Jacob Mendez DaCost a: Medical teacher, clinician, and clinical investigator

HISTORICAL STUDIES

Jacob Mendez DaCosta : Medical Teacher, Clinician, and Clinical Investigator

CHARLES F . WOOLEY, MD

J. M . DaCosta, a scholarly, well-trained and observant clinician, was recognized during his lifetime as a well-known authority on physical diagnosis and had an unexcelled reputation as a clinical teacher . Chairman of Medicine at the Jefferson Medical College for 19 years, president of the College of Physicians of Philadelphia in 1884 and again in 1895, he was one of the original members of the Association of American Physicians and its president in 1897 . Earlier in his career, his extensive Civil War study of "a form of cardiac malady common

among soldiers . . . the study of which is equally interesting to the civil practitioner" was described in his 1871 paper "On Irritable Heart ; A Clinical Study of a Form of Functional Cardiac Disorder and Its Consequences." Soon labeled DaCosta's syndrome, the irritable heart lineage can be traced through the soldier's heart, the effort syndrome, and neurocirculatory asthenia in World War I, anxiety neurosis in World War II, and the mitral valve prolapse syndrome in the second half of the 20th century.

The Jefferson Medical College Alumni Bulletin (spring 1975) contains an article by Robert I . Wise' which traces the history of the Chair of Medicine at Jefferson from its origins with the founding of Jefferson Medical College on June 2, 1824, when 4 physicians were appointed by the trustees of Jefferson College of Canonsburg (now the Washington and Jefferson College) as the first faculty of the new medical college . Joseph Klapp (1 year), John Eberle (5 years), Daniel Drake (1 year), John Revere (10 years), John Kearsley Mitchell (17 years), Samuel Dickson (14 years), Jacob DaCosta (19 years), and James C . Wilson (20 years) occupied the Chair of Medicine from 1824 to 1911, the period pertinent to my quest . The early years : Jacob M . DaCosta entered Jefferson Medical College in 1849, graduated 3 years later at the age of 19 at a time when the medical faculty included John Kearsley Mitchell (medicine), T . D . Mutter (surgery), Charles D . Meigs (obstetrics), Franklin Bache (chemistry), Robley Dunglison, Joseph Pancoast (anatomy), and Robert Huston (dean of faculty, materia

medica), during a "golden age, a time of distinction and academic prosperity for Jefferson ."' DaCosta brought an unusual background to medical college, at a time when the educational background of many American medical students was limited or nil . He was born on the island of St . Thomas, West Indies, in a family of Spanish and Portuguese extraction . His father, John Mendez DaCosta, a gentleman of wealth and culture, descended from an English branch of the family. Jacob was 4 when his parents left St . Thomas to live in Europe, where he and his brother Charles attended a gymnasium in Dresden. Studies included the classics and modern languages, and he became fluent in French and German, with a reading knowledge of Spanish, Portuguese, Italian and Dutch . He came to Philadelphia in 1849, where his mother was then living, and entered Jefferson Medical College . As a student of Professor Mutter, DaCosta, along with friend and fellow student John H . Brinton, conducted demonstrations of tumors and specimens removed by Mutter at his clinics . Brinton, a Philadelphian, graduated with DaCosta in 1853, later served with Grant in the Tennessee and Cumberland River Campaign in 1862, and became Professor of Surgery at Jefferson after Samuel Gross in 1882 . DaCosta married Frederica Brinton in April 1860. After graduation, DaCosta spent 18 months in Paris and Vienna, involved in the study of pathology and internal medicine . Participation in medical and cultural

From the Department of Medicine, Ohio State University College of Medicine, Columbus, Ohio. Manuscript received February 1, 1982 ; revised manuscript received April 19, 1982, accepted April 26, 1982 . Address for reprints : Charles F. Wooley, MD, Ohio State University Hospital . Means Hall, Room 647, 1655 Upham Drive, Columbus, Ohio 43210 .

