Empowered Sleep Apnea: THE PODCAST
Season 2: STORIES FROM THE FIELD
Episode 7: BOSTON
© 2024 www.EmpoweredSleepApnea.com
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00:00 Change the Channel!
00:23 Disclaimer
Empowered Sleep Apnea is an educational podcast, which is a bit different from a medical advice show. Medical decision-making in Sleep Medicine can be complex, and even empowered patients need a partner. So: play it smart and make sure you talk it over with your healthcare provider before making any changes to your medical treatment plan.
And now…on with the show!
00:46 Titles
Announcer: Empowered Sleep Apnea: THE PODCAST…Season 2: STORIES FROM THE FIELD…Episode 7…BOSTON…
00:59 Before We Begin
Dave: This is Dr. Dave McCarty.
On today’s episode of Empowered Sleep Apnea: THE PODCAST, I decided to throw caution to the wind—literally, and I made the decision to release the navigational controls on our Beautiful Blue Balloon, and leave the destination…up to fate…
On today’s journey, our Balloon will take us backward in time as prevailing winds blow us steadily east, towards the rising sun…we’re going to Boston Massachusetts, back to the winter of 1844, back to a time when medical history tottered on the brink of an epic discovery: surgery without pain.
This whole story starts with one of the most famous quotations in the history of modern medicine. And, as with many interesting quotes, this one hides a fascinating human drama, one which still feels relevant today.
So…without further ado…here’s a little piece I’m calling…The Price of Humbug…hope you enjoy it!
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02:28 The Price of Humbug
Dave: One of my favorite stories in the history of medicine is summed up in a five-word quotation that still lands today like a forehead slap.
“Gentlemen! This is no humbug.”
Those five words were supposedly uttered by the great Dr. John Collins Warren, that American medical luminary, founding surgeon at Massachusetts General Hospital (MGH), the founding editor of the legendary New England Journal of Medicine, the third president of the American Medical Association.
Warren supposedly bellowed these words to a packed MGH Operating Theatre auditorium, head shaking in disbelief, having been blown away by a miraculous discovery. It was uttered at a fulcrum point in history, a day the Earth sighed relief, a day when the world saw human surgery performed completely without pain.
And it probably never happened.
The story of what actually DID happen is much more interesting, though, and it reads like a crime novel. Let’s start with this: In 1844, Dr. Horace Wells and Dr. William. T.G. Morton were successful dentists practicing near Boston.
Let’s just pick it up from there.
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Cue Harp Glissando as Time Travels Backward…
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December 10, 1844: Dr. Horace Wells witnesses a public demonstration of Nitrous Oxide inhalation. Yup, a newspaper advertisement gathered a crowd, to observe some schmuck doing whiffers. The brave soul doing the inhaling barks his knees on a table whilst stumbling, and doesn’t react to it. When he recovers, he has no recollection of the event and appears befuddled by the bruises on his knees.
A light bulb goes on above Horace Wells’ head, as bright as the sun.
January 20, 1845: Dr. Warren is skeptical, but nevertheless invites Dr. Wells to publicly demonstrate inhalational anesthesia at the MGH Theatre. Dr. Wells brings his Nitrous Oxide.
The guy who was scheduled to have an amputation is a no-show, so Dr. Warren extemporaneously creates the first iteration of an employee health plan, asking if anybody in the audience needs a tooth extracted, and a student fortuitously volunteers. That student happens to be an obese alcoholic, factors which can hamper the effects of Nitrous Oxide, though none of that was known then.
The demonstration couldn’t go worse. Dr. Wells will later admit that he thinks he didn’t apply the gas long enough. The student was not fully anesthetized, and upon completion of the extraction, reported he felt pain.
That was enough to send the students into a jeering frenzy: “Humbug! Humbug!”, an event which would eventually drive Wells to an insane and colorful doom involving acid, prostitutes, and a shaving kit.
But I’m getting ahead of myself.
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Back to our story…
February 15, 1845: Dr. Wells advertises his home for rent. His dental practice becomes more sporadic and his health begins to suffer. He eventually sells his practice to the student of the extracted tooth.
