$ 84. The patient details his sufferings; the persons who are bout him relate what he has complained of, how he has behaved himself, and all that they have remarked in him. The physician see, hears and observes with his other senses whatever there is changed or extraordinary in the patient. He writes all this down in the very words which the latter and the persons around him make use of. He permits them to continue speaking to the end without interruption, except where they wander into useless digressions, taking care to exhort them at the commencement to speak slowly that he may be enabled to follow them in taking down whatever he deems necessary.
One of the most important things in securing the image of a sickness is to preserve in simplicity what the patient tells us in his own way unless he digresses from the important things and talks about things that are foolish and not to the point; but as long as he confines his information and in the record use his own language, only correcting his grammatical errors for the purpose of procuring the record as perfect as possible. If you use synonyms be sure that they are synonyms and cannot be perverted.
Of course, when the woman speaks of her menstrual period as “monthlies” or as her “show,” the more suitable medical term is “menses,” which is a synonym for those expression, and is more expressive than her own way of calling it “a show”. So in general terms you can substitute terms of expression so long as you do not change the idea. Of course, the changing of “legs” into “limbs” if you feel like making such a change is not a change of thought, but be sure in making a change it is not a change of thought.
It is one the most important things in forming the record of a patient to be able to read it at a subsequent examination, without being disturbed by the repeated statements of the patient. If you write a record in consecutive sentences, you will be so confused when hunting out the symptoms of the patient that you will be unable to form an image of that sickness in the mind.
It is truly impossible when the mind is full with the effort at hunting out something to listen with proper and concentrated attention. You should divide your page in such a manner that when the patient is talking to you about this thing and that thing and the other thing of her symptoms, you can with one glance of the eye look down over the page of the record and see everything there is in that page. If you record is not so arranged, it is defective. Now, a record can be so arranged by dividing the page into three columns, the first of which contains the dates and prescriptions, the second the emphatic symptoms or headings and the third things predicated of the symptoms, thus:
Date } Symptom.
} Things predicated of the symptom
} (<) (aggravation).
Remedy (>) (amelioration).
After the patient has detailed his sufferings in his own way and you have gone through them and discovered all the things that you can predicate of his symptoms then you can proceed to make enquiry of some on who has been with this patient. In a study like this with most of our private patients there has been a nurse, sometimes only a sister or a mother or a wife, who has been observing all the sick individual has complained of. “The persons who are about him relate what he has complained of, how he has behaved himself, and all that they have remarked in him.” Now, this should be listened to with great care.
It is more important in this instance to decide whether the observe is overanxious, if a wife whether she is not frightened concerning her husband and so intermingles many of her notions and fears, which you must accept with discretion. Get the nurse, if possible, to repeat the exact words of the patient. If such a thing can be done in acute sufferings it is worth more than the words or expressions of the nurse, the wife for instance, because the more interested and anxious the person is the less likely she will be to present a truthful image, not that she wants to deceive, but she is dreadfully wrought up and the more she thinks of what he has said the greater his sufferings appear to her, and she exaggerates them. It is important to have the statement from one who is disinterested. Two or three of the observers who are intelligent having been consulted and their statements recorded, the physician then notes his own observation. He should describe the urine if there is anything peculiar about that, but if the urine and stool are normal he need not care about the description of these.