Da Costa's Syndrome (Soldier's Heart)

From en.wikipedia.org

Da Costa's syndrome, which was colloquially known as soldier's heart, is a syndrome with a set of symptoms that are similar to those of heart disease, though a physical examination does not reveal any physiological abnormalities. In modern times, Da Costa's syndrome is considered the manifestation of an anxiety disorder, and treatment is primarily behavioral, involving modifications to lifestyle and exercise.

The condition was named after Jacob Mendes Da Costa, who investigated and described the disorder during the American Civil War. It is also variously known as cardiac neurosis, chronic asthenia, effort syndrome, functional cardiovascular disease, neurocirculatory asthenia, primary neurasthenia, subacute asthenia and irritable heart.

The World Health Organization classifies this condition as a somatoform autonomic dysfunction (a type of psychosomatic disorder) in their ICD-10 coding system. In their ICD-9 system, it was classified under non-psychotic mental disorders. The syndrome is also frequently interpreted as one of a number of imprecisely characterized "postwar syndromes".

There are many names for the syndrome, which has variously been called cardiac neurosis, chronic asthenia, effort syndrome, functional cardiovascular disease, neurocirculatory asthenia, primary neurasthenia, and subacute asthenia. Da Costa himself called it irritable heart[8] and the term soldier's heart was in common use both before and after his paper. Most authors use these terms interchangeably, but some authors draw a distinction between the different manifestations of this condition, preferring to use different labels to highlight the predominance of psychiatric or non-psychiatric complaints. For example, Oglesby Paul writes that "Not all patients with neurocirculatory asthenia have a cardiac neurosis, and not all patients with cardiac neurosis have neurocirculatory asthenia." None of these terms have widespread use.

Symptoms of Da Costa's syndrome include fatigue upon exertion, shortness of breath, palpitations, sweating, and chest pain. Physical examination reveals no physical abnormalities causing the symptoms.

Da Costa's syndrome is generally considered a physical manifestation of an anxiety disorder.

Although it is listed in the ICD-10 under "somatoform autonomic dysfunction", the term is no longer in common use by any medical agencies and has generally been superseded by more specific diagnoses.

The orthostatic intolerance observed by Da Costa has since also been found in patients diagnosed with chronic fatigue syndrome, postural orthostatic tachycardia syndrome (POTS) and mitral valve prolapse syndrome. In the 21st century, this intolerance is classified as a neurological condition. Exercise intolerance has since been found in many organic diseases.

The report of Da Costa shows that patients recovered from the more severe symptoms when removed from the strenuous activity or sustained lifestyle that caused them.

Other treatments evident from the previous studies were improving physique and posture, appropriate levels of exercise where possible, wearing loose clothing about the waist, and avoiding postural changes such as stooping, or lying on the left or right side, or the back in some cases, which relieved some of the palpitations and chest pains, and standing up slowly can prevent the faintness associated with postural or orthostatic hypotension in some cases.

Da Costa's syndrome is named for the surgeon Jacob Mendes Da Costa, who first observed it in soldiers during the American Civil War. At the time it was proposed, Da Costa's syndrome was seen as a very desirable physiological explanation for "soldier's heart". Use of the term "Da Costa's syndrome" peaked in the early 20th century. Towards the mid-century, the condition was generally re-characterized as a form of neurosis. It was initially classified as "F45.3" (under somatoform disorder of the heart and cardiovascular system) in ICD-10, and is now classified under "somatoform autonomic dysfunction".

Da Costa's syndrome involves a set of symptoms which include left-sided chest pains, palpitations, breathlessness, and fatigue in response to exertion. Earl de Grey who presented four reports on British soldiers with these symptoms between 1864 and 1868, and attributed them to the heavy weight of military equipment being carried in knapsacks which were tightly strapped to the chest in a manner which constricted the action of the heart. Also in 1864, Henry Harthorme observed soldiers in the American Civil War who had similar symptoms which were attributed to “long-continued overexertion, with deficiency of rest and often nourishment”, and indefinite heart complaints were attributed to lack of sleep and bad food. In 1870 Arthur Bowen Myers of the Coldstream Guards also regarded the accoutrements as the cause of the trouble, which he called neurocirculatory asthenia and cardiovascular neurosis.

