One
THE WORST BREATHERS IN THE ANIMAL KINGDOM
The patient arrived, pale and torpid, at 9:32 a.m. Male, middle-aged, 175 pounds. Talkative and friendly but visibly anxious. Pain: none. Fatigue: a little. Level of anxiety: moderate. Fears about progression and future symptoms: high.
Patient reported that he was raised in a modern suburban environment, bottle-fed at six months, and weaned onto jarred commercial foods. The lack of chewing associated with this soft diet stunted bone development in his dental arches and sinus cavity, leading to chronic nasal congestion.
By age 15, patient was subsisting on even softer, highly processed foods consisting mostly of white bread, sweetened fruit juices, canned vegetables, Steak-umms, Velveeta sandwiches, microwave taquitos, Hostess Sno Balls, and Reggie! bars. His mouth had become so underdeveloped it could not accommodate 32 permanent teeth; incisors and canines grew in crooked, requiring extractions, braces, retainers, and headgear to straighten. Three years of orthodontics made his small mouth even smaller, so his tongue no longer properly fit between his teeth. When he stuck it out, which he did often, visible imprints laced its sides, a precursor to snoring.
At 17, four impacted wisdom teeth were removed, which further decreased the size of his mouth while increasing his chances of developing the chronic nocturnal choking known as sleep apnea. As he aged into his 20s and 30s, his breathing became more labored and dysfunctional and his airways became more obstructed. His face would continue a vertical growth pattern that led to sagging eyes, doughy cheeks, a sloping forehead, and a protruding nose.
This atrophied, underdeveloped mouth, throat, and skull, unfortunately, belongs to me.
I’m lying on the examination chair in the Stanford Department of Otolaryngology Head and Neck Surgery Center looking at myself, looking into myself. For the past several minutes, Dr. Jayakar Nayak, a nasal and sinus surgeon, has been gingerly coaxing an endoscope camera through my nose. He’s gone so deep into my head that it’s come out the other side, into my throat.
“Say eeee,” he says. Nayak has a halo of black hair, square glasses, cushioned running shoes, and a white coat. But I’m not looking at his clothes, or his face. I’m wearing a pair of video goggles that are streaming a live feed of the journey through the rolling dunes, swampy marshes, and stalactites inside my severely damaged sinuses. I’m trying not to cough or choke or gag as that endoscope squirms a little farther down.
“Say eeee,” Nayak repeats. I say it and watch as the soft tissue around my larynx, pink and fleshy and coated in slime, opens and closes like a stop-motion Georgia O’Keeffe flower.
This isn’t a pleasure cruise. Twenty-five sextillion molecules (that’s 250 with 20 zeros after it) take this same voyage 18 times a minute, 25,000 times a day. I’ve come here to see, feel, and learn where all this air is supposed to enter our bodies. And I’ve come to say goodbye to my nose for the next ten days.
For the past century, the prevailing belief in Western medicine was that the nose was more or less an ancillary organ. We should breathe out of it if we can, the thinking went, but if not, no problem. That’s what the mouth is for.
Many doctors, researchers, and scientists still support this position. There are 27 departments at the National Institutes of Health devoted to lungs, eyes, skin disease, ears, and so on. The nose and sinuses aren’t represented in any of them.
Nayak finds this absurd. He is the chief of rhinology research at Stanford. He heads an internationally renowned laboratory focused entirely on understanding the hidden power of the nose. He’s found that those dunes, stalactites, and marshes inside the human head orchestrate a multitude of functions for the body. Vital functions. “Those structures are in there for a reason!” he told me earlier. Nayak has a special reverence for the nose, which he believes is greatly misunderstood and underappreciated. Which is why he’s so interested to see what happens to a body that functions without one. Which is what brought me here.
Starting today, I’ll spend the next quarter of a million breaths with silicone plugs blocking my nostrils and surgical tape over the plugs to stop even the faintest amount of air from entering or exiting my nose. I’ll breathe only through my mouth, a heinous experiment that will be exhausting and miserable, but has a clear point.
