Cautionary Tales with Tim Harford - "Captain Kirk Forgot to put the Machine on Stun"
Episode Date: July 18, 2025Lying on the cold metal table, Voyne Ray Cox knew the drill. This was his ninth round of cancer treatment - which is why he was certain that what happened next couldn't be right. He heard a sizzling s...ound and saw a blue flash. And then - agony. It was like someone had thrust a hot skewer through his shoulder. He cried out in pain, but the operator was down the corridor and she couldn't hear him. She blasted him again and again with the red-hot radiation beam. Ray wasn't the first patient to be burned by the Therac-25 therapy machine, and he wouldn't be the last. Its dual-purpose design, controlled by a software programme, was supposed to offer hospitals more bang for their buck. But as patient after patient suffered ulcerated skin and yawning lesions, it should have been clear that something was horribly wrong. Why did it take so long for anyone to put this awful puzzle together? For a full list of sources, see the show notes at timharford.com.See omnystudio.com/listener for privacy information.
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Pushkin
Nobody really wants to be deliberately bombarded with radiation, but if you have cancer, radiation
therapy might just save your life.
That must have been what a young man called Voin Ray Cox hoped as he made visit after
visit to the East Texas Cancer Center.
Just 33 years old, Ray, to his friends, was young to be a cancer survivor.
He had a tumour cut out of his shoulder, and now, March 1986, he was there for his ninth
session of radiation therapy, designed to ensure that no traces of the cancer remained. Despite his bad luck, Ray was a cheerful, resilient man.
He knew the drill.
Press his bare chest and stomach
onto the cold metal treatment table,
chat to the operator while she maneuvered him into position
underneath the looming bulk
of the Therac25 radiation therapy machine.
The operator knew the drill too. In his account of the case, the ergonomics expert Stephen
Casey calls her Marybeth, although that's not her real name. We'll do the same.
Marybeth cheerfully caught up with Ray as she used a console control to precisely position
him under the Therac-25's radiation beam gun.
Then, she walked down the corridor to the control room, which was at a safe distance.
Ordinarily the control room and the treatment room would be linked up by CCTV and microphones.
But neither the cameras nor the audio link were connected that day, and that didn't
seem to matter.
Normally they'd be useful for some reassuring chat, or to give the patient a word of instruction,
and Ray being an old hand didn't need any of that.
Marybeth typed the treatment instructions into the computer, a series of letters.
She pressed X to choose the mode.
Then straight away realised her mistake.
Ray needed the other mode.
She deleted the X and pressed E.
She checked the instructions.
They were all correct.
Beam ready, the computer told her.
She pressed B to administer the treatment.
Down the hall on the treatment table,
Ray Cox heard a sizzling sound and saw a blue flash.
And then...
Agony. flash. And then… agony. It was like someone had thrust a hot skewer through his shoulder.
This wasn't right. He knew it couldn't be right. The last eight treatments had been
nothing like this.
Back in the control room, Marybeth couldn't hear Ray's cry of pain, and she couldn't see his body contorting on
the treatment table. All she saw was a bland little notification.
Malfunction 54.
It wasn't clear what that meant. The machine would often pause and produce an unexplained error code. Sometimes 30, 40, 50 times a day. As one operator later commented,
I can't remember all the reasons it would stop, but there were a lot of them.
The machine indicated that Ray had received only a tiny fraction of the intended dose.
And Marybeth had been assured that the THERAC25 had so many safeguards it was almost impossible
to overdose a patient.
It only took a single key press for her to reset the machine and try again.
I'm Tim Harford, and you're listening to Cautionary Tales. Marybeth was an experienced operator of the Therac 25. She must have seen it crash and
pop up an error message ten thousand times or more. Although she didn't know what those
error messages meant. How could she? The machine's manual didn't explain them. It didn't even
mention them.
And because she'd been in that position so many times, it took her mere seconds to
reset the machine for another try at giving Ray his treatment.
That wasn't enough time for Ray to get off the table. He'd rolled onto his side, but Mary Beth,
of course, couldn't see that. And she couldn't hear his agonised yelling.
The machine fired again. Another flash of blue light. Another sizzle. And this time,
a hot skewer went through Ray's neck. He was in too much pain even to scream.
