Pain is an inner, individual phenomenon, and also a term we use to describe a variety of states. This makes its definition elusive.(1) In Hebrew dictionaries, the definition begins with “a severe bodily ache accompanied by distress,” expands to “bodily suffering due to a blow, wound, or disease in one of the body’s organs,” and even reaches “deep sorrow, harsh and depressing grief.”(2) English has many words that reveal pain’s many faces: ache, pang, sting, throb, twinge, cramp, soreness, torment, spasm, anguish, and more. We often reach for descriptive words to separate and explain different pains: strong, weak, sharp, deep, and so on.
The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.” The notes accompanying this definition emphasize that the inability to communicate pain does not negate the reality of the experience or the need for relief.(3) A baby’s cry, before there is language, is a first and basic way to express pain or distress. Pain is expressed mainly through voice and language.(4)
The Austrian British philosopher Ludwig Wittgenstein, writing in the first half of the twentieth century, argued, in contrast with the organization’s definition, that pain does not exist for us apart from the behaviors that flow from it, what he calls pain behavior.(5) He insists that such behavior unfolds within our interactions with those around us, in relation to the community and the culture in which we live.(6) For Wittgenstein, pain exists for others through the ways we express it to the world, not only in words but also in movement or a grimace. Within those expressions, pain takes form.
The difficulty of defining pain arises because it is, on the one hand, personal, individual, and internal, and on the other hand, social and cultural. If I feel pain yet do not express it in any way, no one around me will know I am in pain. And even if I do express it, those around me can only guess which pain I am experiencing. They cannot even be certain I am in pain at all.
Ivan Illich writes that pain is shared with all animals, while suffering, our response to pain, is uniquely human.(7) In Elaine Scarry’s book The Body in Pain she writes: “To have great pain is to have certainty, but to hear that another person has pain is to have doubt.”(8) When we hear another person’s account of pain we cannot truly know its meaning or intensity, so uncertainty necessarily arises.
Why do we experience pain?
In his book on the evolution of the human body, the biologist Daniel Lieberman argues that symptomatic phenomena such as a runny nose, fever, and pain are signs of illness. Symptoms evolved because they helped push us toward action.(9) A symptom is a signal. It tells us something is wrong and needs tending. That signal, pain, need not be physical only. It can also be emotional, as in heartache.
Coping with pain in the modern world: relief
Compared with traditional languages of health, the languages we speak in the modern world offer very few everyday words for describing pain.(10) One of modern medicine’s strongest tools is the relief of pain. Painkillers are in almost every home and easily available. A person in pain can take a pill without any mediator. Prescription painkillers, including opioids and certain antidepressants, are more available than ever. The United States is one of the places with the greatest overuse of painkillers, especially opioids, leading to addiction and many deaths. This preoccupies the U.S. government.(11) In Limits to Medicine, Ivan Illich writes that “only pain that is thought of as curable is intolerable.”(12) When pain relief is so accessible, there is less social legitimacy for suffering because of pain. Pain shifts from tolerable suffering to something we should not have to bear.
Continuing his evolutionary framing, Lieberman worries that our current way of treating symptoms may worsen underlying processes. He writes that it is human to reduce suffering, but it is helpful and sometimes even life-saving to address causes rather than symptoms.(13) Treatment that erases pain is symptomatic treatment. It silences the signals that indicate illness or imbalance instead of finding and addressing the source. We understandably want to stop our pain, but the problem will not be solved by easing suffering alone.
