Pain (6 page)

Demerol and Percodan quickly engendered new social conflicts over the limits of drug relief—proven effective on the front, promoted aggressively at home as “God's Own Medicine,” but increasingly regarded by police and some legislators as a devil in disguise. In 1951, the Senate committee investigating organized crime heard testimony about the drugs' addictive potential and links to a criminal underworld. Testimony from minors, women, and men confirmed the threat. Elsewhere, a former GI described how military service began, for him, an affair with morphine that led him to Demerol. After being bayoneted by a Japanese prisoner, he received a shot of morphine, “my first shot of dope … while I was in the hospital … After that, I was seeking it on my own.” From morphine, he graduated (after the war) to Demerol. The painkiller came to signify
an escape. A physician at the hearings also testified how Demerol helped him to cope, at first, with professional stress but soon dragged him into dependence. Promised the gift of relief, he was now plagued by addiction. Playing into many of the fears of the Cold War era, he described the insidious attachment: “He had become addicted to Demerol, a coal-tar derivative, which he took under pressure of too much work and too little sleep. He said he was confident he could use it in moderation, but failed to keep it under control.”
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Already in the early 1950s, then, the unwanted side effects of these relief-oriented products fed into deeper social anxieties about healthy men, women, and children led astray. Americans saw the good and bad in this new economy: they embraced liberal market access to Demerol and Percodan, yet they remained cautious that indulgent consumption carried many hidden costs.

Tranquilizers were the hottest-selling products of the 1950s go-go drug economy, but by middecade they, too, had come under enhanced scrutiny. Between the end of the war and 1960, drug makers produced an expanding array of such tools for fighting minor pain and major anguish and also for regulating anxiety, nervousness, agitation, and related distress. As
Consumer Reports
noted, the popular tranquilizer Miltown “has become the fastest-selling pacifier for the frustrated and frenetic.” A backlog of unfilled orders illustrated the high demand. The drug went beyond mere pain management, for it not only relieved “the pain of malignant disease” but also controlled so much more—nausea and general disease. “Most patients who come to see a doctor complain of pain and demand relief from it,” insisted Dr. F. M. Berger of the Wallace Laboratories of New Jersey, the producer of Miltown. Speaking before a Congressional hearing, one New York psychiatrist saw the pills as a boon to mankind; it was permitting deinstitutionalization and liberation of the mentally ill and reducing the need for many hospitalizations. A drug associated with the ideals of the 1950s, tranquilizers thus blurred pain relief into a range of more vexing issues from the altering of personality to mood and emotion management and broad social change.
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The slippage from pain relief into personality and mood management worried some doctors and drug enforcement authorities and provoked slow political reassessment of the postwar market's drug revolution. Whether the demand for tranquility was stimulated by the industry's aggressive marketing or by unleashed consumerism, drug makers were well
positioned to respond to the rising demand for pain relief. In 1956,
Newsweek
reported that 5 percent of all Americans had taken tranquilizers in any given thirty-day period, and drivers, flyers, alcoholics, and heart attack and migraine victims all praised its salutary effects. But by 1957, Minnesota congressional representative John Blatnik (who had also criticized misleading ads for cigarettes and diet pills), opened hearings on the era's popular painkillers, concerned about a trend toward deceptive marketing that played fast and loose with science. For him, it was the private market (and AMA complicity with industry), not government relief, that proved worrisome.
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Physicians like Louis Lasagna questioned whether the industry made truthful claims about drugs' effects, and, by the end of the decade, Tennessee senator Estes Kefauver opened a wide attack with dramatic investigations of drug industry pricing, side effects, and advertising. For reformers on the left, then, drug-based relief in the 1950s was no less fraught than government disability compensation was for critics on the right. Both forms of relief seemed to have hidden effects; both were caught in a vortex of suspicions about dependence, indulgence, and guile. These questions of relief both touched on the issue of trust—not only whether the complainant could be trusted but who could be trusted to bring true relief, government or the drug companies?

All these issues of soldiers' pain, disability, relief, and recovery became nearly tragic for President Eisenhower when he suffered a severe heart attack in 1955. Recovering from surgery and anticipating a tough re-election campaign in 1956, Eisenhower relied on Demerol, morphine, sedatives, anticoagulants, and other drugs. Reporters pressed the White House for information on the president's mental state (Was he depressed?), his disability (Was it only temporary or enduring?), his recovery, his pain, and his capacity to continue the duties of the office. Meanwhile, his physician, Howard Snyder, worried in a private letter that Eisenhower now saw every pain, no matter how modest, as an ominous sign: “This past week the President has had, toward the latter part of the day, some pains in the right side of his abdomen. These, we feel sure, are due to accumulation of gases in that area in the large intestine. [But] any pain in that area causes the President great apprehension and is so psychologically disturbing that it is quite depressing to him.”
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At this very moment, the Bradley Commission was asking veterans about their experiences recovering from combat-related and non-combat-related illnesses and asking
doctors whether “suffering, anguish, and pain” (in contrast to the loss of a limb) were legitimate reasons for disability compensation. If asked, Snyder would have answered yes. For the president, these questions were no longer abstractions; the political had become personal.

