Tobacco Documents Online

I I I I I I I I I I I I I I I I I I'NE NEW E,~GLA`D JOUttNAL OF MEr)ICINE Sept. 3. 1981 the personal physician-patient interaction. Dr. Walsh `1cDermott has vividly descrnbed this modern mcdi- cal dilemma.10 The kinds of stattstfc:; on morbidity or mortalttv that are currently collecte:d are very blunt instruments for the 1980s. Thcv do not measure the effcct of what physicians spend most of their time doing nowadays: trying to improve function or re- storing it, and only rarely dramatically saving or ex- tending life. Here, alas, we are victims of our own technologic successes. Because of the striking advances in public health and medical practice, most American children are surprisingly healthy most of the time. Although 750 of every 1000 American children visit a physician each year, only one of that 1000 dies." What we need to know is who can give the other 749 the best guar- antee of living to a vigorous and trouble-free adult- hood without costing a kfng's ransom. Obviously, we wish to have in place a system of child care that can swiftly identify problems that are potentially serious, often in innocent-appearing sft- uattons, and deal with them appropriately. Life- threatening illnesses do befall children, and their rec- ognition and treatment should and will remain a major preoccupation of physicians. However, we must develop better ways to measure the successes and fail- ures of the personal health system in functional terms if we are to reach any reasonable consensus about what makes the most cost-effective sense in caring for children. There are a few cheerful indications that this can be done. Two recent studies suggest that we can obtain reliable functional information about people's health status with relatively uncomplicated methods.'=•'> if we can get a clearer idea about what human and technical ingredients, assembled in what way, most effectively maintain maximal human function or most swiftly restore it after its breakdown, we can surely make wiser decisions about appropriate professional manpower and about the best allocation of our re- sources. Until we have such information, medical edu- cators, policy makers, and patients will continue to have trouble knowing whom to choose as their pri- mary-care doctor. Getting a better fix on how people fare after encounters with the doctor should be a major item on the agenda for those concerned with making medical care all that ft should be, at a price we can handle, during the 1980s. The Robert Wood lohnson Foundatton Prtnceton. NJ 08540 DAVID E. ROGERS, M.D. REFERENCES I Fishbane M. Starfield B. Child health care in the Untted States: a com• : partson of pematrtctans and general pracuuoners. N Engl J Med. 198 1 305:552-6. 2. Blendon RJ. Schramm CJ. Molonev TW. Rogers DE. An era of stress for health tnsutuuonsi the 1980s. JAMA. 1981: 245:1843-5. 3 Aiken LH, Lewts CE, Craig J, Mendenhall RC, Blendon RJ, Rogers DE. The eontrtbutton of specsalisu to the delivery of prtmary care: a new perspective. N Engl J Med. 1979; 300:1363-70. A Sox HC Jr Qualtty of patient care by nurse practitioners and physt- ctan's assistants a ten•vear perspective. Ann Intern Med. 1979; 91:459• 68. S. Blendon RJ. Public health versus personal medical care: the dilemma of post-Mao China. N Engl 1 Med. 1981: 304.981•3. 6. Ray WA , Fcdcrsptu CF. Schaffner W Prescribing of tetracycline to children less than a years old. a two•ycar eptdemtologs study among .mbulatory Tenneuee Medicaid recipients. JAMA. 1977t 237:2069•74 7 Jdrm, Prescribing of chloramphentcol in ambulatory practice: an epr demrologic study among Tennessee Medicaid reaptents. Ann Intern M ed. 1976: 84:266-70. B. Caetano DF. The relattonshtp of medical specialization (obstetricians and general praccruonersl to comoitcauons in pregnancy and delivery, birth mJury, and matformatton. Am J Obstet Gynecol. 1975; 123.221-7. 9 Phillips WR. Rice GA, Layton RH. Audit of obstetrical care and out• come in family medicine. oostetrtcs, and general practice. J Fam Pract. 1978; 6:1209-16. 10. McDermott W. Absence of indicators of the tnflucnce of its physicians on a soctety's health: impact of physician care on society. Am 1 Mcd. 1991; 70133-43. I I. Rogers DE. Biendon RJ• Hearn RP. Some observattons on pediatrter: its past, present and future. Pediatrtcs. 