Coping with pain in the ancient world
Illich describes how, in traditional cultures, responsibility for behavior and coping with pain and suffering rested with the sufferer, and pain was recognized as part of reality.(14) In the local ancient medicine of our region, and in the learned medicine of other ancient civilizations as well,(15) there was a shared language that allowed people to describe health and, in detail, their pains. Pain was considered a sign of imbalance, and imbalance could be described through a broad system of elements, temperaments, and humors. The language used to describe pain was known to the general public as well as to physicians.(16)
The medical theory that shaped our region for roughly two thousand years was itself a language, a shared system of signs meant to name the body’s departures from balance. Pain was a central sign of imbalance, and so this language also served to describe pain, as we can see in many case histories. The physician Abū Bakr Muḥammad ibn Zakariyyā al-Rāzī, who practiced in Baghdad in the early tenth century, wrote Kitāb al-Tajārib (The Book of Experiences or The Casebook),(17) a collection of nearly nine hundred case histories he treated or supervised. The chapter on headache and migraine includes thirty-five descriptions. Each migraine is accompanied by an explanation of its origin. For example: “A man suffered from headache due to vapors of yellow bile hidden in his stomach… sharp headaches… his sight was weak because of the pain…”
Beyond the vocabulary for describing pain, ancient medicine also warned against purely symptomatic treatment. Maimonides, the 13th-century Jewish physician and philosopher, repeats this warning in several of his writings. In his Treatise on Hemorrhoids, where he also discusses general principles of health, he writes about treating pain symptomatically:
“Even if you are cautious and keep your health as best you can, you cannot avoid the occurrence of various bodily events. Sometimes the stool softens a little, and sometimes it hardens a little. One day a person finds weakness in his digestion, or suffers a small headache or a slight pain elsewhere. There are many such cases. One must be very careful and not rush to treat such a minor matter by taking medicines to remove the phenomenon. The greatest physicians have already warned against this. Nature alone is sufficient in such cases and there is no need for drugs. One should persist in the regimen of health. For when you begin to treat these small cases, one of two things will happen. Either your action is mistaken and contrary to the way of nature, and you confuse it and increase the harm. Or your action is correct and renews the natural function of nature, but at the same time you teach your nature laziness and accustom it to depend on outside aid.”(18)
The guidance is clear. Where there is no danger to life, there is no need to erase the symptom. Symptomatic treatment can create harm in two different ways. The medicine may not be suitable and can act against nature, increasing harm. Or it may help in the moment but suppress the very physiological mechanisms that are meant to act. The body then learns that whenever a minor event occurs, it need not respond on its own but must rely on external intervention.
Even in the ancient world, despite warnings from Maimonides and other physicians, people still longed to erase symptoms. A striking example from outside the medical profession appears in a poem by Judah al-Harizi. Born in Toledo in 1165, he became a poet and translator of Arabic texts into Hebrew, later wandering to Provence. One of his most famous works is Tahkemoni, a collection of fifty maqāmāt—poetic narratives—that tell stories of his travels.(19) In one of them, “The Physician’s Chapter,” set in the Land of Israel, a man appears and declares himself a doctor who can cure every illness with his medicines: “Before him, bowls full of medicines, these for potions and those for salves.”(20) The people rush to him, “drawn by the cords of his words, caught like fish in his nets,” until the narrator confronts him with his deception: “And I said to him, shall a man like you profane his honor on the roads, and debase his dignity in the craft of tricksters?” The man admits that money is what drives him. Al-Harizi mocks this false healer and condemns him, showing that a true healer is one who first helps patients restore balance before attempting to erase symptoms.
The urge to quiet pain
Even though ancient medicine preferred to examine symptoms rather than suppress pain, it also acknowledged our human tendency to seek short-term relief instead of investing in long-term healing. The theory of ancient local medicine described the “animal spirit” as the vital force responsible for preserving the body in emergencies. In moments of pain or danger, this animal spirit overcomes the rational human spirit and strives above all else to silence the symptom. This is crucial when life is immediately at risk.
