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.
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