Communication between doctor and patient is one of the most important elements in the clinical encounter. It has long been a subject of study in the field of medical anthropology, with its emphasis on concepts and experiences of sickness and healing.Footnote ¹ The subfield of narrative medicine focuses on hearing, understanding, and analysing the stories patients tell about themselves.Footnote ² Today, the emerging discipline of health communication studies how patients and physicians talk to each other across several methodologies, including sociology, psychology, and linguistics.Footnote ³ Most researchers accept that ‘patient-centred’ communication, focused on the patient’s needs and perspective, is important in clinical medicine, although a link to better outcomes can be hard to prove.Footnote ⁴

Although evidence about doctor-patient communication is scarce for Greco-Roman antiquity, it has become a subject of classical scholarship in recent years. Two of the most sensitive and insightful contributions are Melinda Letts’ dissertation on Rufus of Ephesus’ brief treatise Quaestiones medicinales (‘Medical Questions’), which advises on how to question patients,Footnote ⁵ and Daniel King’s book Experiencing Pain in Imperial Greek Culture,Footnote ⁶ which includes substantial discussion of clinical communication. For both of these researchers, Galen is a foil for other Greek physicians of the same period who, as they argue, paid more attention to patients’ perspectives and had more empathy for them. For Letts, this is Rufus of Ephesus, the only ancient physician to write a treatise about questioning patients, while King points to striking comments on patients’ feelings of fear and despair in the work of Aretaeus of Cappadocia, finding nothing similar in Galen.Footnote ⁷ Galen’s authorial persona, and perhaps his real personality, were competitive, polemical, and arrogant – a stance consistent with the cultural atmosphere of the Second Sophistic in which he was embedded,Footnote ⁸ but off-putting to modern scholars. Nevertheless, the contrasts that King and Letts draw on the issue of communication with patients rest partly on arguments from silence and on a small selection of passages – places where Galen sounds dismissive of patients’ views, or on the other hand, where Aretaeus seems especially compassionate.Footnote ⁹

It is true that Galen sometimes mistrusts patients, expresses frustration with their disobedience, finds them hard to communicate with because of their perceived deficiencies, and shows off by guessing a patient’s problem without talking to him or her.Footnote ¹⁰ On the other hand, Galen’s case histories (stories about patients) attest to intimate interactions with his patients in which dialogue and communication play a critical role. Galen quotes his patients directly and indirectly, and his reports of their perceptions, emotions, and history leading up to the illness can be very detailed. Although he wrote no standalone treatise on questioning patients, he would have agreed with what Rufus had to say in Quaestiones medicinales about the need to learn about patients’ emotions, habits, regimen, and pain, as well as the history of events leading up to the disease and the time of the disease’s onset.Footnote ¹¹ Letts shows that one passage in Galen’s commentary on book 6 of the Hippocratic Epidemics – explaining how questioning patients can reveal clues about their mental condition through their words, voice, and demeanour – reveals close linguistic parallels with Rufus’ text, suggesting that he read it carefully.Footnote ¹²

Rather than seeing either Rufus or Galen as outliers who cared more, or less, about communication with patients than other physicians, it may be more accurate to see them both as part of a medical culture that recognised the critical importance of doctor-patient communication in the clinical encounter. Galen would never have argued – as the physician Callimachus, staking out an extreme position,Footnote ¹³ is supposed to have done – that questioning patients was unimportant, and his writing strongly suggests the opposite. In this paper, I develop my passing observations in previous work about Galen’s attention to patients’ exact words.Footnote ¹⁴

I begin by noting that some of Galen’s most prominent ideological positions support a stance that attended to patients’ exact words. While there is much of great complexity to say about Galen’s epistemology,Footnote ¹⁵ and although he engaged deeply on this subject with the philosophical traditions in which he was trained, a theme he stressed throughout his life was the foundation of medical knowledge in experience, and in particular, in clinical practice – that is, the ultimate source of knowledge is the patient. Galen was proud of his training in the school of his fellow Pergamene Quintus, who owed allegiance to none of the named medical sects, but he was also proud of his eclectic education, and some of his earliest teachers were Empiricists, a tradition that influenced him throughout his life.Footnote ¹⁶ Although he criticised many of their premises, especially their rejection of anatomy and their insistence that abstract reasoning has no place in medicine, Galen consistently championed the role of experience and observation in medical knowledge.Footnote ¹⁷