Then the agony started to fade.
He gulped in some air and blew it out again,
tried to calm himself.
Hey, are you pushing the wrong button?
But Marybeth couldn't hear him.
couldn't hear him. Something had gone wrong with the Therac 25.
But what?
Loyal listeners to cautionary tales will be familiar with the Swiss cheese model of accidents,
made famous by the psychologist James Reason.
Imagine slices of Swiss cheese, with those distinctive holes in them. Each slice represents
some kind of safeguard against an accident. Maybe it's a failsafe in the hardware of
a system, so it simply won't work if the right pieces aren't in position.
Maybe it's a subroutine in the software, monitoring
what the system's doing and shutting it down if another part of the software
happens to glitch. But no safeguard is perfect. Every slice of cheese has holes
in it. In James Reason's model an accident becomes possible when all the
holes line up. That means that
every safeguard in the system becomes simultaneously vulnerable to the same kind of problem. To
prevent accidents then, get extra lines of defence and try to strengthen the defences
you already have. To put it another way, get more slices of cheese with fewer holes in them.
So did the THERAC25 need better hardware or software to prevent the accident that happened
to Ray Cox?
As it turns out, yes.
But that's also the wrong question.
We should be looking at a different kind of cheese slice altogether.
Nine months before Ray Cox's excruciating experience, in July 1985, 40-year-old Frances
Hill arrived at the Ontario Cancer Foundation Clinic for her 24th round of radiation treatment for cervical cancer.
The clinic was using a THERAC-25 machine, but there was a problem. The machine didn't
seem to be working. Every time the operator tried to fire the radiation beam, the machine
paused, produced an error message and reported that no dose had been given.
The operator hit the P key to proceed, and the same thing happened.
The operator hit P again, and it happened again.
We've all been there, clicking an icon on a screen, finding that nothing seems to happen,
and then clicking it again. After four attempts, the operator called a technician, who couldn't find anything wrong
with the Therac-25.
Francis Hill left, and the machine was used successfully on half a dozen other patients
that afternoon.
That sort of thing wasn't particularly strange, the operator reflected.
The Therac-25 would often seem to glitch like that, producing mysterious error messages
and then, suddenly, working again for no particular reason.
But while glitches didn't seem strange to the operator, something seemed strange to
Frances. She could feel
a kind of burning, tingling, electric shock kind of sensation in her hip, near where the
therapeutic beam had been aimed. When she came back for another round of treatment three
days later, her doctors immediately diagnosed a radiation burn in her hip, which was painfully swollen.
They called the machine's manufacturers to report a suspected radiation overdose.
The manufacturers were Atomic Energy of Canada Limited, AECL.
A radiation overdose?
AECL had never heard of anything like that before. Strange. They
sent an engineer along to investigate.
The Therac-25 could be used in two different modes. The electron mode attacked cancer near
the surface of the patient's body.
The machine emitted a beam of electrons, spread out by an array of magnets.
The X-ray mode attacked cancer deep inside a patient's body.
The magnet array would be moved aside and replaced by a device called a flattener, which
focused the X-ray beam precisely on the cancer.
The flattener absorbed a lot of energy, which meant the X-ray beam had to be very powerful.
The components which diffused the electron beams or focused the X-rays on the Therac-25
were positioned on a turntable. As the machine was programmed to fire either electrons or X-rays at the patient's tumour,
the turntable would rotate automatically to fix the right component into position.
At least, that was the idea.
Two types of radiation beam then, one that needs diffusing, one that needs focusing. If this sounds like an accident waiting
to happen, well, it was. But machines like the Therac-25 are expensive, and this dual-purpose
design meant that hospitals got more bang for the buck. As long as the right component was in place for the right beam, there would be no problem.
The Therac-25 was fully controlled by a computer. Unremarkable these days, but radical for the mid-1980s. Its predecessors, the Therac-6 and Therac-20,
allowed a human operator to physically position the magnets or the flattener.
On the Therac 25, this manual positioning was replaced by servo motors, computer controlled
to quickly and precisely put everything in position.
When AECL investigated the incident with Francis Hill, they weren't actually able to reproduce
the error. But they suspected that the turntable system hadn't worked properly.