Forty percent of today’s population suffers from chronic nasal obstruction, and around half of us are habitual mouthbreathers, with females and children suffering the most. The causes are many: dry air to stress, inflammation to allergies, pollution to pharmaceuticals. But much of the blame, I’ll soon learn, can be placed on the ever-shrinking real estate in the front of the human skull.
When mouths don’t grow wide enough, the roof of the mouth tends to rise up instead of out, forming what’s called a V-shape or high-arched palate. The upward growth impedes the development of the nasal cavity, shrinking it and disrupting the delicate structures in the nose. The reduced nasal space leads to obstruction and inhibits airflow. Overall, humans have the sad distinction of being the most plugged-up species on Earth.
I should know. Before probing my nasal cavities, Nayak took an X-ray of my head, which provided a deli-slicer view of every nook and cranny in my mouth, sinuses, and upper airways.
“You’ve got some . . . stuff,” he said. Not only did I have a V-shape palate, I also had “severe” obstruction to the left nostril caused by a “severely” deviated septum. My sinuses were also riddled with a profusion of deformities called concha bullosa. “Super uncommon,” said Nayak. It was a phrase nobody wants to hear from a doctor.
My airways were such a mess that Nayak was amazed I hadn’t suffered from even more of the infections and respiration problems I’d known as a kid. But he was reasonably certain I could expect some degree of serious breathing problems in the future.
Over the next ten days of forced mouthbreathing, I’ll be putting myself inside a kind of mucousy crystal ball, amplifying and hastening the deleterious effects on my breathing and my health, which will keep getting worse as I get older. I’ll be lulling my body into a state it already knows, that half the population knows, only multiplying it many times.
“OK, hold steady,” Nayak says. He grabs a steel needle with a wire brush at the end, about the size of a mascara brush. I’m thinking, He’s not going to put that thing up my nose. A few seconds later, he puts that thing up my nose.
I watch through the video goggles as Nayak maneuvers the brush deeper. He keeps sliding until it is no longer up my nose, no longer playing around my nasal hair, but wiggling inside of my head a few inches deep. “Steady, steady,” he says.
When the nasal cavity gets congested, airflow decreases and bacteria flourish. These bacteria replicate and can lead to infections and colds and more congestion. Congestion begets congestion, which gives us no other option but to habitually breathe from the mouth. Nobody knows how soon this damage occurs. Nobody knows how quickly bacteria accumulate in an obstructed nasal cavity. Nayak needs to grab a culture of my deep nasal tissue to find out.
I wince as I watch him twist the brush deeper still, then spin it, skimming off a layer of gunk. The nerves this far up the nose are designed to feel the subtle flow of air and slight modulations in air temperature, not steel brushes. Even though he’s dabbed an anesthetic in there, I can still feel it. My brain has a hard time knowing exactly what to do, how to react. It’s difficult to explain, but it feels like someone is needling a conjoined twin that exists somewhere outside of my own head.
“The things you never thought you’d be doing with your life,” Nayak laughs, putting the bleeding tip of the brush into a test tube. He’ll compare the 200,000 cells from my sinuses with another sample ten days from now to see how nasal obstruction affects bacterial growth. He shakes the test tube, hands it to his assistant, and politely asks me to take the video goggles off and make room for his next patient.
Patient #2 is leaning against the window and snapping photos with his phone. He’s 49 years old, deeply tanned with white hair and Smurf-blue eyes, and he’s wearing spotless beige jeans and leather loafers without socks. His name is Anders Olsson, and he’s flown 5,000 miles from Stockholm, Sweden. Along with me, he’s ponied up more than $5,000 to join the experiment.