Empiricists recognised different types of experience (peira), including that recorded in the writings of previous physicians (historia), but it is evident that when Galen contrasts reason and experience in a general way, he has in mind clinical experience with patients above all – experience ‘among the patients’, a phrase he uses often when demonstrating a point.Footnote ¹⁸ Thus, an Empiricist interlocutor in On Medical Experience begins his refutation of a Dogmatist argument with the words ‘I have often observed that in every case where we sat by the bedside of a person sick with this disease….’Footnote ¹⁹ When introducing his commentary on the Hippocratic case histories in Epidemics I, Galen explains them in the context of the relationship between reason and experience.Footnote ²⁰ Galen himself often uses case histories to communicate the insights of clinical experience.Footnote ²¹ In an especially illuminating passage, before recounting a pair of case histories in On the Method of Healing, Galen justifies the role of stories about specific patients with a strong endorsement of the epistemological and pedagogic value of firsthand experience. ‘It is especially necessary for students to train using examples’, he writes, ‘and even better than examples are the things which we have witnessed ourselves. If everyone who undertook to teach and write something, would first demonstrate these things with deeds, altogether few false things would be said’.Footnote ²² (This is followed by a long discourse on the priority of deeds over words and of practice over social networking.) Here as elsewhere, experience means clinical experience of the type Galen is about to narrate as he tells the story of two fever-stricken patients. The specific example, as told in a case history, was central to Galen’s concept of experience, and probably central to Empiricism as well – little of the Empiricist tradition survives, but a few passages in Galen suggest a foundational role for medical narrative.Footnote ²³ Case histories centred on individual patients and, as will become apparent below, relied on conversation with patients for their construction; Hippocratic case histories were even called ‘patients’ (arrhostoi), a kind of technical term for them in the medical tradition that followed.Footnote ²⁴ The patient, then, was the ultimate source of the kind of experience that Galen valued most.

Galen was also, like others of his class in the second century CE, deeply interested in questions of language; in particular, the question of scientific communication preoccupied him. It was essential to have a precise vocabulary, but Galen rejected the notion of a technical vocabulary for scientific terms and criticised, for example, the metaphorical terms for the pulse and pain used by his predecessor, Archigenes of Apamea.Footnote ²⁵ Ordinary or common usage was one of his criteria for preferred language; the common or universal meaning of a term was, for him, its primary and literal meaning. He had a positivist faith that words, when used correctly, signified their objects clearly, univocally, and in a way understood by all speakers of Greek.Footnote ²⁶ On the other hand, especially when writing about food or drugs, Galen’s search for precision led him to comment on local usage and variant terms, especially those of his home province, Asia.Footnote ²⁷ He rejected the elaborate edifice of Atticism that some of his contemporaries were then using in the context of the Second Sophistic. As will become apparent, one test of whether a term was in common use was that patients used the term spontaneously – that is, Galen’s interest in the words of patients is part of a broader stance that rejected the kind of technical vocabulary comprehensible only to specialists (even if, in practice, much of what he wrote was obscure to laypeople).

Galen valued clinical experience in medicine and common usage in language as part of an overall value system that contrasted the perceptible and concrete with the abstract and erudite. These are strong themes throughout his writing over the course of his whole life. It is, therefore, not surprising that he listened to and commented on the words of patients. Much of what Galen considered relevant for diagnosis could only be elicited by talking to the patient or, sometimes, to a caretaker.

The question of patients’ language is discussed most thoroughly in Galen’s treatise On the Affected Parts. Here, the vocabulary of pain is an especially important topic.Footnote ²⁸ On the Affected Parts attempts to rationalise the diagnosis of internal diseases and specifically to identify the part affected, as the title suggests; often, this means finding out where the patient feels pain and what kind of pain. The only method of acquiring this information that Galen mentions directly is talking to the patient – in modern terms, self-report. Although facial expression, behaviour, imaging, and other methods can also be used to assess pain today, self-report is the only type of assessment Galen describes.

