Pain (7 page)

Although lobotomy had become deeply controversial as a mode of pain relief and would soon embody much about the era's surgical hubris and excess, in early 1950 such surgeries still dominated medicine's approach to pain, particularly in terminal cases. The decision to conduct the lobotomy operation in an advanced cancer patient was fraught. But its advocates insisted that the procedure was humane, compassionate, and nothing less than a therapeutic triumph over a tortured existence. Freeman described one woman given a new life, free from worry, who had once suffered from disabling, intractable pain owing to an abdominal disorder. Many earlier operations had failed. But after Freeman's excision (“boring two holes in the skull above and to the front of the temples and severing the fiber between the thalamus and the prefrontal lobe”), the woman recovered dramatically. Before the operation she had screamed in pain when touched, said Freeman, but now the woman was able to “leave the bed of pain to which she had been confined for two years” and was “free of any feelings of intense pain” and even gainfully employed as a bookbinder. Moreover, this kind of relief—a profound surgical modification of feeling—lasted. He told of other sufferers relieved by the operation, such as the jeep driver who had lost his arm in an accident and “complained of
extreme pain in the stump (a not infrequent complaint in such cases).”
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He too had been helped dramatically by the lobotomy.

Neurosurgeons were sensitive to the accusation that the operation left people as “vegetables,” but this was untrue, Freeman argued.
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For men like Freeman and for many Americans, lobotomy stood not at the forefront of medical barbarity but as a symbol of humane, compassionate care—a practice that restored people in tortured disability to full functionality, freedom from anxiety, and a fuller health than they had ever had before.

In the micropolitics of medical procedures, new professional divides and subtle tensions were opening up in the 1950s—with the rifts between surgery and drug remedies defining alternative paths in the quest for relief. In an era of heady postwar specialization, each specialty sought to remake the body in its own way. Better living through chemistry or through lobotomy—these were only two of the ways that, as David Serlin has noted, postwar medicine made new inroads in rehabilitating bodies and identities. For surgeons, technical precision was the key to restoration. Harvard neurosurgeon James C. White argued for cutting pain transmission pathways selectively and deliberately. Severing neurological pathways saved sufferers from multiple threats to mood and personality—“from prolonged suffering, the deterioration of drug addiction, or ultimate suicide.” Cutting such conduits for pain also radically altered the personality of the sufferer—“so that pain to him became a sensation rather than a constant threat.” The technical challenge, White explained, was “to cut the pain tracts so completely that pain is permanently relieved” but also selectively so that bladder control and muscular strength was not adversely affected. In the view of such practitioners, lobotomy even constituted a humane, “legal alternative to euthanasia”—easing the cancer sufferer out of life not with sedation and drugs but by removing the worry centers of the brain, diminishing anguish, and allowing the disease to take its course with suffering removed. As White saw it, “lobotomy [was] justified when there is no other solution.”
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Some surgeons also argued that the costs of lobotomy were low when weighed against its alternative: the high social and moral cost of using drugs for pain and feeding addiction. Here was yet another calculus of relief, surgical radicalism to make anguish bearable, to rescue people from torture as well as from addiction. Harvard's White, who had spent the war years with the U.S. Navy treating spinal cord and neurological injuries,
insisted that neurosurgery was the preferred solution to precisely those kinds of pain, “unbearably severe and resistant to all known methods of medical treatment and to operation on the underlying causative factor,” that lent themselves to opiate addition. This type of trouble was increasingly common “in the aged or in young people after certain injuries and diseases [including] the intense burning pain which may follow an eruption of herpes zoster (shingles); cancer … gunshot wounds and other injuries of the spine; and the pains experienced by amputees.” In these conditions, morphine was an obvious choice, but its downside of dependence was well known. Surgeons claimed (and many experts agreed) that the operations they endorsed, if performed smoothly, could return people who once had been disabled, pained, and addled by morphine to productive work and happy, satisfying lives. Indeed, one new study on lobotomy (“cutting the channels to the front of the brain”) showed how a person with intractable pain was simultaneously relieved of his hurt and cured his addiction to forty-two grains of morphine daily.
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Lobotomy as pain relief worked in a perverse way; lobotomized people often reported calmly that they were still in pain, but they simply did not complain about it. This observation only added to the fascination with pain and perception as things of mystery. If the culture of complaint was a problem, surely here was a solution. People suffering in chronic distress emerged from the operation tougher than before, more able to endure hardships, and more tolerant of anguish. In some ways, the practice fit neatly into the era's belief in toughening up chronic complainers and hardening them to life's cruelties. Among the procedure's “interesting effects on personality” was its effect on worrying. As one journalist noted, pain became “a sensation rather than a horror. It gives people a little ‘thicker shell' but doesn't make vegetables out of them, contrary to popular opinion.” Surgeons knew that this thickened shell could be seen as dehumanizing but insisted that observations of lobotomized patients showed only that “certain aspects of personality and perceptual style, which are changed by a prefrontal lobotomy carried out for the relief of pain, are precisely those that differentiate within the normal population those who can tolerate pain well from those who suffer greatly from it.” In this view of lobotomy, the line between the naturally pain-tolerant individual and the lobotomized person was blurred. Essentially, “a person who is exceptionally tolerant of pain has the personality and perceptual style of the individual
after a prefrontal lobotomy, whereas one who cannot tolerate pain resembles in personality a patient before prefrontal lobotomy.”
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But, to nonsurgeons the practice was clearly troubling and double edged, and Freeman constantly defended against charges of radicalism.

