CHAPTER XII CASE HISTORY TAKING BY ARTHUR F. BYFIELD, PH.B., M.D. General considerations, p. 551-Materials, p. 561-The history proper, p. 572-Present illness, p. 572-Previous illnesses, p. 578-Family history, p. 581-Personal routine, p. 583-Venereal history, p. 585Menstrual history, p. 586-Symptoms noted by the examiner while taking the history and before beginning the examination proper, p. 587. GENERAL CONSIDERATIONS A first-class history is a necessary prelude to a first-class diagnosis; in some cases, indeed, a well-elaborated anamnesis practically establishes the diagnosis. The converse is equally true-a history, written hurriedly and aimlessly, composed of data not properly digested or analyzed, is not only valueless but often highly misleading. Case-taking is both an art and a science, and reflects to the very highest degree the skill, judgment, tact and breadth of clinical experience of the recorder, particularly the latter, we may say, as it is only on the basis of a fairly ripe experience that a really valuable case history is possible. To the young physician just launched upon his clinical career this may sound discouraging. He may wonder how, with only the most meager bedside experience to support him, he can pretend to prepare a satisfactory medical history. Until recent years, indeed, such a question would have been fully justified, as the methods of teaching medicine formerly in vogue-and in too many schools at the present datepermitted the medical student but little personal and responsible contact with the patient. The result of these older methods was that, with but few exceptions-the brilliant clinicians and teachers who understood the indispensable aid offered by a properly written history, and who laid emphasis upon the principles of the subject-the student graduated with only an occasional hint relative to case-taking, in the dispensary or clinic, and too often with not even this hint. These men, as practitioners, were apt to disregard the value and importance of a history altogether and to make use of slipshod methods, to which reference will be made later. In the better schools this has, to a large extent, been changed. The patient is given to the student as a case, in his clinical years, and, by means of clinical clerkships in the dispensary and hospital and of small, bedside clinics, he is expected to develop a diagnosis from beginning to end. It need not be said that proper instruction presupposes a careful supervision, on the part of those in charge of such work, not only of the diagnostic routine, but also of the details of the anamnesis. In brief, it may be said without exaggeration that the character of a medical school may be gauged with a very fair degree of accuracy by the caliber of the histories written by its graduates; while, in the case of the man in practice, it is not difficult, on the basis of the kind of history he prepares, to estimate not only the character of his early training, but also the breadth of his subsequent clinical experience. The graduate of the higher type of medical school is, in still other ways, better equipped from the outset to write a good case history, thus compensating to some extent for the experience and judgment that come only with years. We refer first to the fact that some schools include in their curricula didactic work on the preparation of medical histories -this being the subject, primarily, of this chapter-and, secondly, to the fact that in the more advanced colleges the student is so thoroughly grounded in pathology and pathologic complexes that he is in a position, as will appear in the following pages, to direct his questions to the patient in such a manner as best to develop the data essential to a diagnosis. The well-trained physician-one who has had some grounding in the fundamentals of what constitutes an acceptable history, and who, under proper instruction, has had a fair opportunity of applying these fundamentals in actual clinical work for which he is held responsible— will not find it altogether difficult to separate the valuable from the worthless in case histories. This difference is by no means one of length, as so many seem to believe; brevity, indeed, when combined with the faculty of searching out the important and of analyzing the same, is one of the prime essentials of a good history. The uninstructive anamnesis is one the only merit of which is that it adheres to a set outline: symptoms are jotted down and left hanging, as it were, without coherence and coördination in the fabric as a whole; invaluable diagnostic points are omitted, either because the questioner is too inexperienced to ask salient questions, or because one or more answers of the patient have caused him to pass premature judgment upon the case. A history becomes increasingly valuable as it aids in the making of a diagnosis. It is true, as we shall see later, that a definite scheme is necessary in the routine of obtaining the patient's story; but, aside from this guiding outline, each anamnesis should have its individual stamp. Just here lies the pernicious influence of the all too general habit of employing printed outlines in which a fixed space is allowed-determined to some extent by the printer and also by the size of the card or sheet employed for the recording of the several subdivisions of the history. A worth-while anamnesis, brief and to the point though it must be, cannot be cramped within set confines. In some cases, the complaint upon entrance may demand only a few lines and the recording of previous illnesses half a page. How, then, can one do oneself or one's patient justice |