American College of Sports Medicine (ACSM) President-Elect Larry Kenney first asked me to be the D. Bruce Dill Historical Lecturer in early August 2002. He asked me again in late September 2002, and I still did not have an answer. I was flattered to be asked, but thought that such honors were given to historians or to very senior individuals who were not historians. I am a clinical cardiologist and certainly no historian. I also did not consider myself sufficiently “historical” from either an academic or aging perspective, despite my advancing alopecia. After some pressure, and after being told by Dr. Kenney that no nominee had ever refused the honor, I accepted. In retrospect, I have no idea how Dr. Kenney would have known that no previous nominee had refused, but this tactic was successful. I will use the term, “Athlete’s Heart,” to refer to both the physiologic adaptations that occur with prolonged endurance training and to the generalized historical and present concerns about the cardiovascular risks of exercise and exercise training. No topic could be more appropriate for me as a cardiovascular clinician interested in exercise and as an ACSM member. That is because the history of the Athlete’s Heart is a history of cardiovascular medicine in general and the ACSM in particular. In fact, I wonder if the ACSM would have been founded without the interest generated by concerns about the Athlete’s Heart. THE ATHLETE’S HEART IN ANCIENT GREECE AND ROME The history of the Athlete’s Heart mirrors the ongoing debate on the risks and rewards of vigorous exercise and of athletic training and competition, a debate existent since ancient Greece. These real and imagined risks of exertion are epitomized by the story of Pheidippides, the Athenian who in 490 BC reportedly ran 40 km (24 miles) from the battlefield at Marathon to Athens (24). He announced the Athenian victory, collapsed, and died. This story provides a dramatic introduction to the risks of exercise but is likely only partly true. Pheidippides was more likely named Philippides or Phidippus (24). His run was not solely from Marathon to Athens to announce victory, but from Athens to Sparta to solicit military aid and back to Athens with the bad news that the Spartans were not coming (Pheidippides. Internet Communication Accessed 5/2003). This distance was not 40 km, but closer to 500 km (300 miles) (24). Most distressing of all to those who would cite this event as evidence of the dangers of extreme exertion, our runner, name uncertain, probably survived because Herodotus, the major historian of the event, never mentioned the runner’s demise, (24) and Herodotus “was too good a reporter to miss such a story.” (13) The confusion probably arises from the mixing of the marathon story with that of a runner named Eucles who 50 years later also ran to Athens to announce victory and did die (3). The legend of Pheidippides attested to the dangers of prodigious exercise but did not undermine the Greeks’ belief in the benefits of exercise. Herodicus (480–? BC) was a physician as well as a wrestling and boxing instructor who was among the first to integrate exercise with the practice of medicine (34). Herodicus’ interest in exercise influenced Hippocrates (460–470), the author of the Hippocratic Oath and widely considered to be the father of scientific medicine, who dedicated a chapter in his book, “Regimens in Health,” to the topic of athletic training (34). Hippocrates recommended a balance between dietary intake and exercise, (34) implying that exercise should be moderate and balanced with other hygienic interventions. Hippocrates in turn influenced Galen (129–210 AD), a Roman physician, who also wrote on the use and value of exercise (3). The influence of Hippocrates and Galen on medicine extended beyond their times, and their teachings and writings were used in medical schools through the mid 1700s. John Pugh in 1794, for example, quoted Hippocrates and Galen when he wrote on the value of exercise (34). Herodicus, Hippocrates, and Galen addressed the benefits of exercise, but little additional exercise was required in agrarian societies devoid of labor-saving devices. The Industrial Revolution, however, changed this and prompted concern among European and American physicians as to whether urbanites obtained sufficient exercise (47). THE ATHLETE’S HEART IN THE 19TH AND EARLY 20TH CENTURIES Almost simultaneously there emerged concerns about the dangers of overexertion. Jacob Mendez Da Costa studied Union Soldiers from that Civil War presenting with cardiac symptoms including palpitations, tachycardia, dizziness, and dyspnea (47). This constellation was called the “Soldier’s Heart” and was attributed to the physical demands of long military campaigns. That report implied a danger from excessive exertion, even though modern clinicians would more likely attribute such symptoms to the hyperventilation, anxiety, and stress of combat. Later clinicians would refer to a similar constellation as the “Effort Syndrome,” (47) again implying a danger from excessive exertion. Interestingly, the Soldier’s Heart also has a role in the founding of the ACSM as will be discussed later. Interest in competitive sports increased in both the United States and abroad after the Civil War (47). This growth in competitive athletics was linked in no small measure to the concept that competitive athletes built what Professor James Whorton has called “the most prized of Victorian virtues, character.” (47) This was coupled with religious overtones and the idea that competitive and physical fitness built moral fitness. Competition was considered central to this moral development. Consequently, for both British and American society, the Athlete’s Heart was not solely a physiologic but also a moral concept (47). Indeed, Professor Roberta Park maintains that interest in the medical aspects of sports originated in England during the 1800s in preparatory schools such as Eton and Rugby and at universities such as Oxford and Cambridge, where the cream of the British Empire prepared for their roles in society (34). Pre-Victorian sports for the gentry included such activities as riding, hunting, and cricket. Other more competitive sports such as boxing, rowing, walking, and running were primarily activities of the labor class and often tested the skills required in manual labor. This changed during the Victorian period when events such as the Oxford-Cambridge boat race, first held in 1829 (47), became popular among the upper classes. Laboring-class