To expand briefly: ancient medicine divided the human soul into three parts. The vegetative spirit, shared with plants, governs basic bodily functions such as nourishment and reproduction. The animal spirit, shared with animals, governs survival. The rational spirit, unique to humans, governs reason. According to this tradition, grief and pain are activities of the soul in relation to the body,(21) and they fall under the responsibility of the animal spirit, which acts through appetite and anger. Avicenna, the 11th-century physician and philosopher, writes: “The special act of the animal power is appetite, and, as its branch, anger. Its benefit is the preservation of the body through the force of anger, the guarding of the gates against harm, and the continuation of the species through the appetitive power. These meanings are summed up in the force of anger.”(22,23)
Many of us are quick to dismiss such ancient theories. We tell ourselves they are interesting but no longer relevant. Yet a modern position paper on health decisions from the perspective of behavioral economics describes processes that align in intriguing ways with those ancient views.(24) Brain imaging studies show that different areas of the brain are active when we make choices that favor short-term rewards compared with those that affect the long term. The regions that activate for short-term rewards are those we share with animals, while the areas involved in long-term planning evolved later and are distinctly human.(25)
In other words, just as ancient medicine attributed immediate protective action to the animal spirit we share with other creatures, modern research finds that the parts of the brain that govern short-term reward are the more animal parts of our mind.
To choose long-term benefit over short-term relief, we need to rise above the animal impulse. The same applies to pain relief. To avoid silencing pain—the animal instinct—we must look for its meaning and source. This requires delaying immediate gratification and calling on what is uniquely human in us.
But when it hurts, who really feels like thinking?
Before the conclusion
While writing this essay and immersing myself in the subject, my senses for pain became sharper. I began to feel my own pains more clearly and to try to sense the pains of those around me. I carried out a few experiments in the study groups I lead. With people who had long known one another, I asked them to speak in different ways about their pain. These conversations revealed how unaware we are of the pains of those around us, and how important and powerful it can be to talk about pain together, in a community. Conversation makes pain legitimate for the sufferer, and more tangible for the listener who cannot feel it. I was struck by how much we do not know about one another’s pains, how often we hide them. We discovered together how quickly an open conversation can make pain legitimate, and a little easier to bear.
Summary and conclusions
Illich’s claim about the legitimacy of pain, that “only pain that is thought of as curable is intolerable,”(26) was what first drew me to write about pain. In the process, I came to see just how complex the subject is, and especially how difficult it is for a person in pain to convey it to others, and how hard it is for others to know or understand it. Both the sufferer and those around her are drawn toward the impulse to silence pain. It is clear to me that there is a problem in today’s situation, which allows for excessive use of painkillers, yet I also understand the deep difficulty of facing pain without numbing it.
Today, as described here, our culture does not allow pain to be expressed. We extinguish it and hide it. In the past, through history, cultures cultivated entire languages whose role was to make pain speakable. Our nature yearns for relief, and the combination of easy access to relief with the lack of social legitimacy for pain prevents us from truly confronting it. The hiding and silencing become an added burden. A group conversation, a community conversation, may be the first step in bringing pain back into the open.
A few insights I take from this exploration:
- It is important not to lose touch with our warning lights, our symptoms. We must learn to know our bodies and their systems, and to recognize that every ache or pain is a signal of distress. Before we switch off the light, we should first understand where the distress comes from.
- As part of listening to and understanding those warning lights, we should avoid pain relief whenever possible. This is our responsibility as individuals for our own health and fate, and it is also our collective responsibility through the regulation of painkillers.
- One of the most powerful ways to cope with pain and to legitimize it is to talk about it. When we are in pain, it is important to share it with those around us. When we are not, we can allow and encourage others to speak of theirs.
- I suggest that people keep a pain journal. Write down levels and descriptions of your pain in as many words as possible. As a teenager, after years of recurring headaches, I kept such a journal. It helped me trace the source of my pain.
- As a child I was often called a crybaby. That label still follows me. When I hurt, I sometimes tell myself not to cry. This conditioning came from a society that dismissed expressions of pain. Today I understand that when we lack a rich language or legitimacy to describe pain, crying is a legitimate way to express it. Allow those around you to cry.
- I regret all the times I told my daughters or Tali that I understood their pain, because I do not. Or that it would pass, or was not so bad. Pain deserves to be received, held, listened to, and accompanied, with the awareness that we can never truly know another’s pain.