1981: 67:775•84. li Brook RH. Ware JE Jr. Davies-Avery A, et al. Conceptuahzauon and measurement of health for adults in the health insurance studv (R-1978/8 HEW) Santa Montca, Calif.: Rand Corporation, October 1979. 13 htcWhinntc JR. Disability tndtcators for measuring wcil•being. Paris OECD Indicators Development Programme• 1979. (Spectal studies no. 5). WHAT,MAKES US RUN? WHEN the Persian fleet approached the plains of 'l,larathon in 490 B.C., the Athenian Pheidippides set out for Sparta in quest of military aid. Despite the summer heat, he traveled 240 km of mountain roads in 48 hours at an average speed of 5 km per hour. His oxygen consumption, work output, energy stores, water metabolism, and cardiovascular function were sufficient to sustain him on this journey. His brain was adequately supplied with blood, and upon ar- rival, he acted diplomatically as a suppliant and ora- tor. Although the Spartans agreed to meet their treaty obligations, they postponed their departure until the end of a summer festival at the full moon six days later. Somewhat disappointed, he jogged back tt> Athens and then on to Nlarathon, where he helped to defeat the Persians.' By today's standards, Pheidippides' endurance was creditable, but such slow running was not always con- sidered healthful. Bernardino Ramazzini, in his Dis- eases of Workers published during the Renaissanee,= noted that "runners were prone to suffer from hernias and asthma." He saw them as emaciated, comparing them with hunting dogs, and suggested that the vola- tile elements of their blood were used up along with their sweat during runs. That "hunting-dog" look is fashionable again, as evidenced by the exertions of le- gions of joggers. Contrary to Ramazzini's views, run- ners do not risk exhaustion of their "vital humors" in their quest for fashionable sleekness, but, as shown byZ,,,:) Carr et al. in this issue,> physical conditioning in-Q creases exercise-induced secretion of beta-endorphin~ and b-ta-lipotroptn. Many naturally occurring peptides with opium-likeW ~ G>D ~

I I I I I I I I I I I I I I I I I \ui )Uj \o lU EllITUKIALS properties - among them, bcta-cudcrphin - havc been found in the brain and other tissues. They mod- ulate normal pain sensation and perhaps induce the analgesia associated with acupuncture or electrical stimulation of the brain. Their effects can be nullified by the specific opioid antagonist naioxont.' The nu- merous endocrine actions of endogenous opioids in- clude promotion of antidiuretic hormone secretion and inhibition of the release of thyrotropin and go- nadotropin-releasing hormone. They play a part in tcmperature regulation and appetite, and depress the ventilatory response to carbon dioxide. They also af- fect mood and sleep, and have been tentatively linked to drug addiction.' All these actions seem to parallel the measured changes in physiology and homeostasis of a person trained for endurance.° Still lacking, how- ever, is solid scientific understanding of the "runner's high," of his "positive addlction," and of the "de- pression" and "exerclse withdrawal syndrome" that result when hc is deprived of his daily exercise "fix." A great deal has been learned about muscle strength, cardiovascular function, and lipid homeo- stasts in endurance-trained subjects. The interactions of muscular activity, mood, and behavior, however, remain elusive.' lt is clear that reflex movement, which forms an elementary unit of the nervous sys- tem's activity, cannot explain the complex behavioral seqvences that induce millions to exercise daily and to justify what until recently has been considered bi- zarre behavior. The surge of plasma beta-endorphin after exercise in endurance-trained women described by Carr et al.' is maintained in men for two hours after a 4G-km mountain race. Clearly, this transient effect does not reflect permanent alterations in brain beta-endor- phin levels that might link endurance training to long- term change in behavior. Immunity to pain has been demonstrated by pyro- vats, who practice religious firewalking ceremonies in the Balkans. The possibility that these activities arc facilitated by endogenous opioid release has been con- sidered.' Naloxone does not abolish the firewalking capacity of pyrovats, but an increase in the frequency and rapidity of footsteps on the hot coals is evident, In