HISTORY-TAKING BY THE SOCIAL ASSISTANT
History-taking concerns the social assistant especially because
history-taking is one of the things one does, if one is wise, in any
matter in which one is trying to help a human being. Even if you were
concerned to help not a stranger, but a member of your own family, still
you would need a story or history of the person's life whether you wrote
it down or not.
_History and catastrophe_
In our attempts to be of use to people in their misfortunes, there are
two very common and quite opposite points of view (roughly the right and
the wrong), which I call (_a_) the "historic" and (_b_) the
"catastrophic," the accidental, or the emergency point of view.
Confronted with people's troubles, whether physical or mental or
spiritual, we are tempted, and above all _they_ are tempted to regard
the sickness, the poverty, or the sorrow in the light of an emergency,
an accident, and therefore as something to be treated at once and by
means which have little to do with the past and the future. On the other
hand, the standpoint of science and philosophy, and of any one who has
labored long in the field of social work with or without science or
philosophy, is the point of view of history. This is the habit of mind
which makes us believe that a supposed "accident" belongs in a long
sequence, a long chain of events, so that it is impossible to understand
or to help it without knowledge, as extensive as our time and our wisdom
will allow, of that whole chain.
Consider a few examples which contrast these two points of view. When a
boy is brought into court for stealing, it is almost always his attempt,
and the attempt of those who defend him, to show that such a thing has
never happened in his life before; he "just _happened_ to steal." But as
we inquire more closely into the facts, we almost always find that this
is a fundamentally untrue statement of the case. For the offence which
brought him into court is almost never the first offence. He has always
stolen before. On the present occasion he was a member of a boy's gang;
it was not in the least accidental that he got into that group of boys.
As we search back in his history, and perhaps into his father's history,
we find reasons why he is what he is now. Again, we are trying to help
some wayward girl who has taken an immoral step. We are told what a
wholly unforeseeable _accident_ it was that got her into her trouble.
But if we can get a good picture of her past, we find that we could have
traced the tendency to weakness of this kind from the time she was born.
So it is in medical matters. _Emergencies are rare._ I remember being
called out of a sound sleep one night to go "as quickly as possible" to
see a man who had discovered a lump upon his breast bone. He was quite
sure that the swelling had appeared since the time when he went to bed.
It was then one o'clock in the morning, and he had gone to bed at
eleven. Well, I found a slight bony irregularity in his breast bone
which doubtless had been there about forty-five years, as he was
forty-six years old. He did not pretend that it hurt him, and did not
undertake to show that he was ill in any other way. But this lump had
come and naturally he wanted help at once.
The great importance of the contrast between the historic and the
catastrophic points of view is, in the first place, that one way is on
the whole right and the other on the whole wrong; but still more, that
the patients whom we are going to deal with, and all the unfortunate or
needy people whom the social assistant tries to help, are very fond of
the wrong point of view and hang to it extraordinarily. It is _the_
natural first impression of any untrained person that his troubles
"simply happen" without any explanation that he knows. So that we have
to start at once to tear down a structure of innocent and lifelong
belief on the part of the patient, that troubles come suddenly and by
accident. We have to disillusion him, a process which naturally he does
not take to particularly pleasantly.
Our task in a dispensary is the same. The patient almost always starts
with _the catastrophic point of view_, and can only be very gradually
engineered into the other. And yet our work in relation to public health
is largely to be summed up as finding out how,--that is by what history,
through what chain of events, people come to be sick. Repetition and
extension of disease can be checked only in case we succeed in finding
such clues. Hence our labors to change people's point of view in this
particular respect are as worth while as anything we can do, and we must
not be discouraged by the fact that, week after week and year after
year, we come up against the same difficulties, the same conviction,
that troubles "just come" and have no cause.
I have said that the historic prejudice is essentially right and the
catastrophic prejudice essentially wrong. Of course, there are
exceptions. A man may be run over in the street for reasons that we
cannot discover to be connected in any possible way with his previous
history; a man gets a burn, gets a broken leg, is hit by a missile in an
air raid over London or Paris, in ways that are essentially
catastrophic. And yet even in the field of accidents, industrial
accidents for instance, the more we study, the more we find that
injuries are not wholly accidental. The whole of science is the attempt
to prove that nothing is an accident, that everything comes out of
previous causes. The percentage of accident in the so-called
"accidental" injuries decreases as we study industrial accidents. (_a_)
They happen at certain hours of the day more than at other hours of the
day: if they were really accidental this would not be so. (_b_) They
happen on certain days of the week, especially Mondays, for obvious
reasons. (_c_) They happen especially to greenhorns, to the newcomers,
who have not learned how to avoid them. One of the expenses incidental
to hiring new help is the expense of accidents. Thus these events turn
out to have a good deal of law and reason, a good deal in the history of
the individual (alcoholism?), and the nature of the industrial process
(speeding up?) which helps to explain them. By eliminating such
causative factors, we may prevent some accidents.
