opposition to it, that the heart may diminish somewhat in size, and præcordial distress disappear, under strict treatment continued for a sufficient length of time. [14] Clifford Allbutt, 'System of Medicine,' v, p. 843. STRAIN BEFORE FORTY. A more interesting group of cases than those which I have just discussed is composed of persons who have strained their hearts in youth or early manhood, have never been quite well since, and in middle or advanced life are at last driven to us for help. Cases of this character would furnish excellent material from which we might attempt to judge of the after-effects of excess or abuse of muscular exercise in the young. This is a tempting subject of discussion, but one far too long and much too important to be taken up casually at this time. Therefore, I will content myself with submitting to you as plainly as I can certain facts bearing on it that have come before me in my present inquiry, along with a few simple observations of a practical bearing. First, then, let me read to you the history of what I should call a typical case of the kind. A man of 69 complains that as often as he walks any distance or climbs a stair he is arrested by a distressing sense of having a bar across the lower end of the sternum, breathlessness, irregular palpitation of the heart, and a very little choking in the throat; the discomfort has lately deserved the name of pain. His heart is very large, the area of præcordial dulness being increased in all directions and measuring transversely 7 inches. The impulse is weak over the left ventricle, but definite in the epigastrium; the sounds come in couples--moderately good and very weak respectively, without murmur; and the radial artery is large and thick, with rather low pressure and irregular rhythm. It turns out that for the last 40 years these uncomfortable feelings have troubled the man more or less, and that at three different periods of his life--at 31, at 42 and at 67--they increased so much as to incapacitate him for many months, the first time with a sudden sense of something snapping in the heart, the second time with a faint, and always, as he believes, consequent on overwork. Now this man never had rheumatism, nor gout, nor syphilis, and was always a temperate, careful liver; and he volunteers the statement that he first felt his heart at Cambridge, where he was captain of his College boat, and was tried for the University boat but felt that he was not fit for it. Belonging to this type of cardiac strain I have selected 11 cases. The heart is always found to be enlarged, and in about one-half of the cases it is irregular. It may be weak and beating at the ordinary rate, but in other instances it is increased both in force and frequency. Only in quite exceptional cases did I meet with endocardial murmurs in this group of old strained hearts; as a rule the sounds were ordinary, with a disposition to accentuation of the aortic second sound.