September 30, 1846: Dr. William T. G. Morton performs a painless tooth extraction on a client, behind closed doors. This gets favorably written up as an interest piece in the local paper. Dr. Henry Jacob Bigelow notes the story, and invites Dr. Morton to the MGH theatre for a demonstration with the great Dr. Warren.
Just a day that ends in “Y” at the great Massachusetts General Hospital. Dr. Morton is just hoping it wouldn’t be another walk down the gauntlet for the field of dentistry.
October 16, 1846: Dr. William T.G. Morton provides inhalational anesthesia while Dr. John Collins Warren operates on a Mr. Edward Abbott to remove a neck tumor. The operation goes smoothly. Dr. Morton is coy about the substance used, calling it Letheon. But Dr. Warren wasn’t fooled; he later noted in his diary, he notes: Did an interesting operation at the Hospital this morning while the Patient was under the influence of Dr. Morton’s preparation to prevent pain—The substance employed was Sulphuric Ether.
Newspaper accounts make no mention of the apocryphal quote, and everyone who knew anything of Dr. Warren’s character says that it would be unusual for this cautious intellectual to make such a sweeping pronouncement after only one experience.
November 12, 1846: Dr. Morton applies for—and obtains—a patent for a substance he called Letheon, a substance which renders surgical procedures painless.
November 21, 1846: Oliver Wendell Holmes himself writes a letter to Dr. Morton, declaring Morton a Public Benefactor.
December 7, 1846: Dr. Wells writes to the Hartford Courant to cry foul, saying that he did it first, telling the tale of January 20, 1845. In this letter, he says: “several expressed their opinion that it was a humbug affair.”
He is trying to make the public case that he thought of it first, shuddering with increasing rage and resentment, staring at the spot on his wall that did NOT have a framed letter from Oliver Wendell Holmes on it.
1847: Dr. Wells transforms himself into an art dealer. He travels to Paris ostensibly to buy art, and he petitions the Academie Royale de Medicine and the Parisian Medical Society for recognition in the discovery of anesthesia. He is unsuccessful.
January 1848: Dr. Wells leaves his wife and family for New York, addicted to chloroform and ether. In a snowy fog of inhalational stupor on his 33rd birthday, he throws sulfuric acid onto a couple of prostitutes, gets prosecuted for the crime, and bounces into the horrors of Manhattan’s notorious Tombs prison. On January 24, 1848, Dr. Wells slits open his femoral artery with a shaving kit blade, and leaves this life behind.
For the procedure, he supplies his own anesthesia, using chloroform.
1856: Dr. John Collins Warren dies, making it hard to fact-check a certain quote.
1859: W.T.G. Morton commissions Nathan P. Rice to ghost-write Trials of a Public Benefactor, as Illustrated in the Discovery of Etherization.
Nathan Rice would later make angry personal notes about having his name listed as the author, and about unauthorized changes to his manuscript.
It is in this adulterated biography that the heralded quotation attributed to Dr. Warren is seen for the first time.
“Gentlemen: This is no humbug!”
1849-1860s: Morton unsuccessfully applies four times to Congress for what he called a “National Recompense” in the amount of $100,000. When these efforts fail, he tries to sue the government for compensation. In the end, he gets nothing.
1862: Dr. Morton is roundly condemned by the Medical community for conspicuous greed in maintaining his ongoing narrative of ownership and patent-rights over use of Ether. In medical circles, he becomes a pariah.
1868: Whilst riding in a carriage in Central Park, New York City, Morton suffers a stroke, one which apparently alters his temperature perception apparatus. He clambors out of the cab “to cool off” and goes to soak himself in a Lake.
He dies soon after.
And so it goes.
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This story spoke to me for complicated reasons.
It’s a story of greed and jealousy, of pain and relief, of reputations and rivalry.
It’s a story of how a drive to be first or best can ironically drive catastrophic consequences. It’s a story of how innovation can create a chasm of communication. It’s a story of what happens when the Narrative of Personal Validation conflicts with those of Public Good and Medical Inertia.