The remedies that we apply fit the type of trouble; _in so far as the
trouble is accidental or catastrophic, the remedy is mechanical_; in so
far as the thing is historical and continuous, the remedy cannot be
mechanical. When a man breaks his leg we put on a splint; that is
mechanical. But if he is in a low state of health and the fracture won't
unite, we have to do something non-mechanical, physiological,
psychological. We may have to get him into a different state of
nutrition or even into a better state of mind before his tissues will
heal.
Our job, then, in taking histories--that is, in finding out how things
happen that lead up to disease or misfortune--should begin by writing
down _the thing for which the patient comes_--headache, cough,
emaciation, poverty, desertion, unemployment. This is the "presenting
symptom"; it should always be the first thing written down in our
history, not in terms of medical diagnosis such as asthma or anemia, but
in the form of a complaint. Our attempt is first to put that down, to
get a starting-point, and then to weave that into a chain of evidence
which we call a history. That history makes it possible to make a
diagnosis and to plan treatment.
_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 myxoedema, 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.
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.
If the patient complains of _dyspnea_--difficult, rapid breathing,
"short breath" as we say--we shall ask about _oedema_ or swelling of any
part, especially of the legs.
In every patient who has a cough we are concerned primarily with the
diagnosis of one disease, that is, tuberculosis, its presence or
absence. Hence every patient who coughs should be questioned about the
other symptoms of tuberculosis and especially about _emaciation_. A man
with a chronic bronchitis or emphysema does not lose much flesh; he
does not become emaciated. A person does not become thin from throat
trouble. Hence emaciation, especially recent, is a helpful guide to the
doctor in making up his mind. _Fever_ we investigate for the same
reason. The only disease that often causes cough and fever during a long
period is tuberculosis. Unfortunately the patient's statement about
fever is usually unreliable. We can believe most of what he says on the
rest of these points. But he does not know whether he has fever or not.
In women we must ask also about the _monthly sickness_, because it is
suppressed in cases of moderately advanced tuberculosis. Nephritis,
anemia, heart trouble and emotional disturbances may have that same
effect. It is a measure of the degree of disease, not its type.
For the purpose of dispensary consultations I do not think we should
take any family histories except when we suspect tuberculosis. But when
the history leads us to think that the person may have tuberculosis, the
social worker can help the doctor by asking the patient questions about
the possibility of the same disease in mother, father, or others who are
in contact with the patient--grandfather, grandmother, or other
relatives or friends living in the same house. We believe less and less
in the heredity of tuberculosis, more and more in infection by contact.
If separated from a tuberculous father or mother in early infancy we
believe that the child does not acquire tuberculosis. But the main mode
of infection is by association in the same house, over a prolonged
period, with people who have tuberculosis. Often the patients do not
know or will not confess that anybody in the family now has tuberculosis
or has died of it. But if we can establish the fact that one of the
patient's family has died after having a cough for many years, that he
grew very weak, and spit blood, we have established the diagnosis
without the name. Not the degree of relationship to a tuberculous
patient, but _the amount of time spent in the same house with a
tuberculous individual_--what we call the degree of "exposure" to
tuberculosis--_is the important thing_.
_Past history_
After getting the patient's present symptoms, one should ask, "Were you
ever sick _previous to this illness_? If so, what troubles have you
had?" That is of use in clearing up the limits or boundaries of the
present illness. The sicknesses which the patient says he has had are
not of very much use to us in diagnosis because we cannot get true
answers. The patient's diagnoses or his doctor's are apt to be vague or
meaningless. But the questions about the patient's past history tend to
make him more clear as to the date when his present illness began. Hence
his answers on these points should be written down very briefly, a word
or two only about each, and usually in the words used by the patient.
In our written histories in hospitals we usually take a considerable
body of notes about the patient's habits. I do not advise this for
social workers. But there are certain routine questions which should be
asked of all patients concerning their _appetite_, _bowels_, _sleep_,
_weight_, and _work_. The answers should be recorded in a separate
paragraph, at the end of the history.
What is printed here is meant to give a sample, not a full account, of
medical-history-taking. Competence in this field takes long practice.
Nevertheless the intelligent social worker can learn in a few weeks to
be of great assistance to the doctor by taking either in the dispensary
or in the home such histories as I have sketched.
In social-history-taking there is no single order or schedule of
questions agreed upon by all social workers. But there should be _some_
order and system determined partly by the personality of the worker and
partly by the nature of the trouble. If poverty or destitution is the
presenting symptom, one must find out the items in the family budget,
the figures of income and outgo, paying especial attention as in medical
histories to the question, "_How long?_" How long have you paid that
rent, earned that wage, been without a job, taken boarders, been in
debt?
Is sickness, childbirth, alcoholism, injury a factor?
Is there any family history of tuberculosis, pleurisy, insanity,
epilepsy, feeble-mindedness? Of miscarriages or of "scrofulous"
children and "blood diseases"?
What previous hard times? What economic and moral high-water marks and
low-water marks can we trace in the past history?
What relatives, friends, employers, doctors, teachers, neighbors,
landlords, social agencies, public officials or records can be consulted
for additional light on the person and his troubles?
From all these sources one arrives finally at an opinion on "_what sort
of person_ are we trying to help--what sort physically, mentally, and
morally?" That is the central fact.