J. M. Da Costa’s study of 300 soldiers reported similar findings in 1871 and added that the condition often developed and persisted after a bout of fever or diarrhoea. He also noted that the pulse was always greatly and rapidly influenced by position, such as stooping or reclining. A typical case involved a man who was on active duty for several months or more and contracted an annoying bout of diarrhoea or fever, and then, after a short stay in hospital, returned to active service. The soldier soon found that he could not keep up with his comrades in the exertions of a soldier's life as previously, because he would get out of breath, and would get dizzy, and have palpitations and pains in his chest, yet upon examination some time later he appeared generally healthy. In 1876 surgeon Arthur Davy attributed the symptoms to military drill where “over-expanding the chest, caused dilatation of the heart, and so induced irritability".

Since then, a variety of similar or partly similar conditions have been described.

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“Soldiers Heart” How the Civil War Impacted Soldiers During & After

By Chris, 7-9-13

During and after the Civil War surgeons began looking closely at a medical condition that affected some soldiers; what we today know as PTSD (post traumatic stress disorder). It was sometimes first referred to as “melancholy” or “nostalgia” during the war. Then when surgeon Jacob Mendes Da Costa observed symptoms that he classified as a heart issue, which came be to known as “Da Costa’s syndrome,” an idiom developed known as “soldier’s heart” as the description.

In 1871 Da Costa did a study of 300 Civil War veterans that showed there were physical symptoms that he and others associated with combat fatigue. These symptoms persisted in soldiers even after the war. This leads me to the point that soldiers who suffered from PTSD during and after the war really has not received the attention it deserves.

In June 1864, Captain H.L. Patten, of the 20th Massachusetts described mass demoralization and perhaps cases of battle fatigue

"[The men] have been so horribly worked and badgered that
they are utterly unnerved and demoralised. They are easily
scared as a timid child at night. Half our brigade were
taken prisoners the other day, in the middle of the day, by
a line no stronger than themselves, without firing a shot.
You had a campaign of one day, we of fifty-three days; EVERY
DAY under fire, every night either digging or marching. We,
our brigade, have made fourteen charges upon the enemy’s
breastworks, although at last no amount of urging, no heroic
example, no threats, or anything else, could get the line to
STIR ONE PEG. For my own part, I am utterly tired and dis-
heartened and if I stay at all, it will be like a whipt dog
–because I think I must."

Another leading proponent of mental health during and after the war was surgeon general William Alexander Hammond who wrote A Treatise on insanity in its medical relations after the war and noted the impact of battle on “young” and impressionable soldiers, he believed suffered the most. The idea that nostalgia played a significant role was not uncommon as some even believed that after combat soldiers hardened and did not experience further symptoms. Even during the war, some surgeons in various ways considered the condition to be a defect in the rural soldiers or young soldiers who could not adapt to the conditions of soldiering.

However, insanity was a diagnosis during the war that resulted in many soldiers being discharged and even ending up in insane asylums. By World War I battle fatigued (PTSD) was being investigated by Thomas William Salmon who also studied Civil War soldiers and their presence in Insane Asylums.

During the war Richard A. Gabriel of the Senate and House Armed Services Committees and one of the foremost chroniclers of PTSD noted that during 1863 “the number of insane soldiers simply wandering around was so great, there was a public outcry.” As a result the first military hospital for the insane was established that same year, and records for insane soldiers had already been gathered as early as 1862.

From: soldierstudies.org

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The Irritable Heart of Soldiers and the Origins of Anglo American Cardiology: the US Civil War (1861) to World War I (1918) by Charles F Woolley, Aldershot: Ashgate Publishing, 2002.

Reviewed by James Le Fanu, J R Soc Med. 2003 March

One of the striking characteristics of twentieth century medicine was its domination by Anglo-Saxon attitudes and ideas—sustained by the close, almost symbiotic, ties between leading researchers in Britain and the United States. That relationship may be more one-sided than it once was, but it is still heartening to reflect just how many of the important innovations originated from British shores—including antibiotics, of course, but also intraocular implants, hip replacements, CT scanners, in-vitro fertilization, Sir James Black's pharmaceutical discoveries and much else besides.

The transatlantic medical shuffle between the two countries stretches back a long way—Sir William Osler's translation from Johns Hopkins to Oxford being an obvious example—but probably the most significant event was the flood of young American research-oriented doctors who arrived in Britain in 1917 soon after the United States entered the First World War.

