The Act of Puking
Sketches from the International Vomiting Conference.
Dr. James Lackner and two very sick research subjects aboard NASA’s “Vomit Comet,” a reduced-gravity aircraft that uses parabolic flight to produce a near-weightless environment. Photo courtesy of the AGSOL Archive
Like many people over a certain age, vomiting no longer disgusts me. I’m not proud to admit it, but on occasion, I throw up after poisoning my body with too much alcohol. As a result, I’ve developed a handful of techniques that take me from retching to flushing without too much discomfort. Sometimes, when the first pangs of rusty saliva leak down my throat, I like to pretend that I’m an angry dragon, hurriedly flapping my wings to spray an unsuspecting porcelain city with waves of bilious puke-fire. It’s pretty awesome.
“Nausea and vomiting can be at the end of a whole buildup of things,” said Charles Horn, a neuroscientist who specialises in emesis, the clinical term for blowing chunks. “But the truth is, when you vomit, you feel better, almost every time.”
In fact, vomiting makes some people feel so good that they’ve devoted their lives to studying it. This year, along with another neuroscientist named Bill Yates, Charles co-hosted a two-day, single-track academic conference at the University of Pittsburgh, officially known as Biology and Control of Nausea and Vomiting 2013 – the International Vomiting Conference for short. In attendance were 62 prominent doctors who share the goal of advancing research on the biological mechanisms that cause nausea and vomiting. Their ultimate goal is to answer the questions: Why do people blow their grits, and what are we to do about it? The answers are more complicated than one might think.
When Charles accepted my request to report on the conference, I could barely contain my excitement: I am downright fascinated by vomit. There’s a glint of the rarest purity in the act of puking, a black-and-white reality in a world of nauseating, amorphous gray (or green, depending on what’s coming back up). For instance, the most expressive art on the planet can often feel, look, or sound like puke – think Jackson Pollock or punk rock – automatic expulsions of parasitic elements that preempt a sense of therapeutic completion. The primal discharge of a pathogen. Nothing left but stomach lining and bile. In other words, despite its messy downsides, vomiting is a relatively impressive reflexive evolutionary defense mechanism, so what better place to find my people than at the International Vomiting Conference? Unfortunately, it was not all fun and games and research subjects sticking their fingers down their throats, as I hoped it might be, but I still learned a whole lot about ralphing.
A 1950s “pukey doll,” meant to soothe your nausea when you feel like you might want to toss your cookies. Photo by Christian Storm
I stumbled bleary-eyed into the conference at 7 AM, working off a night of very little sleep that was entirely my own doing. The previous evening, I had taken the bus from New York City to Pittsburgh, birthplace of both the Big Mac and the polio vaccine, and the city cradled me in its boozy arms shortly after my arrival. I felt suitably nauseated for the event.
The conference was held at the University Club, an elegantly restored 1923 social center encased in floral white, classically styled limestone. Across the street, students bustled around a lawn outside the Soldiers and Sailors Memorial Hall. Due to my research, I recognised it as the set for the Memphis courthouse scene in The Silence of the Lambs, where Dr. Hannibal Lecter cuts off a cop’s face and wears it to escape jail time. Totally puke-worthy, I thought.
Before the conference, I came to the realisation that even though I was on board with puking as a conceptual phenomenon, I had no idea what vomiting entailed, at least scientifically speaking. Before my trip to Pittsburgh, I had arranged a call with Charles to become more familiar with his research, which was sparked by the realisation that the majority of animals on earth – like rats – are physically incapable of vomiting: they lack the neural connections to synchronise the brain stem with the various muscles needed for a proper puke. It sorted me out on a rudimentary level, while solidifying my standing as a vomit novice.
As I choked down some doughnuts and milky coffee in a ground-level conference room full of bespectacled men with briefcases and pocket protectors, I realized that, besides the administrative staff and various caterers, I was the only person there who wasn’t a member of the scientific establishment. My presence seemed to be weirding everyone out. “I heard VICE does a lot of undercover work,” one researcher snidely told me. “Is that what the tucked-in shirt is about?” I wondered what would happen if I threw up all over his shoes. Would he be disgusted or quickly swab up my fresh spew? The former, I decided, but figured I’d probably be asked to leave either way.
