Athlete's heart
In the 19th century, skiing competitions gradually became more commonplace in Norway, and the Association for the Promotion of Skiing held their first race in 1883. As from 1892, the venue was Holmenkollen in Oslo, where there was both ski jumping and cross-country skiing. Prizes were awarded to the best skiers in various classes, but the Ladies' Trophy was given to 'the most dashing skier from Kristiania' (3). The first 50-kilometre race was held in 1888. Although the purpose of the long-distance race was 'to encourage the youth to engage in sensible training and gain a better understanding of the benefits of skiing', medical examinations were carried out both before and after the races as a precaution. An 'irregular pulse' was observed in several of the participants at the finish line. However, 'in the rush, there was no time to examine the nature of the irregularity more closely'. Descriptions of some participants leave no doubt that the 50-kilometre race was an extreme physical challenge: 'Facial colour tends to be decidedly pale, sometimes a grey pallor, in other cases there is concurrent cyanosis (…) The pulse is rapid, weak and soft, sometimes imperceptible and irregular' (4).
Despite the interest in the skiers' pulses, it was the size of their heart that attracted particular attention. Palpation of the apex of the heart and cardiac percussion revealed that some participants had unusually large hearts (4). This led to the term athlete's heart being coined. Around the same time, a Swedish professor conducted similar investigations and even claimed that the fastest skiers had the largest hearts (5). While some argued that athlete's heart was benign and resulted from physiological adaptations to physical exercise, others were quick to link both symptoms and examination findings to excessive training. In 1902, several newspapers published a critical article written by Dr Cato Aall:
'We doctors know that long-distance skiing is not healthy. We know that it costs many young people their health and well-being in later life. It is not without reason that the term 'athlete's heart' has been incorporated into our native medical language: it is especially found among young people who have overexerted themselves early on, for example in skiing, and who now have to suffer the consequences in the form of heart murmurs, feelings of anxiety, shortness of breath, etc., symptoms that stem from what I might call a 'misused' heart. And these conditions must be prevented.' (6)
The medical history of a racer is described in an article published in a Norwegian medical journal (Norsk Magazin for Lægevidenskapen) in 1915 (7):
'About 3 weeks ago, he suddenly experienced shortness of breath, which has reoccurred frequently over the past 14 days... Two doctors from Kristiania who examined him stated that he had developed athlete's heart through excessive physical exercise, and advised him to refrain from all physical activity for about a year. Upon examination, I was able to observe the following deviations from the norm: heartbeat in the 6th intercostal space. About 1.5 cm lateral to the mammillary line. Pulse: irregular.'
In the decades that followed, systematic heart examinations were performed on athletes in Norway, and it became increasingly common to advise against participation in competitive sports. Between 1920 and 1939, a total of 77,826 medical examinations were carried out on athletes in the Norwegian Sports Federation, across 129 medical practices. Around 500 people were advised against participating in sports, while approximately 2600 were told to avoid physical exercise 'for the time being', and more than 2500 were urged to exercise with caution (8). At the first Birkebeiner (cross-country skiing) race in 1932, all athletes were required to undergo a medical examination before the start. Some skiers were prohibited from starting due to, for example, respiratory infections and abnormal pulse. During the Holmenkollen races in 1935, the heart size of 110 participants in the 50 km and 17 km cross-country races was examined using X-ray. One participant had an abnormally enlarged heart before the start, but follow-up examinations showed no sign of heart disease (8).