athletes were formally excluded from amateur competitions in 1867 when a “mechanics clause” was added to the rules of the Amateur Athletic Club to exclude those whose employment required physical activity (34). Mechanics and laborers continued to engage in professional sports, but amateur sports dominated the competitive scene (34). With increased participation of the upper classes in competitive sports came increased concern over the medical risks of these activities, a concern that had not existed when only the laboring class was at risk. F. C. Skey, a London surgeon, was among the first to warn of the dangers of overexertion. In a letter to the London Times in 1867, he likened the Oxford-Cambridge boat race to cruelty to animals and remarked “… of this form of cruelty to animals no modern example is so great as the annual University boat race” (41). Dr. Skey also raised concerns that extreme exercise could lead to permanent injury: “I only desire to express my own conviction, and … that of my professional brethren … that young men … cannot perform a feat which compels them to put forth the absolute strength of their physical frame for 20 min without injury, often of a permanent nature” (41). Dr. Skey was especially concerned about cardiac effects of such exertion: “The late Dr. Hope, well known to our profession as the author of a work of great authority on diseases of the heart, has often declared that he knew no cause of disease of this organ so common as hard exercise in rowing” (41). Other clinicians were also concerned about the cardiovascular risks of exercise. The Clinical Society of London in 1873 published a report by Thomas Allbutt on “overstrain of the heart and aorta” (34). E. H. Bradford states that Benjamin Ward Richardson, an English physician, warned in the 1880s that all athletes over age 35 who had competed for more than 10 years were disabled (6). Initial medical concerns focused on the cardiac risks of rowing, but other sports also became suspect as they became popular. In the late 1800s, endurance bicycling included events covering 500 miles in 24 h or lasting 6 d (47). The British Medical Journal noted: “Several well-known French cyclists have lately, it is said, been rejected as unfit for military service by reason of hypertrophy and other diseases of the heart…. Lay opinion, professes astonishment at this result. But medical men will be rather surprised that the numbers are so small. There must be very few of us who have not seen the ill effects of over-exertion on a bicycle” (7). The revival of the marathon in the 1896 Olympic Games kindled an interest in distance running. The popularity of distance running was accompanied by concerns about Runner’s Heart. The Journal of the American Medical Association in 1903 included an editorial on the dangers of competitive college athletics stating exercise, such as prolonged training in lead to permanent is Consequently, heart, heart, and heart had their The danger with marathon running to The Marathon was first run in to author who has the history of the “The run in and were not but events in The the on the In the first of the became major sports in the were the and of their running where had run in their and the their and to The the to on the of the race and to whether of the would from In the United interest in the and in heart, after the Olympic Marathon in (47). victory, and on American distance was probably to that of Olympic Marathon victory in in victory, an the first and ran the the and victory, an the first (24). 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Bruce Dill studied in the and is reportedly the first runner to exercise stress After on from a The a of and in the of was published in the England Journal of were to be and were to be or The report that the was because “the had been and a of author had through the heart in there is also an story that I cannot or despite with senior that the was after Dr. had to of as a in the first of the was to concerns about his and on his His published in events from years that about the risks of the had their the training during the of of I my to or from or This from to miles the men in the an interest in my of and would me of the danger to heart and a in the me a for and again through I he said, from be running years have by and the is still After in in his first was again warned about his probably because a cardiac in such an had been “… a of athletic had me about them me These to be … and so me to be by an in He told me that I had a heart and should not run more than a or I asked how first with my heart, and he that in a few years and been for these symptoms for over a of a In than years that the had of heart so often if he to his own heart by These concerns to a from the the marathon came I that I should a to so in the of a from which was to about There were other The of the and of the danger to heart if he running had their as I my I had a that the of running was a for and THE ATHLETE’S HEART and The term, Athlete’s to have been by a physician, in in and after a only as his he that there was both cardiac and hypertrophy and that both the and of the heart were is that have only been by also thought that there was of the heart which he attributed to cardiac from prolonged exertion. including those most of exercise, such as a in the history of the founding of the and an ACSM concern about cardiac with exercise. vigorous exertion for but was concerned about the cardiac risks of exercise for individuals In an that concerns about exercise are and a of the of exercise in to the is in those for exercise, and especially when that the danger of heart is most the cause of symptoms in a who dyspnea and when he the of his is an of a heart on which has been put in the that the of will be years as late as discussed the that a or be of a In most of these the concern is with cardiac after exercise, because of concern that this cardiac and because of the heart This cardiac or after exercise was probably to increased more in athletes in the because of their and about the of exercise were not during the later of the In to on the dangers of rowing, John a physician from England and of the Oxford for of men who had for Oxford between 1829 and published in 1873 that the were in than the general and that only of the men had from heart disease E. H. Bradford in and in 1903 (47) for who had competed for between and In retrospect, a concern about the effects of vigorous exertion and exercise training are given the and of physicians of the the introduction