This was the medical field that John Bonica entered. In favoring drugs, he became a modest reformer—believing that neurosurgery's “destructive procedures” should be employed only as the last resort when pain proved intractable to all other measures. In medicine as in society, then, pain was a Trojan horse containing many hidden dangers. If one were in chronic pain, finding true relief—whether by surgical mood manipulation, drugs, or disability compensation—would be treacherous and contentious whichever way one turned. For many observers delving into the mysteries of pain, the greatest mystery of all was the complainant; and by the mid-1950s, much of the new pain field's theories, speculations, and worries surrounded the complainer him- or herself.

One prominent physician, Ian Stevenson, warned that the blockbuster drugs of the era, rather than relieving worry and distress, only masked underlying problems in people's lives. Tranquilizers and pain-relief drugs allowed people to enter a drug-induced haze, to escape caring and responsibility: “Tranquilizers, like alcohol, numb not only psychic pain, but also love. Thus the widespread use of these drugs expresses—and may also dangerously promote—both the loneliness and the callousness of our crowds.” He warned, “A chemical suppression of psychological difficulties remains a concealment whether with just a little vermouth or with a shiny tablet.” If not handled carefully, drugs—like surgery—had a stealthy power to destroy.
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When General Omar Bradley's Commission on Veterans' Pensions began its work in 1955, among the many questions it tackled was how to rate the soldier's pain as a disability. Was the pain complaint a true disability or an excuse for shirking responsibility? If it was truly disabling, what was pain worth in dollars? The GI's complaint balanced on a tightrope. Here was the commission's dilemma: “If too high, the payment might encourage malingering; if too low, it would simply be a relief grant …
This problem has vexed our legislators and public administrators from the earliest times.”
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Compensation for ailments, including pain, involved a difficult political and moral accounting—translating suffering into cash. “Our central purpose has been … developing a monetary payment sufficient to enable the veteran to readjust financially in his home community,” one 1956 commission report stated. With sixty-six regional offices and many smaller units around the country doing disability determination, creating uniformity was one challenge.
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Also vexing were the ailments that did not fit neatly into the VA's mind-body disability categorization. The system recognized impairments of the body (loss of arm, eye, etc.), and of the mind (categorized as psychoneuroses); the challenge was how to tailor the payout not only to the type but also to the degree of disability while paying heed to the broader social good. Across its thousands of pages, the Bradley report made clear that these were not medical questions but political ones.