It’s also a very personal story of tension that still exists between two similar—but distinct—professions: medicine and dentistry. In the anecdote above, the physicians are the establishment, and it’s the dentists coming up with something new, seemingly at grave personal risk. In this strange place, failure is met by banishment and madness. It doesn’t get any more Grimm’s Fairy Tale than that.
This story stuck to my ribs, because today, a similar story is currently unfolding in Sleep Medicine.
Some of the most exciting work these days on Sleep Apnea is being done by dentists, though it is difficult to get the established medical community to pay attention.
Some really exciting game-changing techniques are out there, but it’s still early in the game. Many emerging strategies are based on shifting understanding in the way the bones of our faces come to be shaped and placed the way that they are.
There is a mounting scientific narrative to support the notion that some of the “moving parts” of adult Sleep Apnea—specifically the bones making up the boundaries of the upper airway—the so-called “craniofacial respiratory complex”—that this is caused by an underdevelopment of the bones of the maxilla and the mandible. It’s not genetic, it’s something after that. It’s epigenetic. This narrative sees some Sleep Apnea as a failure to reach the full genetic potential that’s written into our DNA because of environmental influences, like a soft diet, absent breast feeding, and a tendency to use the open-mouth breathing posture from a young age.
Dentists and orthodontists are natural engineers, and some groups continue to report a consistent clincal signal that expansive orthodontia is a promising future for patients for whom limitations of the craniofacial respiratory complex are an important “moving part” for Sleep Apnea.
One of these innovations, pioneered by the late great Dr. Ted Belfor (whom James Nestor describes in his best-seller Breath: The New Science of a Lost Art) makes use of a retainer-like device that can nonsurgically change the positioning of the bones of the upper airway, enlarging the oral vault and midface dimensionally, making the tongue’s living space larger, and allowing an easier time breathing through the nose. The best adjunctive methods to optimize the technique are still being explored, but can include airway resistance breathing training, tongue mobilization surgery (for those with tongue-tie), breathing rehabilitation exercises, and myofunctional therapy.
Here’s the thing, Life-Fans: There are anecdotal reports of complete reversal of Sleep Apnea over the course of 18-24 months as a result of using these techniques. The providers who are doing it are sure they are on to something.
The pioneers in this field are developing a new type of healthcare identity, something distinct from pulling, filling, and straightening teeth. Some call it Airway-Centered Dentistry. It’s cutting-edge new, and really, really cool.
As of yet, though, very little has been published. Most of this is still happening by doing what dentists and orthodontists do, with an engineering mindset, outside the hallowed halls of Academic Medicine. Some of these techniques have been evaluated in isolation, and some haven’t, and data for these isolated techniques hasn’t shown much.
The perfect combination is yet to be defined.
But, given the complexity, it’s likely that combination therapy is what’s needed!
Today, these techniques are not supported by that angel-choir of scientific studies, the Randomized Controlled Trial. Getting past the anecdotal stage is going to require coordination, patience, time, and a healthy dose of humility. It’s going to require physicians overcoming an overwhelming desire to chant “Humbug!” It’s going to require dentists to collectively craft a research agenda, so their work can be validated.
In short, it’s going to require teamwork, and just a small bit of…dare I say it?
Love.
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Here’s my point, when it comes to science, Life Fans.
At this stage of the game, absence of peer-reviewed data is not the same thing as absence of signal. Sometimes the things that matter most in the process of scientific discovery are, in fact, human emotions and human frailty.
Dr. Wells went to his grave a raving madman, on account of this.
As for me, I’m no John Collins Warren, but I’m watching the development of Airway Centered Dentistry with keen interest.
Personally, I think it’s no humbug.
(Cue music)
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16:23 Majestic Theme Song / Welcome to the Show
Ellen: Welcome back to Empowered Sleep Apnea…
Dave: …the show where we talk about the complexity of Sleep Apnea…
Ellen: …through the power of stories…
Dave: …with a patient-centered perspective!
Ellen: I’m Dr. Ellen Stothard, and I’m here with Dr. Dave McCarty…
Dave: …Hello! It’s so good to be back in the Empowered Sleep Apnea bunker of knowledge…
06:55 Why This Story?