Many of the themes Galen raises in his discussion of pain assessment continue to be relevant in modern medicine. The ‘inherent subjectivity of pain’ and the physician’s dependency on patients to communicate experiences that are difficult to describe remain complex problems.Footnote ²⁹ Measures of characteristics like intensity and chronicity can, to some extent, be standardised, for example by using one of the many scales that measure the intensity of pain.Footnote ³⁰ There are also modern questionnaires addressing the quality of pain. When assessing these measures, one factor modern researchers consider is whether the terms they employ – like ‘shooting’, ‘tingling’, ‘sharp’, ‘itchy’, and so forth – match the words that patients spontaneously use.Footnote ³¹ One assessment, the McGill Pain Questionnaire, has been translated into sixteen languages, each translation demanding attention to what individual words mean to the patients choosing them.Footnote ³²

Pain is an important diagnostic symptom in modern medicine, and there can be ‘a remarkable consistency in the choice of words by patients experiencing similar pain syndromes’.Footnote ³³ On the other hand, research shows that patients can experience different types and intensity of pain even if they have similar underlying conditions.Footnote ³⁴ Pain also may not have a referent; it can be among the ‘medically unexplained symptoms’ that make up so much of the modern general practitioner’s caseload.Footnote ³⁵ However, for Galen, a specific type of pain signifies a specific condition. As he writes, ‘for the most part we are affected in the same way, as we suffer the same things from the same causes’ (Loc. affect. 2.6, 8.87K). In a well-known story about a Sicilian doctor, Galen boldly describes a patient’s pain to him rather than asking about it because he thinks he knows what is wrong with the patient and wants to show off (Loc. affect. 5.8, 8.365K). The pain in question is a heaviness in the hypochondrium and a sensation at the collarbone as though it were being pulled downward. Galen assumes that knowing the cause of pain, one also knows what kind of pain the patient is feeling because it feels the same to everyone. When Galen acknowledges differences in the experience of pain, he attributes these to organic differences in the conditions causing the pain, for example, whether an infection also affects the bone or pleural membrane, and so on (Loc. affect. 2.8, 8.101-2K).

While Galen’s understanding of communication between doctor and patient differs from modern assumptions in these respects, he nevertheless devotes substantial discussion to the subject. In antiquity, beyond the location of pain, its quality was the characteristic most interesting to physicians, or at least, this is the focus of most of Galen’s discussion of pain in On the Affected Parts. Before Galen’s time, Archigenes had developed a vocabulary for pain that was apparently in popular use; Galen devotes quite a bit of space to attacking this system. But Galen also implies that a substantial tradition preceded Archigenes: he writes of ‘all the doctors before Archigenes who wrote about the differences in pain’ (Loc. affect. 2.9, 8.116K).

Because Galen believed that we all experience the same kind of pain in response to the same conditions, he argues that common experience can provide a basis for communication if the physician has felt the pain that the patient describes (Loc. affect. 2.7, 8.89-90K; 2.9, 117-8K). He acknowledges, however, that ‘no one has suffered all the affections even over an entire lifespan, even someone who is sickly’ (Loc. affect. 2.7, 8.89K), and this poses a problem because, as he also writes, ‘what we have not suffered ourselves is unknown to us’ (Loc. affect. 2.9, 8.117K). He reaches for a metaphor, rather than previous experience, in one of his most striking passages about his illnesses – ‘I know that once I had a pain, as though I were pierced through with a trepan at the base of the abdomen’ (Loc. affect. 2.5, 8.81K). He diagnoses himself with a kidney stone at first, but later it appears that the problem is located in the large bowel. Galen had never suffered trepanning himself but was imagining what the pain inflicted by this type of wide-bore drill must be like. He writes that some patients experience the same condition as a pain like a sharp stick (Loc. affect. 2.5, 8.83K), a different sensation than a trepan, but he seems to focus on the feeling of being pierced (diatitrasthai, titrasthai) as the important factor in this passage. ‘Piercing’ can also describe the pain of pleurisy (Loc. affect. 2.5, 8.86K).