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FIGURE 1 . The mature DaCosta . Courtesy of the Scott Memorial Library, Thomas Jefferson University .

activities was enhanced by his knowledge of languages . He studied, attended the clinics, went to the great hospitals of Paris (Hotel Dieu, La Charite), and absorbed the wisdom of a great medical center where Robin, Claude Bernard, Verneuil, Nealton, Broca, and Trousseau were active and teaching . Trousseau, in particular, made a deep and lasting impression on the young DaCosta . Trousseau's magnificent lecture 2 on percussion began with a discussion of Auenbrueger, made the transition to Corvisart and his pupil Laennec, and traced the development of the physical examination of the chest as related to the concomitant development of urinalysis, examination by the speculum, the laryngoscope, and the opthalmoscope so "the most inaccessible organs can now be seen ." Trousseau concluded with a reflection and a charge : "Rich in the possessions bequeathed to you by the physicians of the past, to you belongs the duty of uniting modern science with ancient wisdom, and of rekindling the temporarily despised torch of old medical traditions . Let this be your endeavor! It is a great and splendid aim! Fail not to pursue it!" The impact of the Parisian teachers, and the further experiences in Prague and Vienna with August Klaatsch, Hyrtl, Skoda, Oppolzer, Bamberger, Rokitansky, and Hebra set, as Wilson 3 notes " . . . a clear course toward his lifework-pathological anatomy, visceral disease, the heart and lungs, and the diseases of the skin in their relation to general medicine ; in a word, internal medicine in its broadest sense, the greatest of the specialties ." Again, from Wilson : "He would be a teacher ; at all events, he would fit himself to be one. The talent was inborn ."

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DaCosta returned to Philadelphia in 1853 . Philadelphia, with a long tradition of leadership in American medicine, was the site of the nation's first medical school, hospital, school of pharmacy, and mental hospital. Baltze11 4 notes that in " . . . 1847, when the American Medical Association was founded in Philadelphia to bring order out of the chaos of standards then regulating the profession, all the officers either were practicing in the city or were graduates of the Penn Medical School ; eight of the first ten presidents of the AMA trained at Penn ." When DaCosta returned to this environment, he was invited to take part in the Summer Association for Medical Instruction located on Chant Street, "a place of historical interest in the medical life of Philadelphia, long famous for all kinds of extramural teaching. In this work he was associated with men somewhat older than himself, but still young, who had attracted attention as teachers and practitioners . Prominent among them were John Forsyth Meigs, Frank West, the Wallace brothers, Robert Bridges, John H . Brinton, and Addinell Hewson . To DaCosta was assigned the subject of Physical Diagnosis ."3 DaCosta combined office practice (at 212 South Eleventh Street), instruction of students in physical diagnosis, and an appointment as a physician to the dispensary attached to the Moyamensing House of Industry . The death of John Kearsley Mitchell in 1858 was followed by the appointment of Samuel Dickson to the Chair of Medicine at Jefferson . Dickson, trained under Physick, Dorsey, and Chapman at the University of Pennsylvania, had been one of the founders of the Medical College of South Carolina . "From this date DaCosta became closely identified with the Jefferson College, at first as an instructor of telling influence in connection with the Chair of Medicine, subsequently as clinical lecturer, and finally, in 1872, as the successor to Professor Dickson in the Chair of Practice ." 3 The Turner's Lane years : DaCosta's syndrome: The War Between the States affected Philadelphia in a unique way . Philadelphia became a major hospital center as the war progressed, and by 1865 there were 27 hospitals and 25,000 beds in or near the city . S . Weir Mitchell, son of John Kearsley Mitchell, recalled 5 that it " . . . became necessary to provide additional help in the hospital service, and this was supplied by employing what were known as acting assistant surgeons . They served at home, but were liable to be called into duty in the field. Except in the case of Antietam and Gettysburg this was rare . Among these were Agnew, Gross, Morton, Stille, DaCosta, Harry Hart and many more ."5 A number of specialized infirmaries developed as the war progressed ; one of these was designated by the U .S . Army Medical Department as the U .S . Army Hospital for Injuries and Diseases of the Nervous System, Turner's Lane . Weir Mitchell described the move from the building known as Moyamensing Hall on Christian Street to the Turner's Lane Hospital : " . . . the space proving insufficient, a surburban estate on Turner's Lane was rented in August 1862, and pavilions built for