I’d interviewed Olsson several months ago after coming across his website. It had all the red flags of flakiness: stock images of blond women striking hero poses on mountaintops, neon colors, frantic use of exclamation points, and bubble fonts. But Olsson wasn’t some fringe character. He’d spent ten years collecting and conducting serious scientific research. He’d written dozens of posts and self-published a book explaining breathing from the subatomic level on up, all annotated with hundreds of studies. He’d also become one of Scandinavia’s most respected and popular breathing therapists, helping to heal thousands of patients through the subtle power of healthy breathing.
When I mentioned during one of our Skype conversations that I would be mouthbreathing for ten days during an experiment, he cringed. When I asked if he wanted to join in, he refused. “I do not want to,” he declared. “But I am curious.”
Now, months later, Olsson plops his jet-lagged body onto the examination chair, puts on the video glasses, and inhales one of his last nasal breaths for the next 240 hours. Beside him, Nayak twirls the steel endoscope the way a heavy metal drummer handles a drumstick. “OK, lean your head back,” says Nayak. A twist of the wrist, a crane of the neck, and he goes deep.
The experiment is set up in two phases. Phase I consists of plugging our noses and attempting to live our everyday lives. We’ll eat, exercise, and sleep as usual, only we’ll do it while breathing only through our mouths. In Phase II, we’ll eat, drink, exercise, and sleep like we did during Phase I, but we’ll switch the pathway and breathe through our noses and practice a number of breathing techniques throughout the day.
Between phases we’ll return to Stanford and repeat all the tests we’ve just taken: blood gases, inflammatory markers, hormone levels, smell, rhinometry, pulmonary function, and more. Nayak will compare data sets and see what, if anything, changed in our brains and bodies as we shifted our style of breathing.
I’d gotten a fair share of gasps from friends when I told them about the experiment. “Don’t do it!” a few yoga devotees warned. But most people just shrugged. “I haven’t breathed out of my nose in a decade,” said a friend who had suffered allergies most of his life. Everyone else said the equivalent of: What’s the big deal? Breathing is breathing.
Is it? Olsson and I will spend the next 20 days finding out.
A while back, some 4 billion years ago, our earliest ancestors appeared on some rocks. We were small then, a microscopic ball of sludge. And we were hungry. We needed energy to live and proliferate. So we found a way to eat air.
The atmosphere was mostly carbon dioxide then, not the best fuel, but it worked well enough. These early versions of us learned to take this gas in, break it down, and spit out what was left: oxygen. For the next billion years, the primordial goo kept doing this, eating more gas, making more sludge, and excreting more oxygen.
Then, around two and a half billion years ago, there was enough oxygen waste in the atmosphere that a scavenger ancestor emerged to make use of it. It learned to gulp in all that leftover oxygen and excrete carbon dioxide: the first cycle of aerobic life.
Oxygen, it turned out, produced 16 times more energy than carbon dioxide. Aerobic life forms used this boost to evolve, to leave the sludge-covered rocks behind and grow larger and more complex. They crawled up to land, dove deep into the sea, and flew into the air. They became plants, trees, birds, bees, and the earliest mammals.
Mammals grew noses to warm and purify the air, throats to guide air into lungs, and a network of sacs that would remove oxygen from the atmosphere and transfer it into the blood. The aerobic cells that once clung to swampy rocks so many eons ago now made up the tissues in mammalian bodies. These cells took oxygen from our blood and returned carbon dioxide, which traveled back through the veins, through the lungs, and into the atmosphere: the process of breathing.
The ability to breathe so efficiently in a wide variety of ways—consciously and unconsciously; fast, slow, and not at all—allowed our mammal ancestors to catch prey, escape predators, and adapt to different environments.
It was all going so well until about 1.5 million years ago, when the pathways through which we took in and exhaled air began to shift and fissure. It was a shift that, much later in history, would affect the breathing of every person on Earth.
I’d been feeling these cracks for much of my life, and chances are you have, too: stuffy noses, snoring, some degree of wheezing, asthma, allergies, and the rest. I’d always thought they were a normal part of being human. Nearly everyone I knew suffered from one problem or another.