Charles Woolley, Emeritus Professor of Medicine at Ohio State University, locates the origins of what would prove to be the very fruitful Anglo-American cooperation in cardiology to a truly remarkable coming together of doctors from the two countries at the 700-bedded Military Heart Hospital in Colchester. The US medical officers posted to the hospital—all of whom subsequently would become leaders in their field—included Samuel Levine, Marcus Rothschild and Frank Wilson while the British consulting staff included (amazingly) Sir William Osler, Sir James Mackenzie, John Parkinson, Sir Clifford Allbutt and Thomas Lewis.

It is difficult to imagine a more distinguished roll call or a more stimulating environment, heightened by the intellectual challenge posed by the condition for which the hospital had been established—the enigma of ‘soldier's heart’. Fifty years earlier Jacob da Costa had described a syndrome of pain, palpitations, shortness of breath and tachycardia in combatants of the American Civil War, and now thousands of soldiers were being invalided out of the trenches in Northern France with precisely the same symtomatology. But was this an organic disease—as Sir Clifford Allbutt maintained—whose unique pattern of symptoms and frequently noted regurgitant murmurs seemed characteristic of diseased heart muscle? Or was it, as Thomas Lewis maintained, a functional disorder—an ‘effort’ syndrome mimicking the typical features of excess effort in men while they were still at rest. The resolution of this clinical conundrum was obviously highly relevant in deciding whether the invalided soldiers should be discharged on the grounds of incapacity for duty. But it also touched on the whole spectrum of recent physiological investigations into the control of the heartbeat and cardiac muscle contractility.

Soldier's heart was, in short, a big issue and a testing ground for the scientific credentials of the nascent discipline of cardiology. And if that were not enough to make Charles Woolley's account worth reading, he has been helped vastly by one of those all too rare jewels of medical history—a contemporaneous account of the personalities and events at the military hospital as recorded in Samuel Levine's wartime diaries. Levine is both an astute observer and an elegant stylist, so his portraits of Osler, Mackenzie, Lewis and his fellow American medical officers are of immense value. Particularly memorable is his account of Sir William Osler's brilliant and sympathetic display of clinical skills at the bedside just a few days after his beloved and only son Revere had been killed in action at the front. Woolley's book might have been better organized and would have benefited from a wider perspective to include the experience of those afflicted by soldier's heart—but there is so much else going for it these are mere quibbles. It concludes with a retrospective verdict on the conflicting views over the aetiology of soldier's heart, which is particularly relevant in this age of Gulf War syndrome and chronic fatigue.

From: ncbi.nllm.nih.gov

Image: Pair of Civil War Brass Heart Bridle Rosettes from www.polyvore.

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General Robert E. Lee's Probable Heart Attack in 1863

From: examiner.com

Confederate General Robert E. Lee, at age 56, was experiencing pain in his chest, back and arms in late March and early April of 1863. Several doctors diagnosed pericarditis. Pericarditis by definition, according to the Mayo Clinic, is “a swelling and irritation of the pericardium, the thin sac membrane that surrounds your heart.”

For General Lee, his doctors, Lafayette Guild and S. M. Bemiss, prescribed rest, gave him quinine and sent him into a private home near Fredericksburg, Virginia and away from the rebel camp. He was confined in bed for several weeks and was feverish. By April 16, he was back in camp, but still not feeling 100%.

Modern doctors hold the opinion that Lee suffered a heart attack. They say that doctors of the day were not familiar with angina.

How much General Lee’s illness or condition affected his performance at the upcoming battle at Gettysburg on July 1-3, 1863 is anyone’s guess. He did, however, offer his resignation within a few weeks following that battle, citing his inability to lead caused by extreme physical fatigue. That resignation obviously was not accepted.

General Lee lived until his death in October 12, 1870 following a stroke that had occurred on September 28.

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Dr. Jacob Mendes Da Costa and "Irritable Heart"

From jeffline.jefferson.edu

Jacob Mendes Da Costa’s research, writings, and teaching were influential in the development of internal medicine as a specialty. However, his greatest contribution to American medicine lay in his clinical instruction at various Philadelphia institutions. Born 7 February 1833 on the Island of St. Thomas in the West Indies, Jacob Mendes Da Costa received his early education in Dresden, Germany, before coming to Jefferson Medical College. A graduate of the class of 1852, Da Costa received postgraduate education in Europe - mainly Paris but also Vienna.