Shared experience, then, does not solve the problem of communicating pain, as Galen himself acknowledges. But clearly, he is not saying that communicating pain is hopeless. Rather, the answer lies not in Archigenes’ special, technical vocabulary of pain, but in attention to the words that patients use – the ‘things heard from the patients themselves’ (Loc. affect. 2.9, 8.116K). Patients’ words are the antidote to the intellectual quandary created by those who introduce abstract, technical vocabularies for pain: ‘We have heard laymen interpret the same thing [stomach pain caused by overeating] when it happens to them clearly without any contention about dogma’ (Plen. 7.518K). About the comparison to a trepan, he writes that this is what ‘the patients themselves express’ (Loc. affect. 2.5, 8.83K). Patients may compare their pain to being pierced by a needle or a trepan or being torn apart or crushed by a weight (Loc. affect. 2.9, 8.116K). Archigenes could never have experienced pain in the womb and should not have tried to create a vocabulary for it that was different from what his female patients actually said – ‘none of the patients expressed what she suffered using the words of Archigenes’ (Loc. affect. 2.9, 8.118K).

This focus on the patients’ own words, then, is the second-best solution to the problem of communicating pain after shared experience, and can compensate for the problem that physicians cannot have experienced everything that their patients are describing. This was the method, in Galen’s view, that the ancient physicians used – ‘All doctors before Archigenes who wrote about the differences in pains did not dare to use words other than the customary ones which they could hear from the patients themselves’ (Loc. affect. 2.9, 8.116K). Galen privileges the words of the patients in describing their pain, even though the patients themselves use metaphors based on things they have not experienced, as Galen does when he describes feeling like he was being pierced by a trepan.

What exactly do Galen’s patients say? Galen sometimes uses words or phrases that suggest he is quoting a patient or using the same word that a patient used, for example: ‘someone perceiving that his fingers were difficult to move and numb and, as it were, making a cracking noise, as he himself called it’ (ὡσπερ ψοφούντων καπυρόν, ὡς αὐτός ὠνόμαζεν, San. tuend. 6.11, 6.434K). In a passage from On Compound Drugs by Place, he writes, ‘In cases of pain around the head I am accustomed to ask the patients what kind [of pain] they have. Some perceive a sense as though their body were being ground away with pain, while others [feel] as though they are being stretched or crushed, or pounded, or that violent heat or cold alone predominates’ (2.1, 12.545K). Again, in On Compound Drugs by Type, he writes, ‘I asked [a patient] if he was bitten at the wound from the medicine. And he said that he was not bitten, but had a sort of itching sensation’ (3.2, 13.585K). The term ‘biting’ occurs frequently in these clinical encounters: Galen interrogates a patient with colic about the character of his pain, and receives the reply that it was ‘biting’ (daknodes, Loc. affect. 1.4, 8.40K); and several other patients similarly complain of biting pain in the stomach, often after eating certain foods.Footnote ³⁶ One of his patients told him that his semen felt ‘biting and hot’, not only to himself but to his sexual partners (San. tuend. 6.14, 6.444K). In these cases, Galen either states or implies that the ‘biting’ pain is caused by a ‘biting’ or caustic humour,Footnote ³⁷ or when an astringent medicine or food touches an ulcerated part. He and his patients seem to share an understanding of the term ‘biting’ as applied to pain, and perhaps an idea of what causes that kind of pain, normally a corrosive substance. Usually, this kind of pain is stomach pain, but not in the case of the man with biting semen. The word ‘biting’ occurs more than 300 times in Galen, often applied to fever (biting to the touch?), but frequently to a substance (food, humour, or drug) and sometimes, as above, to pain. Although Galen criticised Archigenes for using the term ‘sweet’, which properly refers to something one can taste, that is, to a substance or humour, for pain (Loc. affect. 2.6, 8.88K), he does something similar with the term ‘biting’, and the justification appears to be that it is a word patients themselves use frequently.