The turntable had three tiny switches designed to measure when it was in position, but it
emerged that a single bit of error – the computer glitching and mistaking a zero for a one could produce a faulty reading of the turntable's position.
So AECL told the clinics that used the Therac25
to visually confirm before each procedure
that the turntable was in the correct position.
Just as a precaution until further notice.
They tightened up the software, making it more robust to a small error like that.
Then they got back in touch with the clinics.
No need for those visual checks anymore.
We've just made the machine five orders of magnitude safer.
Which in plain English means it's about a hundred thousand times safer than before.
And it was safe already.
But one thing AECL don't seem to have done is to have notified the clinics that an accident
had happened, and that a patient had been injured by the machine. The clinics at least
say they weren't told of any injuries. When AECL announced that they had fixed the problem, it was September 1985.
A month later, they were sued by a woman named Katie Yarbrough. AECL had never heard of Katie
Yarbrough. Who was Katie Yarbrough? Cautionary Tales will return after the break.
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Katie Yarbrough's injury happened seven weeks before Frances Hills. Early in the summer
of 1985, she was being treated at the Keniston Oncology Centre in Marietta, Georgia.
Katie was 61.
She had had a malignant tumour removed from her breast.
And now she needed follow-up treatment to destroy any secondary tumours which might
have spread to the lymph nodes under her collarbone.
That treatment, of course, would be provided by a THERAC-25
machine.
But when the technician fired up the THERAC-25, Katie felt an agonising pain. A tremendous
force of heat. This red-hot sensation.
You burned me! Katie exclaimed to the technician. Who was puzzled?
That shouldn't be possible, the technician said. The THERAC-25 was safe. And there wasn't
any sign of a burn. Perhaps Katie's clavicle was a little warm to the touch, but otherwise
nothing seemed to be amiss.
The physicist at the Keniston Centre was a man called Tim Still. When he was informed,
he was just as puzzled.
Tim knew about the two treatment modes – the powerful X-ray fired through the flattener
and the gentler electron beam fired through the magnet array. Katie Yarborough had been
treated in the electron mode, but Tim still wondered
if something had gone wrong with the array. He called the manufacturers, AECL, with a
question. Was there any way the electron beam could be fired directly at a patient, without
the Magnet Array in position? After three days, AECL replied. No, they explained.
That was simply impossible.
But somewhere along the line, AECL didn't seem to get the message that a patient had
been injured.
Maybe Tim still didn't tell them.
Or maybe he did, but the message didn't get through to the key decision makers. It's quite possible
that still didn't even realise that Katie Yarbrough was injured. After all, at first
she seemed fine. But Katie Yarbrough wasn't recovering from that mysterious burn. In fact,
her symptoms were getting worse. The skin above her left breast had reddened.
Her shoulder would freeze up.
And she suffered excruciating spasms.
Her doctors were baffled.
They continued sending her for thorac treatment.
After all, with malignant breast cancer, you can't afford to take risks.
But when her skin started to fall off, Katie refused to continue lying on the treatment table
underneath that machine. And when Tim Still later examined Katie, he noticed something strange.
Not only did Katie seem to have a severe burn to her upper chest, but her upper back was starting to redden too. It was as though
whatever had burned her had passed right through her body and caused an exit wound.
When Frances Hill was injured, her clinicians didn't know about the injury to Katie Yarbrough.
And as hospitals across North America continued to use the THERAC-25, they didn't know about
Frances Hill or Katie Yarbrough. They only knew that the machine was already safe and
had just become 100,000 times safer. And that makes what happened next almost inevitable.
In December 1985, Dora Moss, a patient at the Yakima Valley Memorial Hospital in Washington
State, complained that her right hip seemed red and inflamed in a distinctive striped pattern.
Dora's doctors were puzzled. It wasn't clear what could have caused the inflammation,
although possibly it was a perfectly normal reaction to the course of radiation therapy
she was having on her hip. Which device was being used? Funny you should ask. It was a Therac 25.
But because the hospital staff at Yakima weren't aware of the history of accidents, they were
baffled. Some of them wondered whether a slotted component on the Therac 25 might explain the
striped pattern. Others suspected that it was a burn caused by Dora's
habit of sleeping with an electric heating pad. Maybe those heated wires had slowly burned
her skin. Although on closer inspection, the arrangement of wires in the heating pad didn't
actually match the sore stripes on Dora's hip. So they contacted AECL, who responded,
After careful consideration, we are of the opinion that this damage could not
have been produced by any malfunction of the Tharac 25 or by any operator error.
