11938-000-0044-5. PMID 11096591. 
  18. ↑ "Symptoms & Causes of Celiac Disease | NIDDK". June 2016. https://www.niddk.nih.gov/health-information/digestive-diseases/celiac-disease/symptoms-causes. 
  19. ↑ "Non-coeliac gluten/wheat sensitivity: advances in knowledge and relevant questions.". Expert Review of Gastroenterology & Hepatology 11 (1): 9–18. 2017. doi:10.1080/17474124.2017.1260003. PMID 27852116. "A lower proportion of NCG/WS patients (from 30% to 50%) complain of upper gastrointestinal tract manifestations, e.g. vomiting, nausea, gastroesophageal reflux disease, aerophagia and aphthous stomatitis. (NCG/WS: Non-coeliac gluten/wheat sensitivity)". 
  20. ↑ Iatrakis, George M.; Sakellaropoulos, Gerasimos G.; Kourkoubas, Anthony H.; Kabounia, Stavroula E. (1988). "Vomiting and Nausea in the First 12 Weeks of Pregnancy". Psychother Psychosom 49 (1): 22–24. doi:10.1159/000288062. PMID 3237957. 
  21. ↑ Rostron, Chris; Barber, Jill, eds (March 2021). Pharmaceutical Chemistry (2nd ed.). New York, NY: Oxford University Press. p. 8. ISBN 978-0-19-877978-0. https://books.google.com/books?id=f-AeEAAAQBAJ&dq=vomit+hangover+inpublisher:university+inpublisher:press&pg=SA1-PA7. Retrieved August 9, 2021. 
  22. ↑ (in en) Ferri's Clinical Advisor 2017 E-Book: 5 Books in 1. Elsevier Health Sciences. 2016. p. 590. ISBN 978-0-323-44838-3. https://books.google.com/books?id=rRhCDAAAQBAJ&pg=PA590. Retrieved 2023-01-02. 
  23. ↑ 23.0 23.1  One or more of the preceding sentences incorporates text from a publication now in the public domain: Chisholm, Hugh, ed (1911). "Emetics". Encyclopædia Britannica. 9 (11th ed.). Cambridge University Press. p. 336. 
  24. ↑ Kapoor, Harit; Lohani, Kush Raj; Lee, Tommy H.; Agrawal, Devendra K.; Mittal, Sumeet K. (2015-07-27). "Animal Models of Barrett's Esophagus and Esophageal Adenocarcinoma-Past, Present, and Future". Clinical and Translational Science (Wiley) 8 (6): 841–847. doi:10.1111/cts.12304. PMID 26211420. 
  25. ↑ Decker, W. J. (1971). "In Quest of Emesis: Fact, Fable, and Fancy". Clinical Toxicology 4 (3): 383–387. doi:10.3109/15563657108990490. PMID 4151103. 
  26. ↑ Moder, K. G.; Hurley, D. L. (1991). "Fatal hypernatremia from exogenous salt intake: report of a case and review of the literature". Mayo Clinic Proceedings 65 (12): 1587–94. doi:10.1016/S0025-6196(12)62194-6. PMID 2255221. 
  27. ↑ "Salt: a natural antidepressant?". The Scotsman. April 6, 2009. http://news.scotsman.com/nhshealth/Salt-a-natural-antidepressant.5144129.jp. 
  28. ↑ "Elevation of serum copper following copper sulfate as an emetic". Pediatrics 42 (1): 189–93. July 1968. doi:10.1542/peds.42.1.189. PMID 4385403. http://pediatrics.aappublications.org/cgi/content/abstract/42/1/189. Retrieved 2009-03-06. 
  29. ↑ Wang, S. C.; Borison, Herbert L. (1951). "Copper Sulphate Emesis: A Study of Afferent Pathways from the Gastrointestinal Tract". American Journal of Physiology 164 (2): 520–526. doi:10.1152/ajplegacy.1951.164.2.520. PMID 14810961. 
  30. ↑ Olson, Kent C. (2004). Poisoning & drug overdose. New York: Lange Medical Mooks/McGraw-Hill. p. 175. ISBN 978-0-8385-8172-8. https://archive.org/details/poisoningdrugove00olso/page/175. 
  31. ↑ "Drugs to Control or Stimulate Vomiting". Merck Veterinary manual. Merck & Co., Inc. 2006. http://www.merckvetmanual.com/mvm/index.jsp?cfile=htm/bc/190303.htm. Retrieved 2013-02-23. 
  32. ↑ "How to Induce Vomiting (Emesis) in Dogs". Petplace.com. http://www.petplace.com/dogs/how-to-induce-vomiting-emesis-in-dogs/page1.aspx. 
  33. ↑ "vomiting - definition of vomiting in the Medical dictionary - by the Free Online Medical Dictionary, Thesaurus and Encyclopedia". Medical-dictionary.thefreedictionary.com. http://medical-dictionary.thefreedictionary.com/vomiting. 
  34. ↑ Sleisenger & Fordtran's gastrointestinal and liver disease pathophysiology, diagnosis, management (9th ed.). St. Louis, Mo.: MD Consult. 2009. p. 783. ISBN 978-1-4160-6189-2. http://www.mdconsult.com/das/book/pdf/284431036-3/978-1-4160-6189-2/4-u1.0-B978-1-4160-6189-2..00047-0..DOCPDF.pdf?isbn=978-1-4160-6189-2&eid=4-u1.0-B978-1-4160-6189-2..00047-0..DOCPDF. Retrieved 2011-09-30. 
  35. ↑ Mitchelson, F (March 1992). "Pharmacological agents affecting emesis. A review (Part I).". Drugs 43 (3): 295–315. doi:10.2165/00003495-199243030-00002. PMID 1374316. 
  36. ↑ 36.0 36.1 Furyk, JS; Meek, RA; Egerton-Warburton, D (28 September 2015). "Drugs for the treatment of nausea and vomiting in adults in the emergency department setting.". Cochrane Database of Systematic Reviews 9 (9): CD010106. doi:10.1002/14651858.CD010106.pub2. PMID 26411330. 
  37. ↑ Helena Britt; Fahridin, S (September 2007). "Presentations of nausea and vomiting". Australian Family Physician 36 (9): 673–784. PMID 17885697. http://www.racgp.org.au/afp/200709/200709beach.pdf. Retrieved 2010-02-15. 
  38. ↑ electricpulp.com. "HERODOTUS iii. DEFINING THE PERSIANS – Encyclopaedia Iranica". http://www.iranicaonline.org/articles/herodotus-iii. 
  39. ↑ "Internet History Sourcebooks". http://sourcebooks.fordham.edu/ancient/herodotus-persians.asp. 
  40. ↑ "9 BEST VOMIT SCENES ON FILM | Screen Junkies". 2009-03-13. http://www.screenjunkies.com/general/9-best-vomit-scenes-film. 
  41. ↑ Shanon, B. (2002). The antipodes of the mind: Charting the phenomenology of the ayahuasca experience. Oxford: Oxford University Press.
  42. ↑ Andritzky, W. (1989). "Sociopsychotherapeutic functions of ayahuasca healing in Amazonia". Journal of Psychoactive Drugs 21 (1): 77–89. doi:10.1080/02791072.1989.10472145. PMID 2656954. 
  43. ↑ [1] University of Salford. January 28, 2007.
  44. ↑ Aggrawal, Anil (2009). Forensic and Medico-legal Aspects of Sexual Crimes and Unususal Sexual Practices. Boca Raton: CRC Press. p. 373. ISBN 978-1-4200-4308-2. 

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