Galen sometimes describes a sensation he calls ‘heavy’ (barus), also in passages where he implies that this is the patient’s description or at least the patient’s perspective, for example, in the case of a man with a bladder wound who has accumulated urine in the abdominal cavity (Loc. affect. 1.1, 8.4 K). For Galen, this type of pain indicates a swelling, abscession, or inflammation of an internal organ.Footnote ³⁸

Sometimes, in On the Affected Parts, Galen writes as though it is the patient’s striking and spontaneous phrasing, rather than his or her consonance with other patients, which is so informative about the patient’s condition. An example is the patient stung by a scorpion who felt like he was being pelted by hailstones (Loc. affect. 3.11, 8.195K). This kind of metaphor recalls Galen’s references to pain like being pierced with a trepan or a stick, or, in another passage (Loc. affect. 3.13, 8.204K), to a headache that is like being hit with a hammer. But in this latter passage, Galen claims that the words he is quoting are common expressions (ἔνιοι μέν…ἔνιοι δέ), whereas the hailstone metaphor is unique in his work.

Some more abstract expressions for quality of pain also fall into the category of terms that patients commonly used for pain, the terms that, in Galen’s opinion, are also the ones that doctors should use. He insists that ‘we all know the pulsing pain (nugmatodes)Footnote ³⁹, the tearing pain, and similar expressions to these…that are expressed in customary words used every day by everyone’ (Loc. affect. 2.9, 8.118K). ‘We’, that is, Galen and his audience, understand the meaning of a biting or pulsing pain but not of Archigenes’ ‘harsh’ pain. Galen’s preferred expressions are not necessarily less abstract or metaphorical than Archigenes’ specialised vocabulary of harsh, sweet, rough, astringent, and so forth; they are just more commonly used, and it is this quality that, in Galen’s eyes, makes them more literal and accurate. Galen also cites the ‘heavy’ pain – what English speakers sometimes today call a ‘crushing pain’ – in this context: as he writes, ‘Often people perceive something heavy on their chest’ (Loc. affect. 2.5, 8.121K).

Galen is drawing on a collective experience that has shaped what he sees as a common vocabulary of pain, one that both doctors and patients share, even if the doctor has never personally experienced the pain in question. That is, there is a common, shared vocabulary of pain that we can uncover if we pay attention to the words that patients use, and this common vocabulary reflects a shared cultural experience that we can draw on, even if we do not have personal experience of the pain.

Besides pain, there are other sensations about which Galen tells us that he questions patients directly, or he tells stories in a way that suggests he is representing their perspective and perhaps their words. An athlete named Secundus describes weakness (atonia) of the diaphragm (Loc. affect. 4.7, 8.254); patients with difficulty swallowing may describe a weakness (atonia) of the oesophagus (Loc. affect. 5.5, 8.335). Patients needing bloodletting may describe a sense of fullness (plerosis);Footnote ⁴⁰ or to put it another way, ‘tension (tasis) in the body as though it had been filled up’ (Meth. med. 9.4, 10.611K). The last quotation is from a passage in which Galen describes several intense subjective experiences that must have been elicited by talking to the patient and may reflect some of the patient’s own words: ‘the patient experienced unbearable heat, and a tension in his whole body as though he had been filled up, and a pulsation in his head, and a terrible insomnia…’. This sense of fullness in a cultural context that blamed retention of blood for many problems may illustrate the role of culture in shaping our perceptions of illness.

Another example may be the term ‘anomaly’ (anomalia). In Galen’s treaties on the pulse, ‘anomaly’ can simply mean irregularity, but in his treatise The Opportune Moments in Disease,Footnote ⁴¹ it is something more elusive – the paroxysmal shuddering that signifies the onset of a fever, or a shorthand term for the first stage of a recurrent fever. It is also a word that patients understood and used themselves; indeed, in the same treatise, Galen writes that ‘all the patients say that suddenly an anomaly or a shuddering comes over them’ (Morb. temp. 7.416K). Thus Galen forbids a man to use oil in the bath because the man reports feeling an anomalia, and probably in this case both patient and doctor interpret this as an early stage of fever (Meth. med. 8.2, 10.550). In one long case history, the patient’s perception of an ‘anomaly’ is the ominous beginning of a recurrent fever from which he nearly dies; Galen writes, ‘He became aware of his own fatigue and perceived an anomaly. He drank water as he was accustomed to, but he became no better; rather, the anomaly increased, and he vomited’ (Meth. med. 10.3, 10.672-3K).Footnote ⁴² In another passage, Galen comments that he forbade a patient to use dropwort in the bath ‘at the time when he said that he felt an anomaly’, again implying that this was the patient’s word for his experience (Meth. med. 8.2, 10.550K).