Upon his return from Europe, Da Costa began his practice in Philadelphia and his private teaching at the Moyamensing Dispensary (1853-1861). During the Civil War, Da Costa served as assistant surgeon in the U.S. Army and at Turner’s Lane Hospital, Philadelphia. Here, he undertook research on "irritable heart" (neurocirculatory asthenia) in soldiers, research that was of landmark importance in clinical medicine. After the Civil War, Da Costa continued his teaching at the Pennsylvania Hospital (1865-1900). He began at Jefferson Medical College as a lecturer on clinical medicine (1866-1872), then professor of theory and practice of medicine (1872-1891), and finally professor emeritus (1891-1900). While Da Costa retired in 1891, he continued his medical efforts as a consultant and supporter for medical education reform and served as a trustee of the University of Pennsylvania in 1899.

Of Da Costa’s writings, his most well known include his "Clinical lecture on spurious or "phantom" tumors of the abdomen," Philadelphia Medical Times (1871) and his monograph Medical Diagnosis (1864).  Medical Diagnosis went through nine editions during his lifetime and served as the first complete guide of its kind.

Jacob Mendes Da Costa died in Villanova, Pennsylvania on 11 September 1900.

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Cardiology History 101: Lessons Learned from the Civil War

By Dr. Stephen Sinatra

I've had a longtime interest in the Civil War. In fact, some of my patients in Connecticut may recall how my waiting room was decorated with my collection of Civil War generals and battle scenes. So, this summer I was delighted to take in the annual Deep River Ancient Muster, a two hour event with fife and drum corps.

My wife feels strong ties to this town because it was her paternal grandfather's hometown, and he often brought her there to visit his family. Little did either of us realize that this sleepy little village hosts the largest fife and drum corps muster in the world! Its impact on me was palpable.

Decades ago my Civil War curiosity involved taking my kids to visit Civil War battlefields between New England and Atlanta, Georgia. But it took this summer's muster—and hearing the marching band music that originated as far back as the American Revolution—to help me envision the sounds on the battleground. I listened to the antique musket-fire, the fifes, the drums, and the cadence of the feet and imagined the call to arms, battle cries, the thunder of cannons, and cries of agony.  

That experience reminded me cardiology has some pretty impressive historical roots that date back to that sad time. What was then referred to as "soldier’s heart" was a set of symptoms very similar to what we know of as heart disease now. Some of those poor soldiers—many of whom were very young men, and even boys—had complaints that were at first written off as lack of sleep, or "bad food." They would report shortness of breath, fatigue with exertion, inability to keep up with comrades, palpitations of the heart, sweating, dizziness, and even chest pain.

This condition was eventually referred to as "Da Costa's Syndrome," named for Jacob Mendes Da Costa—the physician and surgeon who investigated and described the disorder back then. He worked in Union hospitals and observed patients with what he called an "irritable heart." Yet, they didn’t exhibit any of the physical abnormalities he expected to find with an irritable heart, such as an enlarged or dilated heart. In his 1871 report of 300 soldiers, he also described GI ailments, diarrhea, and high fevers in those with more advanced cases.

Moreover, Da Costa identified rapid heart rates that were extremely influenced by body position. This kind of "orthostatic intolerance" is also seen today in medical conditions such as mitral valve prolapse, postural orthostatic tachycardia syndrome (POTS), and chronic fatigue. He also observed symptom relief in more severe cases when the soldier was removed from the stress. Da Costa’s Syndrome has been described as both an anxiety disorder and a neurological condition—known also as battle fatigue. It laid the foundation for what we call post traumatic stress disorder (PTSD), which is a condition that affects many people today.

Yes, you may not know it, but the Civil War taught us a lot about the effects that chronic, unrelenting stress has on the heart. As I've mentioned before, the many forms of human heartbreak can also impact the heart catastrophically. Today, our soldiers continue to serve and remind us of the huge impact unrelenting stress can have on the body.

So, what’s the takeaway here? If you’re having any cardiac symptoms, and think stress has any role to play, take action. Do NOT underestimate the fact that stress can kill. Maybe you are at war with yourself. Maybe your battlefield is the office, or your home situation, finances, or a family member's illness. Remember, you don't have to be under as much stress as our veterans have experienced for your own heart to be affected. The first step is recognizing that it's a problem, just like Dr. Da Costa did, and see your doctor for a thorough evaluation.

Excerpted from: drsinatra.com

IMAGE: Jacob Mendes Da Costa

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