KONRAD EHLICH

THE LANGUAGE OF PAI N*

ABSTRACT. The expression 'pain' refers to a phenomenon intrinsic to individuals. The
object of the language of pain is restricted to an individual experience which excludes
any form of direct access by others. Speaking about pain is thus one of the most difficult
forms of linguistic activities, as has been repeatedly pointed out by Wittgenstein. The
difficulties involved in this type of communication are not only dependent upon individual
linguistic ability but are also clearly reflected in the state and structure of the linguistic
means which are at the disposal of the speakers of a language. Linguistic means vary in
status and complexity with respect to the ends which they can be used for.
In this paper, I discuss two aspects of communicating pain: types of expression which
are involved in speaking about pain, and linguistic activities which are carried out when
speaking about pain. The two aspects are interrelated. My analysis makes use of categories
belonging to the theory of linguistic activity and to the extended field theory of language
(an expansion of Biihler's concept of symbolic and deictic field analysis of language).
1. MEDICAL COMMUNICATION
Language has to do a vari et y of j obs. It was when phi l osophy t urned its at t ent i on
to ' ordi nary language' t hat linguistics - perhaps for the first time - learned to
take seriously i nt o consi derat i on the wide variety of funct i ons language performs
in social life. One of the domai ns of social life where language plays an i mpor t ant
part is medicine, and one of the most salient aspects of medi cal discourse is
communi cat i ng pain. It is to t hat funct i on of language this paper addresses itself.
Medical communi cat i on is a highly specific t ype of discourse. It has its own
hi st ory from the ancient medicine man' s myst eri ous formulae t aken from old
spells and ' wi sdom' down to the 20t h cent ury doct or' s myst eri ous formulae,
part of a j argon wi t h hybri ds of Lat i n and Greek origin, produci ng the fascina-
t i on wi t h ' Science, curer (and causer) of our diseases' . Medical communi cat i on
is not t aught - it happens. Act ual l y, i nst i t ut i ons of medi cal training seem to
assume t hat speaking ' goes wi t hout saying' . Doct or-pat i ent communi cat i on is
a t ype of funct i onal communi cat i on: the goal of doct or-pat i ent i nt eract i on - to
put i t very simply - is to cont ri but e to, or even to achieve the pat i ent ' s cure.
In tiffs paper, I want to concent rat e upon a very common and wi despread
form of consul t at i on communi cat i on, as it takes place in the consulting-room
of ordi nary general pract i t i oners and specialists. This t ype of communi cat i on
forms part of a general course of interaction. There is a st andard structure to
this i nt eract i on (see Figure 1). The st andard course runs from phase I to phase V.
The goal of the whole structure lies in V. Phase V det ermi nes the substructures
of the course of i nt eract i on. Ia and Ib need not co-occur. Whereas V is the
TheoreticaIMedicine 6 (1985), 177-187. 0167-9902/85.10
1985 by D. Reidel Publishing Company.
178 KONRAD EHLICH
. . . . . . . . . . . . . i l l . . . . j
~b p feels ill 'j
............ ' 1
I
Ii P presents the symptoms of his disease to D
II ....... D identifies the disease
v
II V ........ D cures P ]
V~ P is healthy ' j
Fig. t. Consultation communication. 'P' stands for 'patient' and 'D' for 'doctor'.
final goal of the doctor-patient interaction, the transition from Ia to Ib, in many
cases, is a condition for entering into the medical apparatus.
2. PAIN AND INTERACTION
As soon as the patient has identified the disease (Ib in Figure 1) and has over-
come the obstacles which hinder him from entering the socially established
apparatus of healing, the linguistic means which are at his disposal become of
major importance. In the doctor' s consulting room tile patient's verbalization
competence can be crucial for the phase to follow.
One of the most important difficulties the patient confronts concerns the
language of pain which arises when he wants to use language for transmitting
a picture of his problems to the doctor. Whatever the psychological charac-
teristics of pain may be, in most theoretical accounts, pain is conceptualized as
a, if not the form of individual sensation. 1 As pain is seen as an individual
sensation, the problems of pain appear as a consequence of its individualized
character. Pain seems to be conceived of as an intrinsically personal and in-
dividual experience which isolates the pain-suffering individual from his/her
surroundings. The pain-suffering individual thus is a very good example for
the traditional philosophical conceptualization of ' man' - the individual man.