Another word Galen believed to be in common usage, this time among women, was the word ‘hysterical’ (hysterikos): ‘I myself have seen many hysterical women, as they call themselves and as midwives, from whom they likely heard the word, called them earlier’.Footnote ⁴³ Uterine suffocation or hysterike pnix – in which the uterus moves upwards, causing choking, convulsions, coma, and sometimes death – was a prominent concept in Greek popular medicine over many centuries, and Galen’s comment is evidence that his patients were familiar with the idea and the terminology. Galen’s patients were not describing themselves as emotionally unhinged, the modern connotation of the word; they were saying that they had symptoms of uterine dislocation.Footnote ⁴⁴

Attention to specific words is one indicator of the importance Galen attached to talking to patients. Another is his interest in symptoms like pain that must be communicated verbally. Other symptoms that must normally be elicited by talking to the patient are hallucinations and delusions. Galen acknowledged several different diseases or disease categories with these symptoms, mainly mania, melancholia, and phrenitis, and distinguished different types of hallucinations depending on their cause, on their association with other symptoms like fever, and on their phenomenology.Footnote ⁴⁵ In his commentary on the first book of Hippocratic Epidemics, regarding the word dianoemata, ‘thoughts’ (Hipp. I Epid. comm. 3.1, 17.1 212-3K), he writes, ‘He [Hippocrates] does not mean something perceptible nor something apparent, but something discovered from evidence [tekmeria]. The evidence is what the patients say and what they do’.Footnote ⁴⁶ The example he gives is a patient with an irrational worry that Atlas will drop the world, who disclosed this delusion in response to questions from his anxious friends.Footnote ⁴⁷

Dreams are another symptom that cannot be observed but must be recounted by the patient. Galen took dreams very seriously, as messages from a god, inspirations for therapy, and diagnostic clues. In this, he followed most doctors before him; for example, a section of Rufus of Ephesus’ Medical Questions addresses how to question the patient about dreams.Footnote ⁴⁸ (The Methodist sect, that Galen detested, rejected dreams as a source of medical knowledge, as Galen writes,Footnote ⁴⁹ but Empiricists accepted them.Footnote ⁵⁰) A brief work On Diagnosis from Dreams survives under Galen’s name; it is possibly an excerpt or summary of a treatise on ‘those dreams which indicate the disposition of the body’, or of one on ‘dreams, birds, and all of astrology’, that he mentions having written.Footnote ⁵¹ He describes how dreams can be helpful in diagnosis, for example: ‘when a wrestler seemed [in a dream] to stand in a cistern of blood, and barely to be able to keep himself above it, we guessed that he had a superfluity of blood, and that he needed evacuation’ (Dign. insomn. 6.834K). In this treatise, Galen also emphasises that one must pay attention not only to the content of a patient’s dream but also to the time when it occurred and to what the patient had eaten beforehand, as these factors influence how the dream should be interpreted. He does not directly describe talking to patients about their dreams, but he must have done so.

Galen’s most careful interrogations of patients, however, are about what we now call the patient’s history – the things that happened leading up to the patient’s presentation with a problem.Footnote ⁵² Galen is sometimes explicit about the need to ask patients about their history; for example, in cases of nerve damage causing incontinence, ‘It is necessary in all cases of this type to ask about the things that happened previously; and whether there was a chill, or a blow to the spine’ (Loc. affect. 1.6, 8.64K).Footnote ⁵³ Many of his longer stories include detailed medical histories written from the perspective of the patient, and some of them illustrate the importance of questioning patients about their history. A notable example is from Galen’s Synopsis of the Books on Pulses. A patient presents with fever, and at first it is not clear what the cause is; seeing that his hand is bandaged, Galen asks him what happened, and the patient replies that it is nothing important; he hit someone. As it turns out, Galen reports, he hit a slave. Galen advises the patient to treat the finger, but the patient ignores him and later suffers a seizure (Syn. puls. 9.495-6K). A better-known example is the case of Pausanias the sophist, whom Galen interrogates in depth about potential causes of paralysis in some of his fingers. Galen finds out that Pausanias had fallen out of a carriage and struck his upper back.Footnote ⁵⁴

