The network of events
But the particular event, the particular complaint for which the patient comes to us, is woven not merely into one chain of evidence, but into several. Let us carry out the metaphor of the chain. We must imagine many chains woven into one another like the chain-armor of the mediæval knight. Each link is a fact. But many chains of facts are interwoven in the history of one single patient. First there is the chain of medical evidence, the links (or symptoms) leading up to a diagnosis; second, the chain of social evidence, which we try to classify on our social history card. Third, we must trace the links in the chain of relationship with other people, other members of the family, with friends and fellow workers or schoolmates. Finally, the chain of heredity, of which we cannot make much at present except in relation to tuberculosis and mental disease or mental deficiency. But these studies of heredity in its bearing on character are going to be more important as the science of social work develops.
Our first attempt, then, after determining the "presenting symptom," is to find out by a series of questions how this symptom is linked up into a tissue composed of many chains of facts. Our next task which is usually difficult, and frequently impossible, is to find out why this great tissue of evidence issues just now in one particular "presenting symptom." Why did the patient come to us to-day? This question is often impossible to answer because the patient does not know, though he may think he knows. Nevertheless, the social worker must try to find out. Often it is not until we have known and liked a person for days or weeks that we find out why he came to us at this particular time. Yet the answer to this question may be the most important thing that we can find out. For two reasons it is important; first, because it furnishes the clue to all our later investigation and assistance in this case; secondly, because it may show that the individual's complaints are not of any significance at all.
I can illustrate this by a case studied at the Massachusetts General Hospital in Boston. We looked up a series of patients at their homes in order to find out if we had really been of any service. The cases were not selected, but were taken from our files in numerical order. Among others we visited a lady whose malady had been diagnosed as "sacro-iliac strain." She had been given a prescription for a belt. We wanted to find out whether she had ever bought the belt and whether it had helped her. After some difficulty the visitor finally got the following details: The lady had come from a city twenty miles distant from Boston. She had taken an early morning train, and could not get back to her home the same night. Hence she could not soon make another trip like that. She came to have her eyes examined. Now it happened that we had no eye clinic at the hospital at that time. But the lady had heard a great deal about the hospital and its efficiency. She was determined not to go home without having got something out of the hospital. So when she was told at the Admission Desk that she could get no treatment for diseases of the eye, she wandered into the medical clinic, trying to remember or imagine some symptoms for the relief of which she could be admitted to the clinic. Finally she managed to get out some sort of a story about a pain in her back; she was referred to the orthopedic division; there a diagnosis of sacro-iliac disease was made and a belt was advised. When she got home, of course, she laughed at the idea of buying a costly belt.
Now, if we could have found out in the beginning why she came to the hospital, we might have saved a good deal of bother for a good many people. It is astonishing how many patients turn out to have as little reason for coming now as this lady did. One of the things that shows the arbitrariness of choice in selecting a time for visiting the hospital, is the striking diminution in the number of patients in the week before Christmas. That suggests that there are many postponable visits. Or again, patients may come merely because somebody else from the same neighborhood is coming.
Listening and questioning
As the history-taker traces out the symptoms of the patient's illness after finding an answer to this first question, Why to-day? two opposite habits of mind must be employed, one passive, the other active. We must be sure that the patient shall feel that he has had a good listener, that his troubles have really been appreciated. But if we are constantly putting in questions, as we certainly must later, the patient does not feel that he has been listened to. We desire first of all to get his own story in his own words, passively. We may not necessarily write down a single word of it. But I have found that the patient's own way of expressing the nature of his troubles is often important and characteristic. It helps to prevent our histories from looking too much alike, which is their commonest fault. Hence we should get into them somewhere a phrase or several phrases reported passively in the patient's own words; if possible a phrase in which he describes his "presenting symptom," the thing of which he chiefly complains.
But the second stage in the process of taking a patient's history is the most important. In this part we should be active, not passive. We must attack our task with a tool in our hand, a mental tool fitted to rake out of the mass of confused ideas in his mind certain significant facts. That rake is a logical schedule of questions which you use upon him actively, not passively, and by using which you get answers either negative or positive. Whenever you think well, you think with a schedule of that kind in your mind. If you pack a trunk well, you pack it using a list, a schedule of the things that ought to go into that trunk. Our printed social face-card helps us to think and question with a schedule before us, to think in an orderly way, without forgetting our items, and thus to select what we need out of the mass of disorderly facts in the patient's memory.
In the second phase of history-taking, then, which begins after we have listened appreciatively but quietly to the patient's own version—usually catastrophic and full of fanciful theories—we lead him by questions (but not by "leading questions") along the paths which will open up a full view of the trouble, medical or social, which has been suggested to us by the patient's first statements. Suppose, for instance, one happened to know of an extraordinarily rare but curable disease, one symptom of which the patient had mentioned, "My hair comes out by handfuls." One would go on to ask, "Do you feel warmer or colder than usual this winter?" Then, "The expression of your face is not notably changed, is it, so that your friends comment on it?" "Is your skin drier or moister than usual?" "Does your tongue bother you in any way?" "Is your mind more or less active than usual?" Thus one would confirm or refute the suggestion of the disease called myxœdema, a suggestion which was given to us by the patient's first complaint—rapid loss of hair. Given one symptom in a known group, one can trace out the others as the anatomist who finds a single fishbone may be able to reconstruct imaginatively the whole fish.
I said just now that we must not ask "leading questions." If we do, we can make a patient of a very suggestible type of mind say anything. If you ask him whether he has any symptom whatsoever he may obligingly say "yes." The way to avoid this is to put our questions in the negative: "You have no headache at all, have you?" "You do not cough?" "You never spit blood?" By these negatives we can get at the positive symptoms if they are present.