Ellen: …well, this is a really, really interesting story to me, and I wanted to ask you a couple of questions about it, because, actually…it’s something I’ve never heard!
It’s not a story that they tell you, on your first, second, third, or fifth year of grad school! Can you tell me why this story spoke to you? You said it had a pretty complicated appeal...
Dave: Yeah, this story is legendary. I did my medical training…Internal Medicine…at Mass General Hospital…and the old operating theater is now sort of a conference hall…they don’t do operations in there anymore…but it’s kind of what you might expect from an old movie…it’s kind of a circular theater with stepped places for people to sit and observe, and down there on the stage, you could do things, in front of people.
And that operating theater is now in a building that they call “The Ether Dome” because of this event…the discovery of Ether anesthesia, for the prevention of pain…you can have surgery without going through excruciating agony…this is a turning point in history!
And that quote from Dr. Warren…”Gentlemen: This is no humbug!”…is sort of part of the legend of what they teach us about what happened in this room…that this was a big moment!
So, the idea that that utterance was never actually probably said…and the reason for why we THINK it was…was all this…it had to do with egos, and the desire for recognition, and pushback that came between professions that are related but distinct…all of this just felt very very familiar, right now, because of a seeming divide between medicine and dentistry in this regard.
Ellen: So this is a narrative that you’ve heard through your training…kind of…
Dave: Yeah, it’s one of the legends of Mass General. When you walk through and you do the tour, they say Well, this is the ETHER DOME…this is where Dr. Warren said “Gentlemen: This is no humbug!”
GHOST OF DR. WARREN: Gentlemen! This is no humbug!
Dave: So we kind of learn that as part of being the culture of being at MGH, and then you chalk it up to one of those interesting historical footnotes. But, then you realize that there’s a drama there!
Ellen: Yeah! And it’s a drama that’s not unique just to that time and place, right?
Dave: It doesn’t feel unique, no.
Ellen: You’ve seen it happen more and more throughout your time…
19:14 The Pain of Emerging Science
Dave: Well, it calls to mind…How does science develop? How does clinical science develop? How do we make discoveries?
These were two guys…Dr. Morton and Dr. Wells…who kind of stumbled across the same idea at the same time, which is that—hey! They can pull out teeth without pain by using these techniques!
Field engineered solution! Right? Now there’s a desire to be The One Who Did It…
…recognized for what one has done…
…and this desire for recognition can take pretty nasty turns. This is just a lesson in human frailty as much as anything else. How are we to accept this new science, if all the time there’s this pushback, and this desire for profiteering?
Humanity is messy business! You know?
Ellen: Yeah! Absolutely! It’s so wild to me because it’s also…imagine being in that room with them! Did they know what they were seeing, at that time?
Dave: They probably didn’t!
Ellen: How do you—thinking of yourself as someone in that room—recognize what they’re about to contribute, there? And how do you make the decision whether it’s a humbug, or whether it’s something you should pay attention to?
Dave: Yeah! “It’s not in my rule book, so I’m not going to accept this!”
Am I going to chant HUMBUG for this?
Ghosts of Humbuggers Past: Humbug! Humbug! Humbug!
Dave: You know? What is the scientific exploratory process actually about?
And if we recognize that we are in a new environment, where there is new information coming in that we need to incorporate into our whole data structure…that requires a different frame of mind…one that’s a little less likely to just sort of…object because it doesn’t fit with a neat rule book…it allows for a more receptive mindset.
Ellen: Yeah! And I was thinking about this from my perspective as a researcher. You would think that research would be much more open…our job—every day—is to find new ideas, and to validate them.
I feel like, unfortunately, a lot of the “research” narrative…there’s like these blinders on…that you don’t necessarily know when to turn left or right…unless you have enough data to PROVE that you need to turn.
And in this situation, they didn’t have randomized controlled trials!
Dave: Yeah!
Ellen: So, they couldn’t say “Ok, let’s try this on a number of people and then statistically, we will know the answer!
Dave: The history of medicine teetered on a case demonstration!
Ellen: On someone who had all these…contraindications!
Dave: Yes! Yes!
Ellen: …that they didn’t even know about!