In these cases, Galen describes a dialogue with the patient, for example:

Here, I have added italics to emphasise the back-and-forth between Galen and his patient. A few case histories almost resemble philosophical dialogues, in which Galen and the patient exchange views in alternating speeches of some length.Footnote ⁵⁵

Some of the examples above illustrate that Galen did not only ask leading, closed-ended, or scripted questions, although sometimes he did.Footnote ⁵⁶ He thought that asking a patient very specific questions about their pain was a good way to show off, as the story of the Sicilian doctor, discussed earlier, illustrates. In another case history, also discussed earlier, ‘I asked [a patient] if he was bitten at the wound from the medicine’, apparently putting words in the patient’s mouth. But the patient pushed back, and Galen noted what he said: ‘And he said that he was not bitten, but had a sort of itching sensation’. Other formulations also suggest that Galen asked open-ended questions that might elicit quite a lot of information:

In a few cases, Galen’s wording suggests that patients poured out long narratives:

And finally, Galen is able to report details of patients’ history, emotions, and perceptions that he could only know by talking to them:

A few case histories include rich narrative backgrounds and descriptions of the patient:

Although Galen considered talking and listening to patients, including attention to their exact words, to be important to medical practice, he acknowledged limitations. First, as discussed earlier, he believed that medicine had a performative aspect, and some comments Galen makes about talking to patients in this regard can be perceived as dismissive of the need for this communication. He sometimes boasts about his ability to diagnose a patient at a glance, for example, from the patient’s skin colour, or the pulse alone, or by deduction from subtle nonverbal clues.Footnote ⁵⁷ (Galen did not invent this emphasis on the performative element of medicine – it was already a prominent theme in the Hippocratic Corpus, especially in the treatise Prognostic.) However, the power of these stories derives from the obvious point that, in most circumstances, Galen and other physicians needed much more information to make a good diagnosis, including information available only by talking to the patient.

The famous story of the woman in love, Justus’ wife, is an exception that proves the rule in this regard. Galen mentions this story many times and tells it fully in his autobiographical treatise On Prognosis (5, 14.625-6K). He thought it made him look like the Hellenistic physician Erasistratus, who in a legendary episode had diagnosed the future Antiochus I with love-sickness for his stepmother. Like Erasistratus, Galen used the patient’s pulse to find out what (or rather, who) was making her anxious; as he explains, there is no pulse specific to love, but Galen believed that anxiety had a specific pulse.Footnote ⁵⁸ Justus’ wife presented with insomnia, a dangerous symptom in Galen’s view. When he visits her, his first step after determining that she is not suffering from fever (this too probably involved putting questions to the patient) is to inquire about her history: ‘we asked her about each of those things in turn, from which we know insomnia arises’. She is unresponsive, giving brief replies or not answering. Because he cannot get the information he needs from the patient herself, Galen befriends her maidservant and, in casual conversation, lands his first important clue. Eventually, he is able to prove his suspicions by tracking her pulse when the name of her beloved dancer is mentioned. Here, because the patient refuses to communicate, Galen must resort to tricks that showcase his diagnostic virtuosity – he reaches the right conclusion even when the patient will not speak to him.

Justus’ wife is reluctant to disclose the cause of her illness for obvious reasons, but sometimes patients tell outright lies, a phenomenon Galen discusses in a passage of his Commentary on Hippocrates’ Epidemics II, which was excerpted and circulated separately as the short treatise How to Catch Those Faking Illness. Footnote ⁵⁹ Galen believed that he could tell that someone was lying from the pulse, in a way similar to a modern ‘lie detector’ or polygraph machine; in a story from his treatise On Prediction from the Pulse, he confidently accuses one annoying wealthy patient of taking pills against his orders (Praesag. puls. 1.1, 9.218-20K). But although Galen discusses the problem of dishonest patients, most of the time he reports information elicited from patients without comment, as though he assumed that it was trustworthy.