So that was it then.
Officially the cause of that stripey burn was cause unknown.
But if the cause was unclear, the consequences were stark.
Dora Moss needed surgery and skin grafts to patch up her ulcerated skin and treat her
chronic pain. Maybe it wasn't the THERAC-25. It certainly
wasn't a burn from a heating pad.
The Yakima hospital staff were even told that there'd been no other incidents with the
THERAC-25. Was anyone putting all these incidents together and spotting a pattern?
It seems not.
Although it's hard to be sure.
Nancy Leveson, software safety expert and the author of a definitive account of the
affair explains that because there was never an official investigation, it's often unclear
who exactly knew what, and when they knew it.
At the East Texas Cancer Center in March 1986, three months after the injury to Dora Moss,
Mary Beth was puzzled. She'd tried twice to administer the treatment to Ray Cox, apparently without success.
Third time lucky, she hit P again.
Ray Cox had been trying to ease himself off the table, but when that searing skewer feeling
hit him for a third time, jabbing through his neck and shoulder, he leapt for safety, barged open the door and
ran to the nurses' station.
When Marybeth emerged, Ray was obviously shaken by what had happened. He told her that he
felt like he'd been given three separate, powerful electric shocks. How strange. Marybeth
reassured him that the machine had automatically shut down, and according to
the computer's display panel, Ray had only received one tenth of the intended dose.
Marybeth informed Ray's doctor and the centre's physicist Fritz Heger about the electric shocks.
They came to examine the machine, and Ray.
There seemed to be nothing wrong with either of them.
But that's the nature of a radiation overdose.
It's invisible.
And at first, the injuries it causes are invisible too.
Ray looked fine.
But he really wasn't.
Heger called the manufacturer of the machine AECL to report the incident. Then he ran through
some tests. And since everything seemed to be in order, pronounced the machine good to
go for the afternoon patients who were waiting for treatment. And everything went smoothly.
That's what happened, remember? The THERAC-25 often produced mysterious error messages,
and then suddenly started to work again for no obvious reason.
Three weeks after the strange incident with Ray Cox,
Marybeth had a new patient, 66-year-old Vernon Kidd, who had
a tumour on his ear. As soon as the treatment beam was activated, Vernon cried out and started
moaning for help. This time the audio link was working. What happened? asked Marybeth.
Fire, he replied.
Fire on the side of his face.
When the physicist Fritz Heger arrived on the scene, Vernon elaborated.
He'd heard a sound like frying eggs and a flash of light and then pain.
He was confused and upset.
What happened to me?
We'll find out what happened to Vernon Kidd after the break.
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society wherever it is you get your podcasts. A podcast by History Hit. September 9th, 1947.
Computer scientists at Harvard University get to the bottom of why their fancy computer,
the Mark II, is malfunctioning. It's a bug. A literal bug. A moth, in fact, which has
crawled into the mass of electrical relays in the room-sized computing machine and caused
a short circuit.
The logbook tells the tale. Handwritten on blue-gridded paper are the words
RELAY 70 PANEL F MOTH IN RELAY
Next to those words, the bug itself is preserved under a short length of yellowing sticky tape.
Underneath the dry remark…
First actual case of bug being found
Software bugs are the bane of programmers, although as that punchline implies, this wasn't
the first time the word bug had been used to describe a device malfunctioning. It was
just the first time that an insect had been obliging enough to turn the metaphor into reality. In fact, software
bugs are older than computers.
The first computer program is widely thought to have been written by Ada Lovelace, an English
mathematician and friend of the engineer Charles Babbage. In 1843, Lovelace published an algorithm that would enable Babbage's proto-computer, the
analytical engine, to calculate a particular sequence of numbers.
What's so striking about Lovelace's algorithm is that the analytical engine had not been
built. Nor would it ever be. Babbage's designs
were just too ambitious, and nobody would be able to construct a general purpose computer
for another century.
But modern analysis concludes that if Lovelace's programme ever had been run on an analytical
engine, it wouldn't have worked. Not first time anyway. Because
there was a typo. Not only had Lovelace published the first software, she had also published
the first software bug.