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400 men . One was assigned to DaCosta, and afforded him a chance for a classical study of exhausted hearts and for other able papers ."5 The Turner's Lane story has been told by William Middleton 6 in a remarkable work. The contributions of S . Weir Mitchell, William Keen, and George Morehouse to clinical neurology represent an early example of the specialty approach in clinical medicine, with clinical research conducted in a controlled clinical research center. The earlier publication and recognition of these neurologic studies eclipsed the work by DaCosta from the same institution ; although DaCosta presented preliminary reports of his work in 1862 and 1864, there was a long lag time from the original studies on soldiers with "irritable heart" to the publication of his definitive work in 1871 . The definitive report "On Irritable Heart : A Clinical Study of a Form of Functional Cardiac Disorder and Its Consequences" 7 is a landmark study in the history of cardiovascular disease . Jarcho8 noted that in an era dominated by the search for organic ailments, "DaCosta's study of the condition which he named irritable heart was an attempt to cross the frontier into the obscure realm of functional disease . . . . DaCosta's paper is an impressive example of nineteenth century clinical research, conducted entirely by simple methods of history taking and physical examination without the assistance of the laboratory . The author was aided by a wise policy of the War Department, which concentrated cases of irritable heart in the hospital at Turner's Lane at Philadelphia under DaCosta's care . This favored the rapid accumulation of data and the synthesis of the clinical picture. A similar method had been in use in the hospitals of Paris and was extremely helpful if not essential to the work of Laennec and his great contemporaries."$ The report is a mature work by a young clinician who made good use of his knowledge of physical diagnosis, recorded and trusted his own carefully documented clinical observations, and filtered the essentials from studies of over 300 cases . After careful reflection he set forth a classic description of a clinical subject that would resurface periodically and be renamed DaCosta's syndrome, soldier's heart, effort syndrome, and neurocirculatory asthenia in World War I, anxiety neurosis in World War II, and the systolic click-late systolic murmur syndrome or the mitral valve prolapse syndrome in the 1960s and 1970s . 9 DaCosta : clinical teacher : His medical treatise, "Medical Diagnosis," was published in 1864 ; it went through 9 editions, was intended as a guide to the knowledge and discrimination of diseases, and later appeared in German, Russian, and French translations . The approach that DaCosta used was to group morbid states "according to their marked symptoms ." DaCosta (Figure 1) was one of the founders of the successful and influential Pathological Society of Philadelphia, served as its secretary during the early years and as its president in 1864 through 1866 . His early medical reports reflected his interest in pathology,

and dealt with the pathologic anatomy of acute pneumonia and pancreatic cancer . He was 39 years old when he succeeded Dickson in the Chair of Practice ; Wilson 3 noted that he had " . . . established himself as a successful practitioner, a teacher of the highest order, and a trusted consultant . . . . He served as physician to the Episcopal Hospital, to the Philadelphia Hospital, and to the Hospital of the Jefferson College, and was for many years consulting physician to the Childrens Hospital . . . . His clinics were models of the finest methods of medical instruction-clear, systematic, and impressive ." As a member of the staff of the Pennsylvania Hospital from 1865 until his death 35 years later, he exerted a "most important influence . . . upon the long line of resident physicians whose good fortune it was to serve with him ." 3 Wilson himself was one of the physicians influenced by DaCosta, served as Chief Clinical Assistant to Professor DaCosta at Jefferson, and was appointed to Chair of Medicine when DaCosta resigned in 1891 . The historical archives at the Jefferson Library contain a "report of clinical lectures of Jacob M . DaCosta, M .D ." for 1875, 354 pages of beautifully handwritten notes by Theodore Horwitz 10 submitted for the Professor DaCosta prize, which dealt with a broad spectrum of disease organized as to presentation, findings, diagnosis, and treatment . Reading through the Horwitz lecture notes and a later set by W . Wehner from 1884 to 1886, one is transported in time to DaCosta's Clinics, to eavesdrop on the professor and reflect on medical thinking of the time . The manuscript of the valedictory address to the graduating class of the Jefferson Medical College of Philadelphia of 1891, "Professional Aspirations," contains a letter dated September 29, 1891 : "My Dear Charlie, You asked me to give you the manuscript of something I have written . I give you this-my valedictory, and the last thing I wrote before resigning my Professorship . Ever affectionately, your father, J . M. DaCosta ." 11 As I reviewed the remnants of DaCosta's career, visited the archives at the College of Physicians of Philadelphia and at Thomas Jefferson University, I wondered why he is little known and honored within and without Philadelphia. After all, DaCosta, " . . . in the opinion of F . H . Garrison was probably the most able teacher of his time in the Eastern states," 8 and Stone observed that he was " . . . perhaps the best know authority on physical diagnosis in this country, and for the past thirty years has had an unexcelled reputation as a clinical teacher ." 12 He did not move once he was established at Jefferson, nor did he write a great deal, and these may be the important factors . The significance and originality of his Civil War researches have yet to be fully appreciated . He did not have the benefit of strong public relations (such as exists at Harvard, Hopkins, or the Rockefeller) during his lifetime or during this century. The class structure and cultural atmosphere of Philadelphia, as articulated by Baltzell, 4