Dave: Yes! We’ve seen science emerge before, and it’s usually not pretty!
Ellen: No, definitely not!
But it does behoove us to be open. Right? To consider things…like in these examples…would you have wanted to be the person chanting “Humbug!”…
Ghosts of Humbuggers Past: Humbug! Humbug! Humbug!
Ellen: …and protecting your reputation?
Because I think of our story with…Robert…and how he had been “burned” before…and how that impacted you as a clinician…that you’re more likely to be like “No, I need to protect my patient!”…you know “I can’t let these other things get to them.”
Dave: Mmm Hm.
Ellen: But that…at what cost?
Dave: This is the effect of practicing medicine “in the trenches” with your patients…and you see someone who’s been burned by maybe some profiteer with a “one-size fits all” solution…and the patient comes back battered and bashed up…and you think: “Well, you shouldn’t be doing that because you’ve got no data!”
And all of a sudden you’re starting to throw these “academic rocks,” using the Randomized Controlled Trial as this shield for your patient.
But then: we have to step back for a moment and recognize that a Field-Engineered Solution is not necessarily bad…it’s how it’s rolled out, it’s how we investigate it, it’s how we talk about it with transparency that’s important at this stage of the game.
22:48 On Anecdotes and Data
Ellen: Yeah, I was thinking about a couple of different phrases that I know and that I’ve heard…”The plural of anecdote is not data.”
Have you ever heard that one?
Dave: (laughs) Yeah!
Ellen: It’s something that’s so widespread in our consciousness, as scientists, that we have a key phrase for it!
Dave: Yeah.
Ellen: But it doesn’t mean that we can’t pay attention to the trends. Because we need to get our ideas from somewhere.
Dave: “The plural of anecdote is not data.” Let’s break that apart, shall we?
What that means is: lots of little stories added up can still just be lots of little stories that are misleading. There are ways to set up a scientific observational trial that helps to limit the amount that you might be fooled by chance.
Ellen: Yep.
Dave: That’s what science is.
Ellen: Exactly!
“The amount that you might be fooled by chance.” Because that’s the key there. How can we eliminate the risk that this is just a fluke?
And…we know now…you know, history has shown that this is not a fluke. So how can we learn from these experiences that we had before, so we don’t miss the next one?
How can we move from anecdotes…to…data?
One of the ways that we can do that is when people don’t have any other option…so we have to use things like compassionate use…to explore these other things that might be out there.
And then you start putting these cases together…and you see a signal.
Dave: Yes, yes.
Ellen: So it’s not that you need to go from “I have an idea” to a Randomized Controlled Trial. It’s that you are actually being responsible…and being a good scientist…and a good medical professional…and trying to do the least amount of harm…
Dave: You know, the thing that really moved my heart in all of this was seeing what this process of scientific emergence did to the human beings that were part of it.
Poor Dr. Wells! He knew he was there first! It was his idea. But he just got it slightly wrong. His chance at fame was just brushed aside.
And it drove him insane.
That, to me, was a devastating example of how humanity interacts with the emergence of science.
25:21 For Truth or Money?
Ellen: Yeah! It’s really interesting that you say that, because one of the other phrases that we talk about in scientific research—as a scientist—is that you don’t get into it for the money. You don’t get into it for the glory…
…because so much of the job is keeping your head down, and pipetting over and over and over…and failed experiments…and all these sort of “non-glamorous” things…until hopefully you get to a place where you can make a change.
And, actually…that’s something that resonates with me, very strongly, because one of the reasons that I think I left academia was because we had this amazing project that we did—that was so cool and so fun—
…The Camping Study, that we’ve talked about before…
…and…it got such attention in the world! You know? It made such a splash!
Dave: It’s hard to go back from that.
Ellen: It’s hard to go back…
Dave: …you want everything to matter that much!
Ellen: …but you also want everyone ELSE’s science to matter that much!
Dave: Yes!
Ellen: Why did ours make the hit that it did? It did help many, many people…but…it didn’t cure cancer!
Dave: No…but it sure helped me explain why going camping feels so darn good!
Ellen: Yeah.
