It is an interesting fact that two-thirds of my cases of cardiac strain in the second half of life presented also a history of gout, fully developed or irregular--in other words, a history of perverted metabolism. Equally striking is another fact in this connection: that in many cases the occurrence of strain in middle or advanced age was but the latest of a series of similar events as the result of muscular effort for a period of 10, 20, 30, 40, or even 50 years--in other words, the heart had been strained originally in youth or early manhood, and had given serious trouble as often as it was taxed again. Rowing or running at college was in a good many instances given as the cause of the first strain. I need not do more than mention previous valvular disease, usually of rheumatic origin, as a condition powerfully predisposing to cardiac injury by physical exertion. Excepting in this indirect way, rheumatism has no effect in lowering the resistance of heart or vessels to mechanical stress. The principal safeguard which the arteries possess against strain is, of course, the extensibility and elasticity of their tissues. Unfortunately the metabolic disorders, including gout, which we have just found weakening the cardiac walls, are amongst the commonest causes of arterial degeneration also; and the two influences--gout and strain--acting together no doubt are accountable for a considerable number of cases of atheroma and chronic arteritis. It naturally might occur to us that gout and exertion could not well be associated, but this very consideration serves to explain their mutual influence in straining the heart. It is unwise, ill-timed, ill-planned muscular exercise that injures the circulation, most often on the part of the middle-aged man, who, awaking to the consciousness of growing fat and gouty, rushes inconsiderately to violent exercise for relief.