Later on Dr. Yates, one of the co-founders of the International Vomit Conference, gave a lecture entitled “Integration of Vestibular and Gastrointestinal Signals by Brainstem Pathways That Produce Nausea and Vomiting,” where I learned that ejecting partially digested food from your stomach is merely a strange form of breathing.
“What happens is this: the skeletal muscle contracts, and the normal respiratory patterns during breathing are interrupted,” Bill lectured. “During breathing, you contract your diaphragm. During vomiting, you co-contract your diaphragm and your abdominal muscles, squeezing the stomach between the two muscles.” Then the muscles go through a series of co-contractions, usually referred to as retching. Finally, the diaphragm stops contracting, thus unblocking the esophagus while the abdominal muscle continues to contract, forcing food through your throat and out of your mouth. Breathing is momentarily suspended via a process called apnea, which allows you to get all the bad stuff out without the threat of asphyxiation.
At another lecture, I was surprised to learn that humans are the sole species with the ability to consciously will our bodies into puking. Certain activities like pedophilia and incest induce a sense of moral disgust, and if you think about them deeply, with regard to your own life and experience, some people can actually induce vomiting. In the science-puke world this is known as “conscious vomiting,” and it’s actually recommended by certain yogis, who refer to it as a component of dhauti, the purification of the esophagus and stomach. I attempted this during the preliminary research for this article and found—to my amazement—that I could consistently make myself puke by concentrating hard on a particularly nauseating scenario involving my beloved cat, Niko.
Leading up to the conference, I’d had a shaky Skype call with Dr. Val Curtis, the director of the Hygiene Center at the London School of Hygiene and Tropical Medicine. She refers to herself a “disgustologist,” so you know she really means business. Dr. Curtis told me the feelings of disgust that can lead to nausea and vomiting are actually part of an evolved adaptive system linked to our primal fear of death. The reasons you recoil from nasty situations are instinctual, if not primordial. According to Dr. Curtis, we are all the offspring of primeval ancestors who “tended to avoid feces, nasal mucus, and bad-smelling food. They were healthier, mated more often, brought up more children to sexual maturity, and hence had more grandchildren. And these grandchildren, the descendants of the disgusted, were more disgust-able themselves—and so on, till the present day, and us.”
Dr. Curtis said disgust can stem from anything, but the root cause is usually the reflexive avoidance of a parasite. According to her logic: If spiders and bugs make you puke, this could be because vermin carry disease. If seaweed grosses you out, it’s because it can carry things like cholera. Evolutionary biologists refer to this as Parasite Avoidance theory. According to this theory, vomit is disgusting because it also carries disease. Weight was added to this theory as recently as this past July, when the Hunday Manor Country House Hotel on the west coast of England was closed after a norovirus outbreak was spread by vomit.
Kimber MacGibbon and geneticist Marlena Feijzo of the Hyperemesis Education and Research Foundation. Photo by Christian Storm
Also lecturing at the conference was Dr. James Lackner, a soft-spoken gray-haired man who has devoted his life to studying motion sickness. He began his lecture, aptly titled “Conditions and Environments That Produce Motion Sickness,” with the only joke I heard my entire time there. “So far,” he said, “everyone at this conference is talking about how to treat nausea and vomiting. For years, I’ve been doing my best to really make people sick.”
To better understand motion sickness, Dr. Lackner conducts parabolic flight experiments on the famed “Vomit Comet,” shooting subjects into a parabola and then into a state of free-fall at gravity-defying rates of up to two Gs. Invariably, this produces a neurological disorder called sopite syndrome. When humans are exposed to prolonged bouts of motion, sopite hits, and they begin to feel drowsiness, fatigue, lack of initiative, boredom, and eventually, total apathy.
He told the group that “not all vomit is created equal. I’ve had people on a barbecue-spit motion-sickness device, and before we get to constant velocity he yells out, ‘Stop! I gotta vomit.’ You stop him, he vomits, and then says, ‘OK, I’m ready to go,’ and he can continue for an hour. The next person vomits and stops, then vomits again. He may vomit 15 times over the course of an hour.”