But I came to learn that these problems didn’t randomly develop. Something caused them. And the answers could be found in a common and homely human trait.
A few months before the Stanford experiment, I flew to Philadelphia to visit Dr. Marianna Evans, an orthodontist and dental researcher who’d spent the last several years looking into the mouths of human skulls, both ancient and modern. We were standing in the basement of the University of Pennsylvania Museum of Archaeology and Anthropology, surrounded by several hundred specimens. Each was engraved with letters and numbers and stamped with its “race”: Bedouin, Copt, Arab of Egypt, Negro Born in Africa. There were Brazilian prostitutes, Arab slaves, and Persian prisoners. The most famous specimen, I was told, came from an Irish prisoner who’d been hanged in 1824 for killing and eating fellow convicts.
The skulls ranged from 200 to thousands of years old. They were part of the Morton Collection, named after a racist scientist named Samuel Morton, who, starting in the 1830s, collected skeletons in a failed attempt to prove the superiority of the Caucasian race. The only positive outcome of Morton’s work is the skulls he spent two decades gathering, which now provide a snapshot of how people used to look and breathe.
Where Morton claimed to see inferior races and genetic “degradation,” Evans discovered something close to perfection. To demonstrate what she meant, she walked over to a cabinet and retrieved a skull marked Parsee, for Persian, from behind the protective glass. She wiped bone dust on the sleeve of her cashmere sweater and ran a neatly trimmed fingernail along its jaw and face.
“These are twice as large as they are today,” she said in a staccato Ukrainian accent. She was pointing at the nasal apertures, the two holes in the back of the throat that connect to the nasal passages. She turned the skull around so it was staring at us. “So wide and pronounced,” she said approvingly.
Evans and her colleague Dr. Kevin Boyd, a Chicago-based pediatric dentist, have spent the last four years X-raying more than 100 skulls from the Morton Collection and measuring the angles from the top of the ear to the nose and from the forehead to the chin. These measurements, which are called the Frankfort plane and N-perpendicular, show the symmetry of each specimen, how well-proportioned the mouth was relative to the face, the nose to the palate, and, to a large extent, how well the people who owned these skulls might have breathed.
Every one of the ancient skulls was identical to the Parsee sample. They all had enormous forward-facing jaws. They had expansive sinus cavities and broad mouths. And, bizarrely, even though none of the ancient people ever flossed, or brushed, or saw a dentist, they all had straight teeth.
The forward facial growth and large mouths also created wider airways. These people very likely never snored or had sleep apnea or sinusitis or many other chronic respiratory problems that affect modern populations. They did not because they could not. Their skulls were far too large, and their airways too wide for anything to block them. They breathed easy. Nearly all ancient humans shared this forward structure—not just in the Morton Collection, but everywhere around the world. This remained true from the time when Homo sapiens first appeared, some 300,000 years ago, to just a few hundred years ago.
Evans and Boyd then compared the ancient skulls to the modern skulls of their own patients and others. Every modern skull had the opposite growth pattern, meaning the angles of the Frankfort plane and N-perpendicular were reversed: chins had recessed behind foreheads, jaws were slumped back, sinuses shrunken. All the modern skulls showed some degree of crooked teeth.
Of the 5,400 different species of mammals on the planet, humans are now the only ones to routinely have misaligned jaws, overbites, underbites, and snaggled teeth, a condition formally called malocclusion.
To Evans, this raised a fundamental question: “Why would we evolve to make ourselves sick?” she asked. She put the Parsee skull back in the cabinet and took out another labeled Saccard. Its perfect facial form was a mirror image of the others. “That’s what we’re trying to find out,” she said.