Most of Galen’s stories take place in private households, and patriarchal household values sometimes affect how Galen communicates with the patient; where the patient is a subordinate member of a household, the patriarch’s words and perspective may overshadow those of the patient. Several stories from the same treatise On Prognosis describe cases in the household of Boethus, Galen’s consular friend originally from Ptolemais in Palestine. In a story where the patient is one of Boethus’ children, Boethus does all the talking, describing symptoms that the boy experienced and that the boy’s mother observed, although mother and child are in the room during the conversation (Praecog. 7, 14.627K). In another story, the patient is Boethus’ wife; Galen talks to her midwives, her servants, her other doctors, and to her husband, but does not quote the patient directly or indirectly, and mentions her embarrassment at being treated by male doctors (Praecog. 8, 14.641-7K). In the story of Justus’ wife, although Galen interrogates her as he would a male patient, she is silent and unresponsive. In a story where the patient is the (possibly enslaved) steward of a rich man, Galen begins the story by representing his patient’s words – he was ‘in danger of going blind, as he said, and in great pain’ – but throughout the rest of the case, all of Galen’s dialogue is with the master and he records only the master’s reactions, even though the patient lives with Galen for three days (Ven. sect. 17, 11.299K).Footnote ⁶⁰

Galen recognised other limits to communicating with patients. He believed that some phenomena are indescribable (arrheta), a word he applies especially to sensations of taste, smell, touch, and sometimes to pain.Footnote ⁶¹ This inexpressibility, as he saw it, often frustrated his ability to convey medical knowledge in writing, as opposed to firsthand demonstration.Footnote ⁶² When discussing problems of communicating with patients, he emphasises that even concepts that have appropriate words can be difficult for some patients to express:

Galen goes on to write that doctors can more easily express their symptoms because they lack this ‘weakness of soul.’ Thus, in a passage from Method of Medicine, he seems to value a patient’s ability to communicate with him in sophisticated language because the patient has an interest in medicine, as Galen thought all educated people should.Footnote ⁶⁴ In On Plenitude, regarding stomach pain caused by overeating, he writes, ‘[patients say] it is as though they are bitten (daknointo) and worn away (dibroboskointo), but often since they do not know how to tell accurately what is happening, they say that they are full (asasthai)’.Footnote ⁶⁵ And in a frequently-discussed passage from On the Affected Parts, Galen seems to say in the case of one patient, a thirteen-year-old child he remembers visiting with his teachers at Smyrna, that his seizures affected his brain in such a way that he could not describe the sensation that occurred (Loc. affect. 3.11, 8.194K), while an adult with the same condition was able to describe the feeling of a cool breeze.Footnote ⁶⁶ While it is possible to read these statements as dismissive of the mental capacities of some patients, Galen acknowledges that describing symptoms is difficult and notes the words of even his less educated patients. He thought deeply about language, and it is not surprising that he discussed these kinds of problems. It is evident that he saw them as obstacles to clinical practice that normally relied heavily on verbal communication.

Talking to patients to find out about their histories, habits, dreams, emotions, or perceptions was only one part of diagnosis; Galen also assessed his patients’ physical appearance, their bodily fluids, their pulse, their temperature, and other signs.Footnote ⁶⁷ But much of what he wanted to know when he made a diagnosis could only be elicited by questioning the patient, and though he wrote no treatise on this practice, he took it for granted as an essential part of clinical medicine. Not only that, but he also paid careful attention to what his patients said, often remembering their exact words. He championed the practice of using the same words that patients spontaneously produce when describing their symptoms. He also thought about and discussed the problems that can prevent effective communication between physician and patient.

To be treated by Galen was to be the object of the kind of intellectual intensity that pervades his whole work. He may or may not have been a pleasant person to interact with, but he did not miss much. More importantly, he was part of a culture in which communication with patients was foundational to the medical encounter.