Philosophical thinking on pain largely depends on the vocabulary which
is supplied by everyday language. Whereas there are differentiated, well-de-
veloped terminological distinctions for sense phenomena perceived visually and
THE LANGUAGE OF PAIN 179
acustically, the situation is problematic for other domains of perception such as
smell (cf. Weisgerber 1928), and becomes even more difficult for domains
beyond sensual perception in the traditional philosophical sense of the term.
Pain is one of the most prominent of these non-extrinsic phenomena. Theoretical
analysis resulted in a broad spectrum of opinions on the characteristics of pain.
Nevertheless, none of the ' definitions' proposed in the course of philosophical,
psychological or ethnological analysis has achieved a status of general acceptance
which could be compared to that of vision or other modes of sensual perception.
Even the description of what one is looking for when discussing the concept
of pain is vague and far from being generally accepted. The insufficiency of
theoretical analyses of pain is a reflection of the lack of elaborated terminology
for the phenomenon.
One important tradition of thought on pain is that of Ryle and Wittgenstein.
Their ideas concentrate on some of the linguistic aspects of the problem. Whereas
Ryle uses the language of pain for an analysis of the language of moods, etc.,
Wittgenstein, much more radically, shows that the language of pain is something
very different from the language of usual descriptions (Philosophical Investiga-
tions, 290). 2 To disregard this difference would mean to eliminate completely
the phenomenon of pain: " . . . if we construe the grammar of the expression of
sensation on the model of ' object and designation' the object drops out of
consideration as irrelevant" (Philosophical Investigations, 293) (cf. yon
Morstein 1964). This is a negative statement. It tells us a lot about what the
language of pain is not; it does not tell us very much about what characterizes
the language of pain. As in so many other instances, Wittgenstein does not
really answer the positive question. He is an aporetic thinker, a thinker who
makes obvious the shortcomings and dead ends of traditional thinking; however,
he does not go further - an insufficiency he felt to such an extent that he never
published, e.g., the 'Philosophical Investigations'. Nevertheless, his discovery is
of great importance for a closer analysis of the language of pain.
In his discursive manner of thinking and writing, Wittgenstein involves the
reader in a sort of ' inner dialogue' which, in quick sequence, changes from
' thesis' to 'antithesis'. This ' role-taking' is often not indicated at all in his texts,
and in only a few instances does he offer a sort of meta-statement which can
help the reader find his way out of the dead ends his 'dialogue' has led the
reader into. One of these few instances refers to the problem of the language
of pain. In 304, Wittgenstein says: "The paradox disappears only if we make
a radical break with the idea that language always functions in one way, always
serves the same purpose: to convey thoughts - which may be about houses,
pains, good and evil, or anything else you please". The important hint in this
self-commentary of Wittgenstein with regard to the language of pain is that it
would be helpful, if not necessary, to look for the functions of the language
180 KONRAD EHLICH
of pain in its use. Wittgenstein, making this hint, seems to have come to the
farthermost point possible for him in a theoretical situation in which such
an idea was nearly unthinkable. Since we find few specifications of what the
functions of the language of pain are in his text and it would lead us too
far astray to try to elaborate these, let us consider, instead, where the hint
Wittgenstein gives could lead us.
It may appear somehow puzzling: nevertheless, if one regards pain from a
linguistic point of view, things are quite different from traditional philosophical
concepts on pain. Whereas pain has appeared as one of the most outstanding
solipsistic phenomena in philosophical analysis, from a linguistic point of view,
pain is primarily an interactional phenomenon, not a solipsistic sensation. A pain
which is experienced is in most cases expressed. There are different modes for
doing this expression of pain; nevertheless, all of them are but special cases of
the fact that pain is expressed. The expression of pain in its various forms makes
pain accessible to the 'audience', to the addressees of that expression. Pain is
a form of mental processing of physiological and/or psychic experiences. The
processing is a transformation of sensations into expressions. Pain can be ex-
pressed acustically or visually. Both modes combine 'expression' and 'appeal',
to use Btihler's (1934) terms. For the sake of brevity, I do not discuss visual
nonverbal expressions of pain here.
3. THREE TYPES OF EXPRESSING PAIN
In the following, I would like to make a distinction between three types of
expressing pain: (1) crying and groaning; (2) pain interjections; and (3) pain
descriptions.
3.1. Crying and Groaning
Crying and groaning are part of a whole series of instinctive reactions to painful
injury. These forms, though belonging to the biological equipment of human
beings, can be influenced, i.e., partially controlled, by the person. On the one
hand, it is possible to repress cries, to restrain or control them, while on the
other hand, it is possible to cry without a cause. Thus, the biological form of
expression is not fully automatic. Nevertheless, there is a biological 'program'
which is executed in case of pain. It is one of the earliest forms of expression the
young human being has at its disposal. The cries of a baby who feels uncomfort-
able, i.e., who feels pain, makes clear the (biological) function of this type of
expression: the function of activating the mother in order to achieve relief. In
other words, even this very elementary function of crying is an interactive one?