Evolution doesn’t always mean progress, Evans told me. It means change. And life can change for better or worse. Today, the human body is changing in ways that have nothing to do with the “survival of the fittest.” Instead, we’re adopting and passing down traits that are detrimental to our health. This concept, called dysevolution, was made popular by Harvard biologist Daniel Lieberman, and it explains why our backs ache, feet hurt, and bones are growing more brittle. Dysevolution also helps explain why we’re breathing so poorly.
To understand how this all happened, and why, Evans told me, we need to go back in time. Way back. To before Homo sapiens were even sapiens.
What strange creatures. Standing in the tall grass of the savanna, all gangly arms and pointy elbows, gazing out into the wide, wild world from foreheads that looked like hairy visors. As the breeze swayed the grass, our nostrils, the size of gum drops, flexed vertically above our chinless mouths, picking up whatever scents the wind brought in.
The time was 1.7 million years ago, and the first human ancestor, Homo habilis, was roaming the eastern shores of Africa. We’d long since left the trees, learned to walk on our legs, and trained ourselves to use the small “finger” on the inside of our hands, to turn it upside down into an opposable thumb. We used this thumb and fingers to grab things, to pull plants and roots and grasses from the ground, and to build hunting tools from stone that were sharp enough to carve tongues out of antelope and strip meat from bone.
Eating this raw diet took a lot of time and effort. So we gathered stones and bashed prey against rocks. Tenderizing food, especially meat, spared us from some of the effort of digesting and chewing, which saved energy. We used this extra energy to grow a larger brain.
Grilling food was even better. Around 800,000 years ago, we began processing food in fire, which released an enormous amount of additional calories. Our large intestines, which helped break down rough and fibrous fruits and vegetables, would shrink considerably under this new diet, and that change alone saved even more energy. These more modern ancestors, Homo erectus, used it to grow an even bigger brain—an astounding 50 percent larger than those of our habilis ancestors.
We began to look less like apes and more like people. If you could take a Homo erectus, dress him in a Brooks Brothers suit, and put him on a subway, he probably wouldn’t draw a second glance. These ancient ancestors were genetically similar enough to possibly have our children.
The innovation of mashing and cooking food, however, had consequences. The quickly growing brain needed space to stretch out, and it took it from the front of our faces, home to sinuses, mouths, and airways. Over time, muscles at the center of the face loosened, and bones in the jaw weakened and grew thinner. The face shortened and the mouth shrank, leaving behind a bony protuberance that replaced the squashed snout of our ancestors. This new feature was ours alone and distinguished us from other primates: the protruding nose.
The problem was that this smaller, vertically positioned nose was less efficient at filtering air, and it exposed us to more airborne pathogens and bacteria. The smaller sinuses and mouth also reduced space in our throats. The more we cooked, the more soft, calorie-rich food we consumed, the larger our brains grew and the tighter our airways became.
Homo sapiens first emerged on the African savanna around 300,000 years ago. We were among a coterie of other human species: Homo heidelbergensis, a robust creature who built shelters and hunted big game in what is now Europe; Homo neanderthalensis (Neanderthals), with their massive noses and stunted limbs, who learned to make clothes and flourish in frigid environments; and Homo naledi, a throwback to early ancestors, with tiny brains, flared hips, and spindly arms that hung down from squat bodies.
What a sight it might have been, these ragtag species all gathered around a blazing campfire at night, a Star Wars cantina of early humanity, sipping river water from palm cups, picking grubs from each other’s hair, comparing the ridges of their brows, and scampering off behind boulders to have interspecies sex in the glow of starlight.
Then, no more. The big-nosed Neanderthals, the scrawny naledi, the thick-necked heidelbergensis were all killed off by disease, weather, each other, or animals, or laziness, or something else. There was only one human left in the long family tree: us.
In colder climates, our noses would grow narrower and longer to more efficiently heat up air before it entered our lungs; our skin would grow lighter to take in more sunshine for production of vitamin D. In sunny and warm environments, we adapted wider and flatter noses, which were more efficient at inhaling hot and humid air; our skin would grow darker to protect us from the sun. Along the way, the larynx would descend in the throat to accommodate another adaptation: vocal communication.