Anyone who's had the experience of writing computer code, or even for GenXers like me,
of typing in a computer program printed in the pages of a magazine will know what it's
like to have a bug. In some cases, the bugs are easily fixed. You run the program, and
it doesn't work. Maybe the computer even tells you where things went
off the rails, exactly where the error was. Or maybe not. Because some bugs are more like
an unsuspected hole in one of James Reason's slices of cheese. They sit there, hidden by
other slices, causing no trouble until the holes in the slices align
and the computer crashes.
You may not know why it crashed. You may be able to restart the program and find it runs
with no trouble. But somewhere, under the surface, the bug is still there.
Two of Fritz Heger's patients had apparently been electrocuted, and while the THERAC-25
seemed to be working perfectly well, he wasn't going to risk a third. He shut the machine down, notified AECL, and then tried to figure out what had occurred.
It wasn't easy. After each incident, the machine seemed to be working just fine. Hager
and Marybeth worked together, trying to figure out what had triggered the malfunction 54
message.
Eventually they succeeded.
Marybeth recalled how she had originally typed X to use the Therac 25 in X-ray mode, then
realised she should have typed E. Quickly using the cursor keys to move to the correct
box she corrected the entry to E,
repeatedly hit return to accept all the other treatment variables which were correct, and
awaited the message, beam ready.
What she hadn't known, what nobody had known, is that a quick edit like that confused the computer's subroutines, which checked the
setup only at certain moments. The result? The beam was set to full X-ray power, but
the flattener that would absorb most of the radiation wasn't in position.
To make matters even worse, the Therax software was confused by this dangerous setup and didn't
correctly monitor the dose administered.
It was a particular sequence of keystrokes that caused the problem.
An unlikely sequence, but not an inconceivable one.
It shouldn't be particularly surprising that experienced operators such as
Marybeth might type the wrong mode, notice the error, then swiftly correct it. It was the
swiftness of that correction that bewildered the software. Fritz Hager explained to AECL that he could now reproduce the error on demand.
The AECL engineer couldn't, until Heger explained that all the keystrokes had to be
entered in less than 8 seconds.
The next day, the AECL engineer called back.
Yes, he could now replicate the error. And
he had bad news. If the beam was fired in such conditions, the patient would receive
a dose of 25,000 rads, more than a hundred times more than intended.
Which potentially could be fatal.
Over the course of three weeks, 66-year-old Vernon Kidd moved from disorientation to a
coma to death. The autopsy revealed that the section of his brain
running from under his right temple to behind his right ear
had been withered by a high dose of radiation.
It's natural to describe the problem with the Therac-25 as a software bug. And while that's true, it doesn't really help us understand the problem, or prevent similar
problems in future. As Nancy Leveson writes, virtually all complex software can be made to behave in an unexpected
fashion under some conditions. Demanding software with no bugs is like demanding
a slice of Swiss cheese with no holes. It's in the nature of Swiss cheese that there will
always be holes, and it's in the nature of complex software that there will always be holes, and it's in the nature of complex software that there
will always be bugs.
The question is, what happens when a bug appears?
Perhaps another part of the software is able to spot the problem. A separate slice of software
cheese. That didn't happen with the THERAC-25. The computer would tell the operator what dose
the patient had received, but there was no direct measurement of that dose. The bug that
led to the overdose also led to the software failing to report the overdose.
Or perhaps there are fail safes in the hardware. Again, not with the THERAC-25. The machine relied on the software being perfect.
The shielding components were put in place by the software. The decision to allow the
electron gun to fire, or not, was made by the software. And the dose the patient received
was reported by the software. If the software was wrong about one of these
things, it could easily be wrong about the others.
There is a different approach. The THERAC-20, the predecessor of the THERAC-25, was designed
to operate with or without a computer, and it was built with mechanical interlocks. If
you tried to fire the beam without the right component in place, the machine just wouldn't
do it.
It was only after the Therac-25's problems became widely known that something began to
dawn on Therac-20 users. Sometimes the machine's fuse would blow after quick
edits. It was annoying and a bit mysterious. The machine would have to be switched off,
the fuse replaced and everything restarted. The Therac20 software had been built on the
same codebase as the Therac-25, and on closer examination
it became clear that the Therac-20 had the same software bug.