While it seems silly, Dr. Lackner’s work helps us to better understand many logistical and biological concerns related to astronautics. This is important when you remember that James Hansen, the former head of NASA’s Goddard Institute for Space Studies, posits that unless we phase out fossil-fuel emissions pronto, future generations will be punted a situation well out of their reach to solve. It’s about time we started figuring out how not to throw up all over the galaxy, in the event we accidently turn Earth into an uninhabitable rock.
No one understands puke better than mothers to be, which could be because more than half of them are eating and barfing for at least a portion of their pregnancy. This is another handy trick humans have evolved to protect fetuses from toxins their mothers have thrown down their throats—things like meatloaf topped with gummy bears.
According to Kimber MacGibbon and Ann Marie King of the Hyperemesis Education and Research Foundation, who had a small table set up at the conference, at least two percent of pregnant American women suffer from a very serious disease called hyperemesis gravidarum (HG) that’s barely studied and hardly understood. It’s basically an extreme form of morning sickness, and received a rare dose of public attention late last year when Kate Middleton, the Duchess of York, was diagnosed with the condition while pregnant with her royal son, George.
HG is kind of like having a stomach flu for six months while simultaneously trying to grow a child inside your uterus. Women with HG have been reported to vomit around 50 or 60 times a day for a good six months of their pregnancy. This causes a series of complications, including severe dehydration, nutritional deficiencies, metabolic imbalances, and the loss of more than 5 to 10 percent of prepregnancy body weight. The children of hyperemetic mothers often end up with severe emotional and physical disabilities, and the mothers themselves often die. It’s generally accepted that Charlotte Brontë and her unborn child died from HG: in 1855, in the early stages of pregnancy, Charlotte fell ill, attacked by “sensations of perpetual nausea and ever-recurring faintness.”
For every woman diagnosed with HG, thousands go undiagnosed, or misdiagnosed, and the disease itself is surprisingly controversial. When I asked Kimber how a horribly debilitating disease could possibly be controversial, she told me, flatly, “Because it involves women.”
In the same way that some doctors are hesitant to diagnose and treat pregnant women in general, the pharmaceutical industry is too timid to fund research to prevent HG, fearing lawsuits akin to those that happened in the late 50s, when more than 10,000 children in 46 countries were born with horrific disabilities after their mothers were prescribed the new drug Thalidomide to prevent common morning sickness during early pregnancy. Instead, Kimber said, physicians are often exasperated by their hyperemetic patients, blaming them for their own illness as if it were a subconscious rejection of pregnancy.
The NASA Reduced Gravity Program’s official patch, awarded to participants on completing parabolic flight. It features a sick Snoopy with a barf bag. Photo courtesy of the AGSOL Archive
The International Vomiting Conference closed with a question-and-answer session; various doctors and researchers behind a pair of microphones alternatively congratulated and picked apart one another’s research and conclusions. It’s important to keep in mind that the majority of the attendees were from entirely different fields, and it’s difficult to contradict someone who prefaces a question about preclinical vomiting with “I’ve been studying preclinical vomiting for more than 20 years.”
If the conference proved nothing else, it’s that vomiting is still largely misunderstood—even if we do it all the time. Certain questions persist: Where does nausea begin and vomit end? Is the nausea you feel on the Vomit Comet different from what you’d feel after chemotherapy, or when you drink a few 40s of Olde English? No one could even give me a straight answer as to whether nausea should be considered a stand-alone condition separate from the actual act of throwing up.
As I walked away from the University Club, it suddenly hit me that I’d been thinking about retching for two days straight with no chaser. Aside from Dr. Lackner’s, there wasn’t a single joke at the conference to lighten the mood, and I never got to tell my story about that time I puked into a hedgerow, or when my friend Chris tossed his cookies into a toaster. And that’s OK because, frankly, I learned that vomiting isn’t something to laugh about. At all. The doctors collected at the International Vomiting Conference all had a look of detached sadness to them, as if their specialization would always be misunderstood, belittled, ignored, and ridiculed by the general public. There’s a largely hidden world of puke that most of us will never get to explore, one that I decided I was OK with leaving to the experts, after all. Mostly because puking your guts out is disgusting, and I’ve learned all I ever need to know about the science of vomit.
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