Who knew for certain whether the veteran's chronic affliction with, say, tuberculosis or arthritis really originated in the trenches, in exposures to pathogens abroad in cramped bunkers, or back at home? What kind of expert could judge the origins of these complaints? To tackle this quandary, the commission asked 153 eminent physicians for help. Most of the responding doctors were skeptical that the current disability determination system was based on sound medical evidence. Too often, they believed, the veteran had been given the “benefit of the doubt,” especially in diseases of unknown etiology like arthritis. This needed to be revisited. Chronic disease was a particularly perplexing problem; “one-half of the 153 respondents believed that the presumption of service connection” was not based on “accepted medical principles.” Slightly more than a quarter believed otherwise. The others hedged. One doctor expressed the skepticism of the majority: “I would change the whole system to one where there is no presumption in any case.”
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“In your judgment, should factors other than loss of earning capacity such as pain, suffering, social handicap, and mental anguish be compensated?” Bluntly, the commission put this question to the doctors. The question unleashed a torrent of deeper anxieties—starting with their distrust in subjective complaints, moving on to their belief that rewarding pain complaints encouraged deceit, and then ending with what many
saw as the true problem: the skewed social incentives and overliberalization of the postwar years. “The day has long passed when earning capacity is the sole yardstick,” noted one supportive respondent. “These and other factors are of equal or greater importance.” This respondent spoke for a solid majority (55 percent), who believed that if pain from injury continued long after the war, then, yes, it should be compensated—that is, “unless objective findings by a competent physician negate them beyond reasonable doubt.”
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But in the commission's poll of doctors, 41 percent insisted that accepting pain as a disability pushed them (as reluctant gatekeepers to the public purse) and society into the dangerous terrain of rewarding malingerers. For the skeptics, accepting pain as a disability grated against their views on fairness, feasibility, and human duplicity as well as the male soldier's adaptability to hardship. Pain was easily feigned, and its features were “vague, subjective, readily simulated [by deceitful claimants], and difficult to evaluate.” The category of pain, they insisted, was “imponderable,” “impossible to calibrate objectively,” “too difficult to evaluate fairly,” “practically unfeasible,” and “an insurmountable task,” even if “from a humanitarian standpoint” it was proper to treat it as a disability. Rather than accept immeasurable pain as a reality that might throw their commitment to medical objectivity in doubt, many chose instead to doubt there could be such a thing as disabling pain—primarily because of the impossibility of measuring it fairly. Faced with unfeasibility of measurement, one doctor concluded flatly, “Give medals, ribbons, etc.; but not pension.” Furthermore, another specialist noted, compensating for pain only favored men who were quick complainers and penalized “the adaptable sturdy characters.”
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These anxieties reflected, of course, underlying social codes about masculinity and deeper worries about whether idealized sturdy men should express pain, deny it, or cope with it.

Furthermore, many physicians argued that providing monetary awards for pain and anguish opened the door of relief to hordes of complainers. These doctors harped not only on the difficulty in measurement but also on the capacity for manipulation when a dollar value was put on such vague ailments.
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“These subjective complaints are extremely difficult to evaluate fairly; they are prone to lead to gross exaggeration,” noted one physician.
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Dr. Norton Canfield spoke for many others when he insisted, “These conditions are too hard to measure and to place a dollar
value on them is not reasonably possible.”
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This monetization of pain gnawed at many of the respondents. The irony, they insisted, was that only the complainers would be paid for their pain while hardier souls would tolerate their hardships without payment. As Walter Burrage put it, this was an unconscionable payoff: “in practice the complainer commonly is ‘payed off' [
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] while others ‘carry on.'”
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This was the doctors' deep enduring conceit about the Trojan horse of the soldier's pain. The entire system was not lifting men up but rewarding the wrong kind of men while dragging them down into a pit of government dependency.
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