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wherein the Quaker traits of modest behavior and gentlemanly decorum interfere with the assumption of dominant leadership roles, deserve serious consideration . The replacement of the master clinician-teacher in the medical heirarchy by the scientific researcher, coupled with gradual erosion of Philadelphia's early medical leadership role, must rank as contributing factors . Mary A . Clarke, 13 for many years DaCosta's private secretary, wrote a richly detailed memoir which appeared in the American Journal of Medical Science in 1903, and supports Baltzell's Philadelphia Gentleman's hypothesis: "Dr . DaCosta was greatly opposed to the publications of biographical sketches of the living, and invariably refused to give information concerning himself for such projected works . Only after Harvard had conferred upon him, in 1897, the degree of L .L .D ., and at the urgent request of the editors of the Harvard Graduates' Magazine, he furnished them a brief sketch of his life, which has been made use of by other journals ." Although reticent about publication of details of his personal life, Wilson 3 tells us that DaCosta had "a deep interest in the welfare of the organized profession, an interest he maintained throughout his life ." His leadership qualities were manifest as chairman of a major department at a major medical college for 19 years, in the College of Physicians of Philadelphia as a Fellow (1858) and its president in the line of Redman and Shippen in 1884 and 1855 and again a decade later from 1895 to 1898, and as one of the original members of the Association of American Physicians and its President in 1897 . It seems fitting to recall Jacob Mendez DaCosta for many reasons-as an early American clinical investigator working in a clinical research center (Turner's Lane), as a patron for unsung clinicians and teachers in medical schools, as an example of the finest qualities of the Philadelphia medical spirit, and as a noble man and physician . At a time when ambition and commercialism

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have confused the current medical leadership, hierarchy, and membership as to the essential roles and function of physicians, the simplicity, the directness of purpose, and the essential nobility of the man deserve recall and incorporation into our individual lives . It certainly seems reasonable to search for his qualities within ourselves and among all students of medicine . Acknowledgment

The time, kindness, materials, and assistance extended to me by Robert T . Lentz, Archivist, and Samuel A . Davis, Librarian, Scott Memorial Library, Thomas Jefferson University, and Lisabeth M . Holloway, Christine Ruggere, and Pat Connors, Historical Collections, Library of the College of Physicians of Philadelphia, are gratefully acknowledged . Franklin Freeman, great-grandson of Dr . William W . Keen of Philadelphia and a student of Philadelphia Medicine, shared valuable insights, perspectives, and information . Jo Ann Martin provided secretarial assistance . References 1 . Wise RI . The Magee professor : history and heritage . Jefferson Medical College Alumni Bulletin 1975 ;24:4-17 . 2. Trousseau A . Clinical Medicine : Lectures Delivered at the Hotel-Dieu Paris . Philadelphia: Blakiston, Son, 1882 :949-956 . 3. Wilson JC . Memoir of J. M . DaCosta, M .D. Transactions of the College of Physicians of Philadelphia . Third Series, 1902;24 :82-92 . 4. Baltzell ED . The medical profession in Philadelphia and Boston. In: Baltzell ED, Puritan Boston and Quaker Philadelphia . London : The Free Press, 1979;352-363 . 5 . Mitchell SW . Some personal recollections of the Civil War . Transactions of the College of Physicians of Philadelphia, 1905 ;27 :87-89. 6 . Middleton WS . Turner's Lane Hospital . In : Values in Modern Medicine . Madison: University of Wisconsin Press, 1972;78-100 . 7 . DaCosta JM. On irritable heart . Am J Med Sci 1871 ;61 :17-52 . 8 . Jarcho S . Functional heart disease in the Civil War (DaCosta, 1871) . Am J Cardiol 1959 ;4 :809-817 . 9 . Wooley CF . Where are the diseases of yesteryear? DaCosta's syndrome, soldier's heart, the effort syndrome, neurocirculatory asthenia-and the mitral valve prolapse syndrome . Circulation 1976;53 :749-751 . 10 . Horwitz T . Report of clinical lectures of Jacob M . DaCosta, M .D. Professor of Practice of Medicine, Jefferson Medical College. Archives of the Scott Memorial Library, Thomas Jefferson University . 11 . DaCosta JM. Professional aspirations: valedictory address to the graduating class of the Jefferson Medical College of Philadelphia . Delivered April 15, 1891 by J . M . DaCosta, M .D., L .L.D ., Professor of the Practice of Medicine and of Clinical Medicine. (Philadelphia, 1891) . Manuscript, Library of the College of Physicians of Philadelphia, Cage 10A284. 12. Stone RF, ed. Biography of Eminent American Physicians and Surgeons . Indianapolis : Carton & Hollenbeck, 1894 :602. 13 . Clark MA . Memoir of J . M. DaCosta . Am J Med Sci 1903 ;125 :318-329 .

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