THE LANGUAGE OF PAIN 181
In the course of individual development, the use of cries and groaning de-
creases. The functional interconnection remains the same, however. The sensa-
tion of pain is expressed in cries and groans. These in turn are perceived by the
addressee who mentally processes them in a way which can be described by the
classical Greek term of ' sympathein' . ' Sympathein' comprises the haduction of
an analogous feeling of sympathy and pity, and a search for possible means of
help. The latter leads to activities on the addressee's part.
Crying and groaning as specific forms of expression of pain have the character
of a symptom, in the semiotic sense of this term. They co-occur directly with
the phenomenon they belong to. This ' symptomatic' character of cries and
groans is a necessary one if one looks to the ontogenetic functional context
of their use. Since cries and groans are symptoms, they are semiotic entities
which stand at the fringe of language and which are not yet part of the linguistic
system. The sequence of mental and interactional activities can be visualized as
shown in Figure 2.
Person I
i
i
mental t
sphere I
i
I
f e ns a t i on
f pain h
I
i Person 2
interactional sphere
symptom]
mental
sphere
i~ perceptin 1
it 's mpathei 'l
' 1
i
i !
action
of help
Fig. 2. Crying and groaning.
3.2. Pain Interjections
Whereas cries and groans stand at the edge of language, the second type of
expressing pain has a different linguistic status. This type consists of short
linguistic expressions which traditionally have been called ' interjections' . At
least one of the interjections is bound to the expression of pain; its English
forms are ' ow' or ' ouch' , its German form is ' au' , its French one ' ai' , etc.
For a long time, the linguistic status of interjections has been unclear to
linguistic analysis. In many instances linguistics mixed up cries and interjections.
Interjections were regarded as relics of the animal substratum of man. Linguistics
182 KONRAD EHLICH
failed to give a proper account of the function of interjections, because interjec-
tions do not fit into the framework of assertion-oriented linguistic categories.
The very term ' interjection' shows the difficulty which linguists experienced
during the analysis of these expressions: they termed these words entities
' thrown in between' , namely 'in between' normal assertions.
Another theoretical framework is needed for a proper linguistic treatment
of interjections. Btilaler (1934) introduced into linguistics the concept of 'fields
of expression'. He distinguished two such fields, the 'field of pointing', or
'deictic field', and the 'field of naming', or 'symbolic field'. This concept can
be expanded in such a way that the characteristics of interjections can be made
clear. The 'field of pointing' comprises deictic expressions, such as ' you' and
' I' , 'here' and ' there' , ' now' and ' then' , etc.; the 'field of naming' comprises
symbolic expressions, such as' tree', 'man', 'go', 'feel', 'small', 'big', etc., i.e.,
the overwhelming majority of words in any language. The difference between
these two fields becomes clear only when the interaction between speaker and
hearer is taken into account, a step which Biihler did not take.
I will take the 'deictic' field as an example. The main characteristics of
expressions belonging to this 'field' are the following: Deictic expressions are
expressions which are used to the effect that a speaker S orients the focus of
hearer's (H) attention to a specific entity which forms part of the speaker's
and the hearer's space of perception. For example, when using the word 'here',
the speaker orients the hearer's focus of attention to the place where the ut-
terance of this word takes place. While deictic expressions constitute a very
small number of the words in language, they occur frequently. Though few
in number, they obviously are of enormous importance for ordinary verbal
interaction.
The third field is made up of expressions which are called 'interjections'
(cf. Ehlich, forthcoming). Again, this field consists of only a very small number
of expressions, and again, they serve a very specific and important linguistic
function. This function can be briefly described as follows: 'Interjections' are
expressions by means of which a speaker S directly influences the mental pro-
cesses of a hearer H in order to steer H into a direction of action which is in
accordance with some specific needs of S. These needs can be communicative
(such as in the case of ' hm' ) or they can belong to other types of interactional
needs (such as in the case of ' oh' ). The interjection(s) of pain belong(s) to the
latter type. I call this field the 'field of steering' or the 'expeditive field'.
