The management of surgical disorders requires not only the application of technical
skills and training in the basic sciences to the problems of diagnosis
and treatment but also a genuine sympathy and indeed love for the
patient. The surgeon must be a doctor in the old-fashioned sense,
an applied scientist, an engineer, an artist, and a minister to
his or her fellow human beings. Because life or death often depends
upon the validity of surgical decisions, the surgeon’s
judgment must be matched by courage in action and by a high degree
of technical proficiency.
At their first contact, the surgeon must gain the patient’s confidence and convey the assurance that help is available and will
be provided. The surgeon must demonstrate concern for the patient
as a person who needs help and not just as a “case” to
be processed. This is not always easy to do, and there are no rules of
conduct except to be gentle and considerate. Most patients are eager
to like and trust their doctors and respond gratefully to a sympathetic
and understanding person. Some surgeons are able to establish a
confident relationship with the first few words of greeting; others
can do so only by means of a stylized and carefully acquired bedside
manner. It does not matter how it is done, so long as an atmosphere
of sympathy, personal interest, and understanding is created. Even
under emergency circumstances, this subtle message of sympathetic
concern must be conveyed.
Eventually, all histories must be formally structured, but much can be learned by letting the patient ramble a little. Discrepancies
and omissions in the history are often due as much to overstructuring
and leading questions as to the unreliability of the patient. The
enthusiastic novice asks leading questions; the cooperative patient
gives the answer that seems to be wanted; and the interview concludes on
a note of mutual satisfaction with the wrong answer thus developed.
History taking is detective work. Preconceived ideas, snap judgments,
and hasty conclusions have no place in this process. The diagnosis
must be established by inductive reasoning. The interviewer must
first determine the facts and then search for essential clues, realizing
that the patient may conceal the most important symptom—eg,
the passage of blood by rectum—in the hope (born of fear) that
if it is not specifically inquired about or if nothing is found
to account for it in the physical examination, it cannot be very
Common symptoms of surgical conditions that require special emphasis in the history taking are discussed in the following paragraphs.
A careful analysis of the nature of pain is one of the most important
features of a surgical history. The examiner must first ascertain
how the pain began. Was it explosive in onset, rapid, or gradual?
What is the precise character of the pain? Is it ...