rats profound analgesia induced by inescapable shocks to the feet is antagonized by naloxone only when the shocks are intermittent, but not when they are continuous. The temporal characteristics of stim- uli and intermittent rapid movements that produce cpioid-related analgesia are therefore important ex- perimentally' and perhaps in pyrovasy. In general, movement seems to underlie analgesia; it is impor- tant in the drum-induced and dance-induced anal- gesic trances commonly occurring in shamans in lndia and perhaps also in -he "runner's high." Endurance training with repetitive prolonged movement does lead to changes in homeostasis, but detractors point to undesirable side effects. Jogger's nipples, runner's trots, jogger's hematuria, stress frac- tures, and anecdotal deleterious effects on family and friends cannot be ignored. 1iut, like the proponents of endurance training, opponents have trouble directly and definitively linking these ailments to exercise. Advocates of endurance training claim that it pre- veats or slows what have hitherto bcen considered in- evitable effects of aging on the function of the human body. Visual-c oked responses and peripheral-nerve- conduction velocities suggest that measurable betu- fits can be derived from endurance training, when endurance-trained subjects are compared with age- matched untrained controls. But the muitifactorial nature of aging and behavior and its complexity pre- cludes definitive conclusions from single measure- ments. Ramazzini's view' that professional runners should be retired by the age of 40 as unfit for service may have been correct. However, nonprofessional running as an aid to change one's life style is in a dif- ferent category. His own advice that "when a man wishes to make a change, he ought to habituate him- sclf little by little; indeed, any work is easier even for a boy or an old man than for an unaccustomed adult" remains good advice for women as well as men. lncreasing recognition by physicians and the pub- lic that medical science has not conquered and will not conquer in the foreseeable future most of human- ity's great killer diseases has focused attention on pub- iic-health measures that might add "years to life and life to years" and that also might reduce the inci- dence of all diseases. The number of people who now participate in some form of physical activity attests to this. Previously, interest centered on physical per- formance of "athletic geniuses" or on new extraordi- nary records. But the emphasis is now on physical ac- tivity for everybody, exemplified by searching studies of casual joggers. lt has been predicted10 that a few decades from now the situation of athletics will re- semble that of painting in the middle of the 17th cen- tury, of ballet before World War 1, and piano music during the 1920s, and that through the training of the motor system and its influence on physical perform- ance and behavior, sport is destined to show its powers by creating a "third culture," if one accepts the humanities and natural sciences as the first and second. Unt.erwty of New Meatco Sctwol of Mediane A16uquorquc, NM 97131 OTfo APPENYELL.tit, M.D., Pit.U. RErEassrcFS Z114D I Lbyd A. Marathon: the stor7 of cavtiu.ataab on mWuoe oouhs. Ne. r^ 2. York: Random Housc. 1975. Ranratum B. Discasrs of .ortas. Na+ York; Ha(xr. 1984. Oi--b 3. Cur D8, Builen !A, Stnau GS. a al. PLyacal condttwaa{ laa4• Cn 1 uta the nerase-tnduoed McnWon o( 6eusn6orpAtn aed beu•4Po- troppn in omm, N Ea4l ) Med. 1991: )05:564). Chung S-H. Dtctensoo A. Pua. eerephal+a aad +cvpttaat+re. Natuc. ~ 19W, 213143-4. 5 Byck R. Pcptdc uawmntai a tuufywg A7pasau for NDf+orra. ro- ~ qratwa slecp. aad tdc acuoa of btDttua. L.oon. 1976: 2_72•3. +~ b • Appea[dkr O, Attufsoe RA, e4. Spon. eedaane fitnoa, uauun~, tn ~.~r lunu, Miumorc Urbaa t Scb%au=bcg. 1911. (~ ~ I

I I I I I I I I I I I I I I I I 560 THE NE4`' ENGLAND JOURNAL OF :~,IEDICINE ' Galiistel CR. From musues to mottvatton. Am Sci. 1980: 68:398-509. 8 Xenakts C. Holtmann W Z.ur Psychophystotugtc dcs Fcucrlaufens. II. Schmerzempfmdung bet Pyrovasm (Fcucrlaufan). Arch Psychiatr Ner- ve n k r. 1979: 227:39-47. 9 Lewts JW. Cannon JT, Liebcskrnd JC Opioid and nonoptoid mecha- nnms of stress anafgesta. Sctence 1980. 208:623-5. 10 . Jokl E. Introduction: medicine. science and sport.' 1-10.