References
(1) Waddie, Nicola A. “Language and pain expression.” Journal of Advanced Nursing 23, no. 5 (1996): 868–872.
(2) Even-Shoshan Hebrew Dictionary [Hebrew].
(3) Merskey, H., and N. Bogduk, eds. Classification of Chronic Pain: Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms, 2nd ed. Seattle: IASP Press, 1994. See “Part III: Pain Terms.”
(4) Scarry, Elaine. The Body in Pain: The Making and Unmaking of the World. New York: Oxford University Press, 1985, p. 4.
(5) Wittgenstein, Ludwig. Philosophical Investigations. Especially §§244–271 on pain and private language. Standard English translations.
(6) On pain behavior and expression in Wittgenstein, see accessible summaries and discussions: Philosophy Now, “The Private Language Argument.”
(7) Illich, Ivan. Limits to Medicine [Hebrew translation: Nikmat Ha-Refuah], 1987, p. 76.
(8) Scarry, Elaine. The Body in Pain, p. 7.
(9) Lieberman, Daniel E. The Story of the Human Body: Evolution, Health, and Disease. 2013. See discussion of symptoms as evolved signals around pp. 177–178.
(10) Scarry, Elaine. The Body in Pain, p. 5.
(11) Garcia, Andrea M. “State laws regulating prescribing of controlled substances: balancing the public health problems of chronic pain and prescription painkiller abuse and overdose.” Journal of Law, Medicine & Ethics 41, no. 1 Suppl (2013): 42–45.
(12) Illich, Ivan. Limits to Medicine [Hebrew translation], 1987, p. 76.
(13) Lieberman, Daniel E. The Story of the Human Body, 2013, pp. 177–178.
(14) Illich, Ivan. Limits to Medicine [Hebrew translation], 1987, p. 76.
(15) On ancient “pneumatic” medicine as a current within Greco-Roman theory, see e.g., Britannica, “Pneumatism,” and scholarship on the Pneumatist school.
(16) Mayer-Chissick, Uri. Food and Balance: Practical Medicine according to the Theory of Elements, Temperaments, and Humors [PhD thesis, Hebrew; cited as original source].
(17) Abū Bakr Muḥammad ibn Zakariyyā al-Rāzī (Rhazes). Kitāb al-Tajārib [Arabic manuscripts; modern Arabic editions exist]. For scholarly discussion of this casebook: Alvarez-Millán, C. “Practice Versus Theory: Tenth-Century Case Histories from the Islamic Middle East.” Medical History 44, no. 1 (2000): 1–20; and Aciduman, A. “On pains of the kidney and the bladder in Kitāb al-Tajārib by Rhazes.”
(18) Maimonides, On Hemorrhoids (Arabic original; medieval Hebrew and Latin translations). See the critical parallel Arabic–English edition by Gerrit Bos, 2012. Quotation here is the author’s translation from Arabic.
(19) On the maqāma form: “Maqama (Mahberet).” Brief literary note.
(20) Judah al-Harizi, Tahkemoni [Hebrew]. Standard modern edition: Yad Yitzhak Ben-Zvi, Jerusalem, 2009. For English translation and studies, see David S. Segal, The Book of Tahkemoni: Jewish Tales from Medieval Spain (Littman, 2001/2003).
(21) Anthology of Avicenna’s writings [Hebrew], Tel Aviv University, 2009, pp. 155–156.
(22) Note on terminology: here “anger” translates a broader Arabic concept (ghaḍab) that includes protective, defensive arousal rather than only the modern emotional sense.
(23) Anthology of Avicenna’s writings [Hebrew], Tel Aviv University, 2009, p. 258.
(24) Yael Polak-Hallak, “Health Habits and Behavioral Economics,” Hadassah Hack Motivation [Hebrew position paper].
(25) On short-term versus long-term reward circuitry in decision making, see behavioral-economics summaries; for a general bridge, see works that contrast immediate reward systems with later-evolving frontal systems.
(26) Illich, Limits to Medicine [Hebrew translation], 1987, p. 76.