Dave: You know? It helps us realign our circadian rhythm, and our ability to sleep is enhanced…it’s kind of nice to know that the data bore that out!
Ellen: Absolutely! It was so fun and so amazing to talk about it…and I do believe it helped and changed a lot of people—including my own life! But it’s…not every scientist gets that…you know…experience.
And…in this story…it led to the ultimate destruction of two very great and intelligent individuals.
Dave: Mmm Hm.
27:08 Complexity and Collaboration and Music
Dave: You know what this brings me back around to is the central theme of the second season of this PODCAST, which is the idea of collaboration…
…and the idea that…you know…obviously it takes more than one person to figure out a complex situation.
Obviously.
And looking back on this tragic—I guess you can call it a tragicomedy, in a way, the way it played out…but, looking back at it…they clearly would have helped each other to just listen and learn…rather than be accusatory and defensive and grabby for their needs, you know?
So, it’s in that spirit of collaboration that this is the first episode where I’ve actually incorporated someone else’s music into the episode.
So I wanna do a big shout out—I’ll do it again in the credits—but, Mr. Billy Barnett…musical savant from St. Louis, whom I met through the PULMONAUTS project. He was our musical advisor and actually played on stage with us…
…just a brilliant guy, and a wonderful human…and I love that we can kind of combine our artistic forces into something unique!
So: shout out to Billy in the spirit of collaboration!
Ellen: Yeah! And the collaboration between medical and dental…you have both brought it all the way around to create something bigger than yourselves.
Dave: Yeah! What if, back in the Ether Dome days, they had a rock band?!
Ellen: Man! They probably would’ve communicated a little bit better!
Dave: They would’ve communicated a lot better…and they probably would not have gone to that colorful doom!
Ellen: Oh, yeah!
Announcer: Ladies and gentlemen…The Billy Barnett Band!
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Music swells: “User Friendly” by Billy Barnett’s band STREETCORNER
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28:59 Majestic Theme Song and Ending Credits
Dave: This is Dr. Dave McCarty speaking…
Empowered Sleep Apnea is a production of Empowered Sleep Apnea, LLC.
The preamble of today’s episode, The Price of Humbug, was adapted from an essay originally appearing in my blog, Dave’s Notes, original ePublication date 6/22/22.
The show was otherwise written and performed by me, and the magnificent Ellen Stothard, PhD.
In lieu of a cartoon for today’s episode, our show featured the work of the multi-talented St. Louis musical treasure, Mr. Billy Barnett. I got to know Billy through our PULMONAUTS music project…so I’m so proud to feature his musical creations today because Billy’s not just a marvel of a musician, he’s just one of those remarkable humans that you wish there were more of, in this world.
Songs featured on today’s program were the instrumentals Late Night FM and User Friendly, from Billy’s first band Streetcorner. Links to his stuff will be in the Show Notes, and you can find his stuff on the interwebs at www.billybarnett.com.
I’m going to give you just one more taste of this incredible musician and performer and his friends, here they are, the Billy Barnett Project, with Late Night FM…stick around…after this brief bite of musical delight…we’ve got your Sleep Medicine Dad joke…
…and thanks, as always, for being with us!
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Music swells: “Late Night FM” by The Billy Barnett Project.
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And now…your sleep medicine Dad Joke…
31:02. Sleep Medicine Dad Joke
Dad: Aye laddie rough seas!
Not-Dad: Aye. Rough seas, Daddy-O, Rough seas!
Dad: Say, laddie…
Not-Dad: Yah, Daddie-O
Dad: You know there’s a king mattress and a queen mattress…
Not-Dad: Yah, Daddie O, sure
Dad: Well, where d’ya suppose the prince sleeps?
Not-Dad: Erm…I’m not sure, Daddy-O? In a crib?
Dad: Naghhh ya grandacious lerb! In the HEIR MATTRESS
Not-Dad: Whaaaa?
Dad: Ya get it? As in: the HEIR to all me trappings! Ha HA!
Not-Dad: Ha! That’s hilarious. Ha ha ha ha! The HEIR mattress!
Dad: Keep a lookout, laddie, rough seas!
Not-Dad: right, rough seas!
31:50 End Program
