he believes that there is distinct functional disturbance of the heart and loss of power, relatively to the change in pressure and the increase of the pulse rate. He further believes that a heart showing this kind of weakness should, if possible, not be subjected to general anesthesia.

Stange [Footnote: Stange: Russk. Vrach, 1914, xiii. 72.] finds that the cardiac power may be determined by a respiratory test as follows: The patient should sit comfortably, and take a deep inspiration; then he should be told to hold his breath, and the physician compresses the patient's nostrils. As soon as the patient indicates that he can hold his breath no longer, the number of seconds is noted. A normal person should hold his breath from thirty to forty seconds without much subsequent dyspnea, while a patient with myocardial weakness can hold his breath only from ten to twenty seconds, and then much temporary dyspnea will follow. Stange does not find that pulmonary conditions, as tuberculosis, pleurisy or bronchitis, interfere with this test.

Williamson [Footnote: Williamson: Ant. Jour. Med. Sc., April, 1915, p. 492.] believes that we cannot determine the heart strength accurately unless we have some method to note the exact position of the diaphragm, and he has devised a method which he calls the teleroentgen method. With this apparatus he finds that a normal heart responds to exercise within its power by a diminution in size. The same is true of a good compensating pathologic heart. He thinks that a heart which does not so respond by reducing its size after exercise has a damaged muscle, and compensation is more or less impaired.

Practical conclusions to draw from the foregoing suggestions are:

1. An enlargement of the heart after exercise can be well shown only by fluoroscopic examination, and then best by some accurate method of measurement.

2. The blood pressure should be immediately increased by exercise, and after such exercise should soon return to the normal before the exercise. If it goes below the normal the heart is weak, or the exercise was excessive.

3. The pulse rate should increase with exercise, but not excessively, and should within a reasonable time return to normal.

4. The stethoscope will show whether or not the normal sounds of the heart become relatively abnormal after exercise. If such was the fact, though the abnormality was not permanent, heart insufficiency is more or less in evidence.

5. The relation of pulse rate to blood pressure should always be noted, and the working power of the heart may be estimated according to Barach's suggestion.

6. The dumb-bell exercise tests suggested by Barringer (only, the dumb-bells may be of lighter weight) are valuable to note the gradual improvement in heart strength of patients under treatment.

7. The holding the breath test is very suggestive of heart efficiency or weakness, but a series of tests must be made before its limitations are proved.

THE EFFECT OF ATHLETICS ON THE HEART

We can no longer neglect the seriousness of the effects of competitive athletics on the heart, especially in youth and young adults. Not only universities and preparatory schools, but also high schools and even grammar schools must consider the advisability of continuing competitive sports without more control than is now the case. In the first place, the individual is likely to be trained in one particular branch or in one particular line, which develops one particular set of muscles. In the second place, competition to exhaustion, to vomiting, faintness, and even syncope is absolutely inexcusable. Furthermore, contests which partake of brutality should certainly be seriously censored.

A committee appointed some time ago by the Medical Society of the State of California [Footnote: California State Med. Jour., June, 1916 p. 220.] has recently reported its endorsement of Foster's "Indictment of Intercollegiate Athletics." After five years of personal observation of no less than 100 universities and colleges, in thirty-eight states, Foster concludes that intercollegiate athletics have proved a failure, and that they are costly and injurious on account of an excessive physical training of a few students, and of such students as need training least, while healthful and moderate exercise at a small expense for all students is most needed.

Experts, [Footnote: Rubner and Kraus: Vrtljsehr. f. gerichtl. Med, 1914, xlviii, 304.] appointed by the Prussian government to investigate athletics, reported that for physical exercise to be of real value it must be quite different from the preparation of a specially equipped individual trained for a game. Exercise should benefit all children and youth, while athletic prowess necessitates taxing the organism to the limit of endurance, and hence is dangerous and should not be allowed in schools or universities.

McKenzie [Footnote: McKenzie: Am. Jour. Med. Sc., January, 1913, p. 69.] found that exhausting tests of endurance were not adapted to the development of children and youth, because the high blood pressure caused by such exertion soon continued, and he found athletes to have a prolonged increased blood pressure. As is recognized by all, boat racing is particularly bad, especially the 4-mile row. Such severe exertion of course increases the blood pressure, even in these athletes, and the heart increases its speed. There is then exhilaration, later discomfort, and soon, as McKenzie points out, a sensation of constriction in the chest and head. This is soon followed by breathlessness, and soon by a feeling of fulness in the head, and then syncope. The heart, of course, becomes dilated. Heart murmurs are often found after much less severe exertion than boat racing. They may not last long, or they may disappear under proper treatment. He reported that after exercise there were heart murmurs in seventy-four of 266 young men who were in normal health, and that nearly 28 per cent of all normal young men will show a murmur after exercise. He thinks that it is rare to find, after a week, a heart murmur in a previously healthy heart, if the athlete has not passed the age of 30.

There can be no doubt that even one, to say nothing of more, such heart strains is inexcusable and may leave a more or less lasting injury. Such heart strains and exertions are not entirely seen in athletes. A man otherwise well may cause such a heart strain by cranking his automobile, by pumping up a tire, by strenuous lifting, by carrying a load too far or too rapidly, or by running, and an elderly man may even cause such a heart strain by walking, hill climbing, or even golfing, if he does these things. More or less acute dilatation occurring in such persons is likely to recur on the least exertion, unless the patient takes a prolonged rest cure and the heart is so well that it recuperates perfectly. Any chronic myocarditis, however, may prevent such a heart from ever being as perfect as it was before.

Torgersen, [Footnote: Torgersen: Norsk Mag. f. Laegevidensk., April, 1914.] after making 600 examinations of 200 athletes, and 1,200 examinations of members of the rowing crew, decides that it is absolutely essential that there should be skilled daily examinations of every man during training, and a record kept of the condition of his heart, urine, and blood pressure, before and after exercise. When he found albumin in the urine it was always accompanied by a falling of the blood pressure and a rapid heart, with loss of weight and a general feeling of debility.

Middleton [Footnote: Middleton: Am. Jour. Med. Sc., September, 1915, p. 426.] examined students who were training for football, both during the training and after the training period, and found that after the rest succeeding a training period there was an