Let us look for the sequence of mental and interactional activities involved
in the case of expeditive expressions for pain. The sensation of pain is not
directly transposed into a symptom; on the contrary, there is a mental step
inserted, a step of inverbation. This step is subject to the usual psycho-linguistic
procedures. Thus, it is controlled to a much larger extent than cries are; it can
THE LANGUAGE OF PAIN 183
be used for tactical purposes, etc. On the part of the addressee, again, there is an
insertion of another step of mental processing. This step can induce ' sympathein' ,
and it also can lead directly to an action by H. The insertion of the linguistic
sphere makes ' sympathein' a much less 'animalistic" process than in the case of
cries (Figure 3).
Person I Person 2
T r
mental ~ interactional sphere I mental
s phe r e ~ i s phe r e
t .........
ensation I 1
f pain
~nver~batin~ ~xpedi-lationarticu-lve
perception [
-- of verbali- I
:I ztin
me nt a l pr o-
1
Fig. 3. Pain interjections.
Pain interjections form part of language. They share all the characteristics of
linguistic expressions, and their use participates in the mental and interactional
features of linguistic activity. At the same time, they affect the addressee in the
same ways as cries do because they share the specific functional character of
expressions in the expeditive field. This is different in the third case, the case
of pain descriptions.
3.3. Pain Descriptions
Pain descriptions make use of expressions of the symbolic field and of the
deictic field. The linguistic forms that are used in the case of pain descriptions
are the schemas of either describing, in the strict sense of the term, or of telling.
These forms demand a different type of mental processing on the part of the
184 KONRAD EHLICH
addressee. In hearing a description or a narrative, the addressee performs a
cognitive analysis of the verbal ' input' . This analysis involves a different domain
of the mental capacity of the addressee, the analytic part of language processing.
There is, so to speak, a great distance to the following steps on the heater' s part.
The result of the analysis of what the speaker tells is brought into connection
with the repertoire H has for action. There is no strict necessity for entering
into the domain of ' sympathein' , a domain which may be involved, but is only
one possible subsequent procedure the addressee can choose. The involvement
of H is also different in the two cases of pain descriptions in this respect. The
linguistic form of description is even farther away from the type of crying
than is the narrative, because the latter has ' slots' for the hearer' s emotive
involvement. Figure 4 gives a diagrammatic representation of the case of pain
descriptions.
Person I ] Person 2
mental
sphere
sensation
of pain
nverbation
interactional sphere
telling i
mental
sphere
perception
of verbali-
zation
analysis
action-
repertoire
v
'sympathein'
Fig. 4. Pain descriptions.
The third way of expressing pain comes closest to the traditional categories
of linguistic analysis, since it seems to consist of nothing but assertions. But
only in the case where pain description is done in an objectified way, does
this give the full account of what is going on from the point of view of linguistic
action.
THE LANGUAGE OF PAIN 185
3.4. Wittgenstein's Aporetics And Some Difficulties With Pain Descriptions
Wittgenstein topicalizes one of the tacit presuppositions of traditional analysis
of language: the assumption that al/language use is t o be seen as an instance of
making assertions. The analysis of the different ways for expressing pain shows
that Wittgenstein' s criticism is fully correct: The expression of pain has an
interactional goal. The use of non-expeditive forms of language, i.e., deictic and
symbolic forms, shares this aim in most instances in which the speaker is the
subject of the pain he expresses. When S uses these forms, however, he com-
municates - linguistically speaking - in a more mediated form than when
he uses expeditive means of expression. As soon as symbolic expressions are
used, the interacting agents are faced with all the difficulties which have been
mentioned above.
The vagueness or even absence of words hinders a clear verbalization; the
underdevelopment of the semantic field of expressions for pain forces S t o
speak with unclear metaphors. Ryle comment s on that point when he describes
our speaking about pain:
When a sufferer describes pain as a stabbing, a grinding or a burning pain, though he does
not necessarily think that his pain is given to him by a stiletto, a d~ill or an ember, still he
says what sort of pain it is by likening it to the sort of pain that would be given to anyone
by such instruments . . . . The present point of mentioning these ways of describing our
sensations is to show how and why there exists a linguistic difficulty in discussing the logic
of concepts of sensation. We do not employ a 'neat' sensation vocabulary (1969, p. 203).
The addressee of a description of pain easily gets lost when he demands pre-
ciseness on the part of the speaker. Nevertheless, these descriptions exist. Their
function shares the general characteristics of the specific interaction form of
expressing pain: Their primary goal is t o move H towards an action in favour of
S - be it an action of material help, or be it an act of solidarity. The assertions
are nothing but a means to that end. Wittgenstein on various occasions points
to the fact that it is not tolerable in ' real interaction' t o refuse that action (cL,
e.g., 303): "Just t ry - in a real case - to doubt someone else's fear or pain".
