Da Costa's Syndrome

Da Costa's syndrome or "Disorderly Action of the Heart (DAH)" was first described in 1874 by Dr J. M. Da Costa when he gave a lecture entitled"On Strain and Overaction of the Heart".

By 1917, it was still considered to be a condition requiring treatment as the following extract from
"Clinical Cardiology", by Selian Neuhof MD. (MacMillan NY 1917 Chapter XX, p.255) describes. Dr Neuhof was unusual in that he recognised that reassurance about the heart was the mainstay of treatment. During WW1 it was a recognised illness, causing considerable apparent disability in the armed forces and usually followed significant stress such as occurs during war service. In 1920-1921 some 8,832 pensions had been awarded for "Functional Disease of the Heart" (See The Official History of the War, Medical Services, Casualties and Medical Statistics, page 323) Many patients considered themselves to be cardiac invalids and prolonged rest was often recommended.

Nowadays Da Costa's syndrome is rarely diagnosed. It is now recognised that the condition is not associated with any significant cardiac disease process and in particular it is not considered to be associated with instability of the vaso-motor mechanism as described by Dr Neuhof in 1917. Patients are treated by reassurance, advice that there is nothing wrong with their heart, that no medication nor extra rest is required and that they should live a normal fully active life.

Dr M. G. Miller

Chapter XX, '"Weak" Heart' from "Clinical Cardiology" by Dr Selian Neuhof, 1917 (MacMillan NY)

Clinical Symptoms

"Weak ", "asthenie," " neurotic," " neurasthenic " hearts are some of the terms more or less loosely applied to various ill-defined conditions in which the salient feature is an unstable state of the vasomotor mechanism. I shall not here include a discussion of the arrhythmias which in themselves are sometimes regarded as evidence of a "weak" heart. Stress is often laid upon the presence of a soft, faint, systolic murmur over the apex, only slightly or not at all transmitted. Moderate hypotension is also common in these individuals. Unless one chooses to interpret such findings as organic there is no evidence of organic cardiovascular disease. Subjectively, the patients complain of tiring very easily; if the occasion demands it, however, they can undergo long-continued physical exertion with no sign of strain upon the circulatory system. They also often complain of feeling faint or dizzy; sometimes they actually lose consciousness. Their faces and hands readily redden or blanch, with a corresponding feeling of warmth or cold in these parts.

These changes are due to vasomotor instability and not to "weak" circulation. This is evidenced by the fact that these patients never suffer from edema or visceral congestion, or from any of the signs found in decompensation.

Aside from symptoms and physical signs referable to the circulation, these individuals sometimes suffer from ill-defined gastric complaints of non-organic nature often associated with referred intercostal and precordial pains. It is because of these that one's attention is drawn to the heart as the presumed offending organ. Nervous strain, joy, worry, excitement, and physical fatigue quickly elicit many of these symptoms I have referred to. The same factors seem occasionally to exercise an influence upon the apical. murmur, which, at such times, becomes somewhat louder. The cause of this increased intensity is not clear; it may consist in some disturbance of the muscular ring at the mitral opening, allowing regurgitation.

These patients are as a class usually regarded as neurasthenic, because, though frequently of robust appearance, little or no physical basis for their symptoms can be found. Many have been fluoroscoped in a search for some abnormality in the size and shape of the heart in order to account for the instability of the circulation. I have studied a number of cases of "weak" hearts fluoroscopically. In some I have found the abnormal orthodiascopic types above referred to; in others, I have found the heart of normal size and contour, or with the left ventricle lying quite broad and flat upon the diaphragm. In other words, there was no orthodiascopic picture that I observed to be definitely correlated with "weak" heart. In addition, I have made the fluoroscopic observation that some of these "weak-hearted" individuals show particularly vigorous and strong ventricular contractions. It is therefore clearly evident that there is no constant parallelism between the vasomotor symptoms and the muscular power of the heart.

A few brief illustrative clinical histories and findings will serve to typify some of these patients.

A buxom woman of 45 had been told for years that her heart was weak. There was no history of any previous serious illness. She had had two children who died. Very soon after the death of the last child, there began a series of symptoms consisting of giddiness, nausea, and flushing or pallor of the face. These symptoms have been intensified since her menopause two years ago, so that, in addition, she often feels faint .and, in fact, actually fainted several times. There is a very soft systolic murmur at the apex, the orthodiascopic tracing shows an outline slightly broader than the normal, the blood pressure and all the other physical findings are normal. Thispatient has been under my observation for several years. She has undergone a severe operation for appendicitis with no effect upon her circulation.

A vigorous woman of 40, married and the mother of two children, while abroad was suddenly called home by illness in her family. She became worried, and soon complained of feeling fatigued; her hands and face readily became cold; she had pains across the chest upon exertion. There was a faint systolic murmur at the apex; orthodiascopic examination revealed a somewhat broad left ventricle; otherwise the cardiovascular and general examination revealed nothing abnormal. Upon being assured that her heart and other organs were normal, she soon recovered her mental poise. She began taking active exercise and now walks several miles daily without cardiac or other complaints.

A tall, narrow-chested, and somewhat anemic youth of 20 complained of frequent flushes and a feeling of "heat" in the face. The lungs and cardiovascular system were normal. The only abnormal finding was a narrow and pendulous heart. Upon being told after the examination that there was no lesion of any kind in the heart and lungs, he began leading a more normal and athletic life with rapid disappearance of the vasomotor symptoms.

I believe it is worth while emphasizing that the fundamental abnormality of this entire group of patients lies in an instability of the vasomotor mechanism, the cause of the irregular flushes, pallor, dizziness, and faintness. Nerve shock of any kind is often the culminating factor initiating the more acute symptoms.

To a great extent, therapy lies in firmly assuring the patient that there is no organic disease, and that the symptoms can be cured or at least greatly alleviated. It is a diagnostic and therapeutic error to dismiss these individuals by telling them that they are "nervous" for the symptoms are real and usually beyond their control. The treatment sometimes requires patience and always careful individualization. The patient should never follow any form of exercise, no matter how slight, to the point of fatigue. If no improvement follows, a rest cure for a longer or shorter time may be required. Patients too intent upon business must decrease the number of hours and the intensity of their work. At no time should these individuals feel hurried at their work or even at their pleasures. Rest in the reclining position, getting up late, having breakfast in bed, long rest at night, mild balneotherapy; later, graded calisthenics, or exercise in the open (golfing, tennis, swimming), are measures which, appropriately applied and carefully selected, are of great aid to the patient in helping him regain his vasomotor equilibrium and in finally enabling him gradually to return to his accustomed duties.

Among drugs, I have found a combination of atropine sulphate (grains 1/200 to 1/100) with nitroglycerin (grain 1/150 to 1/50, three times a day before meals, of most value. Where hypotension is present, suprarenal extract is sometimes of value. In addition, strychnine may be helpful. if symptoms are intensified at menopause, ovarian extract (corpus luteum) may be tried. It must be stated, however, that because of the type of the fundamental disorder - instability of the vasomotor mechanism - the effect of treatment is sometimes disappointing to the physician and discouraging to the patient.

Adler and Krehbiel: Orthodiascopic Observations concerning a Certain Type of Small Heart, etc.; Archives of Internal Medicine, 1912, IX, 346.

DaCosta, J. M.: On Strain and Overaction of the Heart; Third Toner Lecture, May, 1874.

DaCosta, J. M.: Cardiac Asthenia or Heart Exhaustion; American Journal of the Medical Sciences, 1894, CVII, 361.

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