Standing before the Trojan horse, medical specialists (like the citizens of Troy) were deeply divided about this thing called pain. What was it? How should it be treated, if at all? Almost everything that society offered for relief—disability payments for those who could not work on the public side or drugs and surgery to restore the body's functioning on the private side—had a double-edged quality. A new field devoted to pain theory and management, growing out of the war work of doctors, made sense in this context, and it is no coincidence that 1953 saw the publication of a major work in the field, John Bonica's
Mechanisms of Pain Management
. Working among injured soldiers, Bonica (like Beecher) had seen distress and ravaged bodies up close. His sympathies inclined toward the suffering veterans. Directing the anesthesia and surgery unit at Ft. Madigan Army Hospital in Washington, with its nearly eight thousand beds of injured soldiers from the Pacific theater, the twenty-eight-year-old Bonica noticed “an unusually large number of patients with severe intractable pain.” Doing a kind of intellectual triage of pain types, Bonica began to think of pain not as one entity but as many different problems—organic pain being different from psychic pain, and functional pain being distinct from imagined pain. And then there was the vexing mystery of phantom limb pain. For Bonica, this last type was neither feigned suffering nor psychic maladjustment but something more complex, “a fundamentally psychobiological phenomenon.” “Though it is a common habit of the mind,” he continued, “to think of pain in physical terms and to draw an artificial distinction between what one is pleased to call ‘real' or ‘organic' and ‘imaginary' or ‘functional' pain, whatever its source of origin, it is in the final analysis a psychic event.”
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Such typologies, and Bonica's observations on analgesic effects on each type of pain, formed the basis for a new specialization. To build pain as a specialty, simple theories of perception and personality would not
do—such as the view that some soldiers were “can'ts,” others were “won'ts,” and that some were simply stoic heroes built, like Private Alford McLaughlin, for tolerance and endurance. The pain field's founding theorists and practitioners (Henry Beecher, John Bonica, and others) rejected these simple truisms. After treating and observing soldiers in war, they now sought to make a specialty out of this new and difficult social and psychic problem.

For Bonica, the management of pain through analgesia (drugs used for various kinds of numbing and sensation) opened into the management of mood, hope, emotion, and much more. No one knew better than he that different people reacted differently to hurt and relief, depending on “what the sensation means to the individual in the light of past life experiences and his attitude toward it.” Pain sensation, in turn, depended on the person's mood, emotional status, will, cerebral functions, anxiety level, and many other factors. As an anesthesia expert, he knew also that any one drug could have multiple effects in one person and that the same drug had diverse effects across many individuals.
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Postwar Americans needed relief, but at what cost? Furthermore, finding the right kind of relief for each individual (pain management) was a complex undertaking.

As Bonica left military medicine for work in Tacoma, Washington, these questions of pain and mood management followed him. The 1953 book that followed—years later called the bible of the pain field—outlined the core commitments and practices of the specialist. Pain, after all, was “the leading reason why patients go to doctors,” and his publisher hoped that many other physicians would look to Bonica's text for guidance. They were not disappointed; the book was well received, particularly among doctors trying to find their way through the thicket of the new pain-relieving drugs. The expertise Bonica embodied—whether on the benefits of new drugs, on their adverse effects, or on patient complaints—was in much demand. In short order, he also became an expert
for
the pharmaceutical industry—meeting regularly with executives, attending company-sponsored meetings, publishing studies on their new products, and testifying on their behalf at trials about alleged side effects. His was a partnership with industry in the fine art of balancing pain relief and regulating mental states. As he wrote to one executive, “I am anxious to use this drug not in postoperative patients but in patients with inoperable cancer pain. As you no doubt know, many of these patients
are depressed mentally because of their hopeless prognosis. This, in addition to the depressant effect of narcotic therapy which is frequently used for pain relief, takes a very heavy psychological toll.”
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For Bonica, managing pain, mood, side effects, expectations, and disability were as one—making his work on behalf of patients and industry complex.

FIGURE 1.2.
John Bonica, later regarded as the “father of pain medicine,” pictured in the 1960s signing one of his widely read analgesia textbooks.

Image courtesy of History and Special Collections for the Sciences, UCLA Library Special Collections.

As he moved deeper into the field of pain management, however, Bonica realized that surgeons had already carved out a place for themselves in the management of pain and mood through aggressive brain surgery, especially the lobotomy. Surgeons had their own well-developed theories about people in pain—who they were, the organic origins of their complaints, and why such neurosurgical therapies as lobotomies worked best. Neurosurgeons' faith in lobotomy as the best medicine for the patient suffering in excruciating, intractable anguish had similarly been shaped by their experiences in World War II. Like Bonica and Beecher, the neurosurgeons had
gathered new insights managing the traumas of war wounds. In war, the field had developed a set of radical surgical practices in the name of saving lives, emerging confident that “the neurosurgeon plays an important part in ridding these patients of pain.” One noted prewar pioneer in the pain management/lobotomy field, surgeon Walter Freeman, agreed that “there is no fine dividing line” between organic pain and imagined pain. Following in Freeman's bold footsteps, 1950s surgeons answered the double-edged problem of how pain sensations could be both anatomical in origin and personality based with their own double-edged therapy. In some people, said physiology professor George Wakerlin, the lobotomy resolved the mystery. Once patients were lobotomized, he argued, “pain ceases to be bothersome, altho [
sic
] it is still felt, when the front part of the brain is severed in an operation called a lobotomy. This disconnects the anatomical switchboard thru [
sic
] which the pain signals are dispatched.”
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Across these fields, there was much disagreement about what pain was and what were its underlying mechanisms. But few could dispute that lobotomy worked against pain, particularly if the goal was to subdue the complainant.