4. CONCLUSIONS: THE LANGUAGE OF PAIN AND THE DOCTOR
Crying, using expeditive expressions and using deictic and symbolic expressions
are three basic means for soliciting help and support in a situation of danger
and threat. They are based on an elementary structure of human interactive
solidarity. In decreasing degree of directness, t hey involve the hearer and do not
allow him a chance of refusing t hat solidarity. The interrelationship of these
three types of expressing pain can be visualized as in Figure 5.
186 KONRAD EHLICH
Preverbal
Verbal
C h a r a c -
t e r i s -
t i c s
D i r e c t -
n e s s
cry
o~
~z
u
o
o
expedi-
tive ex-
pression
! ,2

4~ r"
-,-I 0
O~
4-~ U (I) I=
U tm ~ 0
'~ 0 O
q3u~ U ~
d i r e c t
pain
narrat-
ive
o
o ~
~.~
x~
~ o
pain
descrip-
tion
'I' 'he'
("x
0 @
~0( ~
m e d i a t e d
Fi g. 5. Interrelationship of the types of expressing pai n.
As the ontogenetic development of the system of expressing pain demon-
strates, and as can be supposed with regard to its phylogenetic development,
the functionality of that system relies on an immediate relation of support
among humans. The directness of the system makes the execution of what it
demands inevitable. The initiation of help is prompted by it - but it cannot
influence the forms of help that are really useful. The development of the
institution of medicine commences, systematically speaking, when this im-
mediacy is interrupted and broken down by the insertion of steps of analysis of
disease, and by the application of means of healing that are literally 'far-fetched'.
Thus, medicine in itself demands from its representatives that they look at
disease from a detached, uninvolved point of view. That means for the doctor
that he has to interrupt the directness of verbal and preverbal forms of demand
for help. He has to dismiss forms of immediate appeal to his helping capacity in
order to act adequately. This is a somehow paradoxical situation brought about
by the fact that the doctor, as a speaker of the ordinary language, participates
in all of its illocutionary forces whenever they are realized by a speaker who
addresses himself to the doctor. Thus, the problems doctors and patients ex-
perience in their institutionalized communicative interaction are not simply
'mis-happenings'; at least some of them are rooted deeply in a communicative
paradox. The best remedy for paradoxes is insight into their structure, i.e.,
reflection.
KONRAD EHLICH
Abt. 15, Universitiit Dortmund,
Postfach 500 500, D-4600 Dort mund 50.
THE LANGUAGE OF PAI N 187
NOTES
* I t hank Angelika Redder and Zsuzsa Baross for their critical comments, and I am grateful
to Cony Guhl for her help with the English version and to Martina Liedke for technical
assistance.
1 For an excellent and detailed treatment of the psychology and psychosomatics of pain,
cf. Bergsma (1983).
2 For a thorough analysis of Wittgenstein on pain, see Baross (forthcoming).
3 It is a highly interesting question to analyze the application of cries in solipsistic situa-
tions. As it is well known, crying can provide a sort of relief. This effect is similar to other
forms of associative shortcuts.
REFERENCES
Baross, Z.: forthcoming, ' Speaking of pain - or Wittgenstein' s fundamental misunderstand-
ing', Maiuntics, vol. 1, No. 3.
Bergsma, J.: 1983, Sornatopsychologie, op zoek naar psychosociale dimensies van de
geneeskunde, J. Wristers b.v..
Biihler, K.: 1934, 19652, Sprachtheorie, Fischer, Stuttgart; parts of the book have been
translated in: Jarvella, R. J. and Klein, W. (eds.): 1982, Speech, Place andAction, Wiley,
Chicester.
Ehlich, K.: forthcoming, Interfektionen, Niemeyer, Tiibingen.
von Morstein, P.: 1964, Wittgensteins Untersuchungen des Wortes ' Schmerz' , Arehiv fiir
Philosophie 13, 131- 140.
Ryle, G.: 1949, 196911, The Concept of Mind, Hutchinson, London.
Weisgerber, L.: 1928, 'Der Geruchsinn in unseren Sprachen' , lndogermanische Forschungen
46, 121- 150; also Jn Weisgerber, L.: 1964, Zur Grundlegung der ganzheitlichen
Sprachauffassung, Schwann, Diisseldorf, 99- 121.
Wittgenstein, L.: 19673, Philosophical Investigations, translated by G. E. M. Anscombe,
Blackwell, Oxford.