The larynx works as a valve to shuttle food into the stomach and protect us from inhaling it and other objects. Every animal, and every other Homo species, had evolved a higher larynx, located toward the top of the throat. This made sense, since a high larynx functions most efficiently, allowing the body to rid itself quickly should anything get stuck in our airways.
As humans developed speech, the larynx sank, opening up space in the back of the mouth and allowing a wider range of vocalizations and volumes. Smaller lips were easier to manipulate, and ours evolved to be thinner and less bulbous. More nimble and flexible tongues made it easier to control the nuance and structure of sounds, so the tongue slipped farther down the throat and pushed the jaw forward.
But this lowered larynx became less efficient at its original purpose. It created too much space at the back of the mouth and made early humans susceptible to choking. We could choke if we swallowed something too big, and we’d choke on smaller objects that were swallowed quickly and sloppily. Sapiens would become the only animals, and the only human species, that could easily choke on food and die.
Strangely, sadly, the same adaptations that would allow our ancestors to outwit, outmaneuver, and outlive other animals—a mastery of fire and processing food, an enormous brain, and the ability to communicate in a vast range of sounds—would obstruct our mouths and throats and make it much harder for us to breathe. This recessed growth would, much later, make us prone to choke on our own bodies when we slept: to snore.*
None of this mattered to the early humans, of course. For tens of thousands of years, our ancestors would use their wildly developed heads to breathe just fine. Armed with a nose, a voice, and a supersized brain, humans took over the world.
I’d been thinking about our hirsute forebears ever since I’d visited Evans months back. There they were, crouched along the rocky African shore, articulating the first vowels with their flexible lips, pulling in easy breaths through gaping nasal apertures, and chomping on braised rabbit with perfect teeth.
And here I am, slack-jawed under an LED light, staring at Wikipedia’s Homo floresiensis page on my phone, chewing on bits of a low-carb nutritional bar with crooked teeth, coughing and wheezing and sucking exactly no air through my obstructed nose.
It’s evening on the second day of the Stanford mouthbreathing experiment, and I’m in bed with silicone plugs jammed inside my nasal cavities, covered with tape. For the past few nights I’ve been splayed out in a part of my house usually reserved for relatives and friends. I had a feeling that my mouthbreathing lifestyle might be a challenge for my wife. Lying here, tossing and turning, thinking about cavemen and unable to sleep, I’m happy I moved.
I’ve got a pulse oximeter device about the size of a matchbook strapped to my wrist. There’s a glowing red wire extending from it and wrapping around my middle finger. Every few seconds, the device records my heart rate and blood oxygen levels, using this information to assess how often and how severely my too-deep tongue might get lodged in my too-small mouth and cause me to hold my breath, a condition more commonly known as sleep apnea.
To gauge the severity of my snoring and apnea, I’ve downloaded a phone app that records a constant stream of audio through the night, then provides a minute-to-minute graph of my breathing health every morning. A night vision security camera just above the bed monitors every movement.
Inflammation in the throat and polyps both contribute to snoring and sleep apnea. Nasal obstruction triggers this nighttime choking as well, but nobody knows how quickly the damage comes on, or how severe it might become. Before now, nobody had tested it.
Last night, in my first run of self-inflicted nasal obstructed sleeping, my snoring increased by 1,300 percent, to 75 minutes through the night. Olsson’s numbers were even worse. He went from zero to four hours, ten minutes. I’d also suffered a fourfold increase in sleep apnea events. All this, in just 24 hours.
Now, lying here again, no matter how I try to relax and submit to this experiment, it’s a challenge. Every 3.3 seconds another blast of unfiltered, unmoistened, and unheated air enters through my mouth—drying my tongue, irritating my throat, and pissing off my lungs. And I’ve got 175,000 more breaths to go.