Social Work; Essays on the Meeting Ground of Doctor and Social Worker

by Richard C. Cabot

Schedules of questions to be used in history-taking may be medical or social. Some of the social question-lists are suggested in later chapters of this book. A masterly account of social questioning is contained in Miss Mary E. Richmond's "Social Diagnosis" (published by the Survey Associates, New York, 1917).

I wish now to illustrate the methods to be used by social workers in questioning patients about their symptoms so as to assist the doctor in his diagnosis.

Pain: How long? For a day, a month, a year, six years? Very chronic pains are seldom serious but seldom curable. Headache that has lasted years either has no cause known to medical science, or else it means neurasthenia. In either event it is apt to be stubborn. A headache that has lasted only a day, and did not occur before, cannot possibly be due to migraine. This suggests how the length of time that a pain has lasted is very important in diagnosis. The patient will often say, "I have always had it"; but to this we should oppose a pretty strong cross-examination. The patient usually means that he has had it off and on throughout an indefinite period. We ask him then, "When did you first have it?" and then, "How much of the time—half the time, a quarter of the time, for one day a week or one day a month?"

Pain: Where? Patients rarely come to a doctor for a single point. But pain in several points is never as significant as pain in one point. One cannot learn much from scattered pains in relation to what ails the patient and what to do for him.

Pain: How bad? That is a very difficult question to get the answer to. There is no thermometer or measure for pain. I suppose every doctor has wished many times that he had one. But there are certain rough measures which are of some use in judging how bad a pain is. (1.) We ask, "Does it compel you to lose sleep?" Some headaches may be pretty severe and yet a person sleep despite the pain. It may link itself up with a dulling of consciousness leading to sleep. But most pains and even most headaches that do not keep a person awake are not as bad as those that do. (2.) We ask, "Does it prevent work?" Any one can see all sorts of limitations to the use of that criterion. A man with a rugged type of mind will work with a pain that another weaker man will give up to. Yet the question does bring out evidence of some value.

(3.) Another criterion, more subtle and not quite so useful, is this, "Do you feel the pain more when you are quiet or when you are moving about?" The pains due to organic diseases are generally worse when one moves; while the functional type of pains are apt to be better when one moves about. One forgets it. Quite often patients are very lucid and candid about this.

Pain: How aggravated? How relieved? (a) A pain may be aggravated by position—for example, when the patient is on his feet—or worse when he is lying down—a headache, for instance. Most abdominal pains are worse when the patient is on his feet. (b) A pain may be aggravated by motion. Most of the surgical injuries, sprains, strains, tears of muscle or ligament, and fractures of bones are naturally made worse by motion. Pain may be aggravated by certain particular motions, as is the case with some of the innumerable pains in the back. Lumbago is a pain characteristically described as one that comes when the patient tries to lace his boots. Especially when he tries to get up from that position, the pain is intolerable. Pains in the chest are often worse on deep breathing—pleuritic pains, for example. But other thoracic pains may also be made worse by deep breathing. (c) Pain may be aggravated by the taking of food, or by movements of the bowels.

Pain may also be relieved in any of these ways. The most important thing that one can know about a stomach pain is that it is relieved by food. The majority of all stomach pains are aggravated by food. Pains are also relieved by heat or cold or by drugs or by rest. But those are not very important points. They may be important in relation to what we do to help the patient, but not in relation to diagnosis. Some pains, whatever their cause, are relieved by cold, more by heat, and most are also relieved by rest.

Next to pain, Cough is the symptom, especially in the colder months of the year, that we have most to deal with. The question How long? is vastly the most important one about cough. One can also measure its severity by the question, "Does it keep you awake?" and to some extent by the question, "Does it prevent work?" More important is the question, "Is it dry or productive of sputum?" The patient's description of his sputa in gross, without any microscopic examination, is also of a good deal of use. There are usually three things a patient can tell us about it: either it is yellow, or it is white, or it is bloody. There are two other important questions about bloody sputa. Unless one gets these answered, the mere fact of spitting blood is not important. We must know whether there are merely streaks of blood which one often sees in the sputa of anybody who coughs hard, are of no importance, and have nothing to do with tuberculosis. But if, in contrast with this, we can really establish evidence of the spitting of blood in quantity, we have almost proved a diagnosis of tuberculosis. In ninety-nine cases out of one hundred the spitting of blood in quantity means tuberculosis. "In quantity" means a cupful or thereabouts of pure blood. If the doctor does not find tuberculosis after that he should nevertheless assume it, for it is almost always there. I should pay no attention to negative physical finding in such a case.

The next point to ask about is whether the patient's breathing is wheezy. When a horse has become broken-winded we can hear his breathing in the street as he comes along. He has become emphysematous. We find this wheezing respiration in emphysema, asthma, and bronchitis, which are diseases important for us to distinguish from tuberculosis; we almost never get it in tuberculosis.