of the and cardiac were by of the of the to heart and cardiac to cardiac The of the Athlete’s Heart including cardiac and as well as were as heart and of these had because they were with the medical because cardiac with the after exertion was to cardiac THE ATHLETE’S HEART AND THE to the concern about the Athlete’s Heart would the of the This concern would to the of the ACSM on in the in who to this was was a physician in medicine at who was Professor of at the University of from his in the concept that vigorous exercise and exercise training could the In he after exertion in of physical and that with exertion were and not In at the Soldier’s Heart in an dedicated to the of heart disease in from the War James of was a in this and an of exercise in the of the in the Heart was who would the physician, and Thomas an in the of studied James In and his interest in the Athlete’s Heart would influence both and of the of ACSM Indeed, at of the ACSM and had a interest in the Athlete’s Heart. was a who in became of and for the of was not only a and first of ACSM but also a cardiologist to he was of the at was also a of the American Association for that of and a and of the American College of Dr. to the Medical and Heart in The exercise at this Heart was named the for and interest in the Athlete’s Heart. 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Dr. would to England in as a physician to the English He again with Dr. at the and was certainly with Dr. use of exercise for this After his to however, Dr. to and where he and the service when he to of the Heart the of the and Dr. when he was to with the of in after a heart Dr. in when a was in his to both the of the Athlete’s Heart and the use of exercise in heart disease He the and of the of in and the by his English was to whether the cardiac by extreme exercise was with a of cardiac He that not the heart sufficiently to of the In he that a runner named had been rejected for military service because of a heart 40 thought a heart 40 not since I myself had not or of such a but after the of including a to only as but the American he that such could be especially in was reportedly for military service and the Dr. was to exercise. in Dr. for in the England Journal of Medicine with the that Dr. a and Dr. wrote the in his of Dr. of our for exercise, Dr. he and was a his in his after from to he from to that where he was to with John at the the at the the that at the the and all did to he I from the all of including the with in This was not an by Dr. of that asked how it was from the American Heart Association which was on the of and in to The was Dr. the to Dr. Dr. that should exercise a could not exercise an the on the in an event that the of Dr. professional in and exercise, he in running to the of the Marathon Dr. on from The American ran a Dr. a in the over THE ATHLETE’S HEART IN THE THE 20TH This on the Athlete’s Heart to the of the that endurance exercise both cardiac and and that exercise has both risks and The of that Athlete’s Heart in the of the concerns that exercise cardiac the of exercise and and the of the cardiac adaptations to endurance exercise. and in the of in who during War of disease In of the the of during or after physical that only of their in physical activity and that “the of those whose to exertion was in of that which would be by This report is among the early that exercise the of cardiac but this early is because of the that some with cardiac with and with is by by exertion, and cardiac often occur in the when not be and even be in Consequently, without a of how individuals their it is to the of physical The for cardiac during exertion was during the of the in and hypertrophy in to the cause of in young individuals in the United have been first by in but is as the cause of cardiac in his and clinical in in of or during exertion with of an or what they as in the This report was among the first to the of as a cause of and cardiac and of this concept by and in the cardiovascular of exercise in the in to increased popularity of exercise, especially running and and to in medical Dr. in in men who during activity Dr. and in in the in 24 of during was popular during the in in the clinical of individuals who during This was to be published in on September and was but was to the early on September after from during a The and including the of the Times This was of that what was called the named after Dr. Thomas a The that a marathon disease The was in to the in medical These had an of because they often the The after and the risks of exercise. in in that cardiac was more likely during than at and that the was for in the England Journal of Medicine in that cardiac for men and that the was for the These the of the of exercise in an annual of only or has been in form for of a fitness in the of among and college by the for Sports they that for and athletes and in in in the England Journal of Medicine that vigorous exercise the of and as with that the was for the The of the cardiac adaptations to exercise training have also been during the of the The of these have been at the of Sports in on in the medical of athletes a medical physical and with additional such as a and exercise and in athletes including athletes or had a the upper of of these athletes were or sports that both and and a The in was of the athletes had These in athletes in sports was in than in was than the upper of in of the athletes and in The cardiac were for a and for a The sports most with an or than were of and are sports that athletes with as well as a These from the of the of the raised There is cardiac from exercise, but this is small and at in most common among those who exercise exercise has benefits as discussed by early and Roman training cardiac also over a only the about exercise cardiac as by so early have in modern have in some only in ancient THE ATHLETE’S HEART I would to by with the of my own interest in the Athlete’s Heart. I my first if my is in when my father me from our in to the at the father was a who never that had his class when my father was a in his my father at the of a The my father and that of my prized father also and me his to when I was in in me a with exercise, the and the Athlete’s Heart that is how such long have on of us even There is an that who the not the who the have all at the well by clinicians and interested in the cardiovascular of I that this D. Bruce Dill Historical honors Dr. Dill and those who have so hard in that The author to for in the topic and for the and did the and in the