Because of the mechanical interlocks, which would physically prevent the machine from
working unless it was correctly set up, the bug was never anything more than an annoyance.
The most precious thing that was damaged was a fuse.
The Therac-25 needed better software. And it needed better hardware. But as I said earlier,
that's also the wrong place to focus. Another kind of cheese slice was missing.
focus. Another kind of cheese slice was missing. There was no proper process for noting anomalous incidents, suspected malfunctions or possible
injuries. Hospitals should have been reporting both the strange incidents and the later mysterious
injuries. Someone, either AECL or a regulator should have been collecting and analysing the reports.
Because that didn't happen, every new incident caused a new wave of muddle and bewilderment.
Of course we should try hard to eliminate bugs, especially when lives are at stake.
But the real lesson here is that safety is not a function of good software alone, it's
the function of the whole system.
And the system goes beyond the software, in fact it goes beyond the machine.
The system includes the network of people who make the machine, use the machine and regulate the machine.
In this case they should have been keeping each other closely informed. They weren't.
And as a result, it took months for anyone to assemble the pieces of this awful puzzle.
of this awful puzzle. Voin Ray Cox was young and strong, but had taken a triple blast of high dose radiation
to his back, shoulder and neck. Before long he was starting to spit up blood. The awful
radiation burns on his back and neck turned into yawning lesions
as the skin and flesh started to peel off his body. While over the weeks that followed,
the damage to his spinal column paralysed his left arm, both legs, and his vocal cords.
Ray tried to keep his sense of humour.
Before he lost his ability to speak, he would joke to friends and family,
Captain Kirk forgot to put the machine on stun.
Ray Cox died in August 1986, a few months after the accident. And five months after that? Glenn Dodd, a 65-year-old
cancer sufferer, was given radiation therapy at Yakima Valley Memorial Hospital, where
Dora Moss had acquired those mysterious striped radiation burns after treatment from a THERAC-25, Glenn Dodd was
being treated by a THERAC-25. He received a fatal overdose.
Dodd was terminally ill, but doctors concluded that the injuries he'd suffered from the malfunctioning machine had
killed him before his own cancer could.
Why hadn't AECL fixed the software fault? Well, as it happens, Glendod wasn't killed
by the glitch that had killed Ray Cox and Vernon Kidd, but by
a different software error. You see, there's always another bug, lying in wait for the
moment to strike. This isn't the first cautionary tale we've done about radiation overdoses. Two of my
very favourite episodes of the podcast were Glowing Peril, a magical glitter that poisoned
a city, and How the Radium Girls Fought Back, two episodes, which came out as a pair late in 2023. You may enjoy
listening to them.
I first heard about Ray Cox's case from Stephen M Casey's book Set Phasers on Stun,
while the definitive authority on the Therac-25 case is Nancy Leveson's investigation, written with Clarke Turner.
For a full list of our sources, see the show notes at timharford.com.
Cautionary Tales is written by me, Tim Harford, with Andrew Wright.
The show is produced by Alice Fiennes with Marilyn
Rust. The sound design and original music are the work of Pascal Wise. Sarah Nix edited
the scripts. Cautionary Tales features the voice talents of Ben Crow, Melanie Guthridge,
Stella Harford, Gemma Saunders and Rufus Wright. The show wouldn't have been possible without the work of Jacob Weisberg, Ryan Dilley,
Greta Cohn, Eric Sandler, Carrie Brody, Christina Sullivan, Kiera Posey and Owen Miller.
Cautionary Tales is a production of Pushkin Industries.
It's recorded at Wardour Studios in London by Tom Berry.
If you like the show, please remember to share, rate and review. in London by Tom Berry. slash plus. Have you ever found yourself talking to someone and the conversation has gone completely flat.
Well you never have to experience that horror again, but Twix the Sheets is filled with
fascinating historical nuggets that will make you the most interesting person at any party.
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or not famous Lotharios deserved their reputations. It's a podcast with all the best bits from
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Betwixt the Sheets, the history of sex scandal in society, wherever it is you get your podcasts.
A podcast by History Hit.
This is an iHeart Podcast.