For neurosurgeon and immunologist Kevin Tracey, now director and chief executive of the Feinstein Institute for Medical Research, the case of baby Janice, scalded by hot water just before her first birthday, was one of the ones a doctor never forgets. In his book Fatal Sequence: The Killer Within, he recounts her medical story to explain the spiral of sepsis, an immune system over-response to infection, and how a body getting the best of care—and recovering—can suddenly and fatally veer off track.
This is your first book?
Yes. I was trying to develop a book about a particular, very emotionally moving case of a one little girl, but it was also the story of scientific discovery, of the vagaries and the unpredictable nature of doing science in the modern era and of what the answers actually turned out to be. I wrote the book for patients and their families, as well as for students, trainees, and the interested lay public.
I was pleasantly surprised by the book reviews that were published in JAMA, the Journal of Clinical Investigation, and others. The reviewers captured the messages that I had tried to develop, and hopefully the words will provide some insight to the families of other patients that have suffered from the terrible problems of sepsis.
What was it like to go back, and feel those feelings again? You describe them really well.
I was surprised, writing, at the vividness and reality of those memories; they really came back to life. And what really struck me was that rereading what I had written, even after the eighth and tenth drafts, continued to bring me back to that little girl’s bedside, as if it was yesterday.
This does not happen with every patient but, having spoken to doctors before and since, it seems that every doctor has one or two of those patients in their life. As in this case, the most memorable ones often occur very early in the career.
The discoveries you describe in the book happened really fast. It was only two years after you met Janice that you knew one part of puzzle, and then a year later you knew another part of it. Have all these ideas been accepted now?
I think the TNF part [tumor necrosis factor] is accepted because it’s a recognized drug target that generates around $5 billion in annual drug sales, and has benefited the health of millions of people. It is now dogma, in the textbooks. The next cytokine, HMGB-1, is moving towards clinical trials.
And the vagus nerve story is progressing on multiple fronts, for device development, for understanding classical physiology, meditation, biofeedback and drug discovery. So that pathway continues to generate a lot of interest for a variety of audiences; even casual people interested not in medicine so much but in meditation and generalized health questions.
One of the chapters in your book discusses why biofeedback, meditation and yoga seem to have benefit but haven’t been included in standard science because people couldn’t explain them. Do you think the explanation is clearer now, or are we still on our way?
I think that we’re on our way towards--not explaining it--but studying it. It’s a loaded question. Last September I had the privilege of discussing this topic with the Dalai Lama. He expressed interest in understanding whether vagus nerve pathways can underlie the beneficial effects of meditation.
Western science has until now not provided an explanation for how such practices might work. My colleagues and I did not set out to try to understand the biological basis of meditative practice, nor are we doing that now, but what we discovered is clearly a hypothesis, a theory, that can be tested and studied in people who meditate, in people who do biofeedback and in people who have relaxation therapy. Each of these activities increases vagus nerve activity.
So now the scientific questions are 1: Does the vagus nerve control inflammation in humans? 2: Does the brain, which controls the nerve in other cases, also control inflammation through this nerve in humans? and 3: If the brain is controlling the nerve and the nerve is controlling inflammation, can altering brain function, with meditation or other states, activate the nerve to reduce inflammation?
So today we are working on an exciting new idea that is, I’d say, getting closer to proving a connection between meditation and positive effects on immunological health.
There are some now who say that, “Look, everybody knows that meditation is good for your immune system.” Well, perhaps it is, but Western science requires, “show us how it works.” Today we know that we can study the vagus nerve in a clinical experiment to learn whether it connects some of these Eastern medical practices to improved health.
Eastern practioners are not particularly concerned about how their practices work, but they are interested in getting their message get out, and if in fact there’s an explanation that’s acceptable to Western scientists and doctors, the word will go out faster, to more people. I think that this idea resonated with the group.
The Dalai Lama has said that he is confident that there a scientific basis for their practices will be forthcoming. Perhaps the vagus nerve connection will prove to be part of the answer.
What’s your next book?
I don’t know. [laughs] It might be a monograph dedicated to the role of vagus nerve signaling in preventing disease, but it also would be fun to tell another patient’s story, with other scientific underpinnings. The topics are so compelling--how people think about their response to stress, to illness, the ability to stay healthy or get sick during various types of stress; may of us seem to be interested in understanding how this fits together. I treated patients for almost twenty years; there’s a lot more stories to tell.