Pain (3 page)

Pain and its relief defined a high-stakes challenge—a topic not easily controlled by politicians, physicians, judges, or any single group; for that reason, it has incited a steady struggle over who has the right, jurisdiction, and authority to say who is in pain: doctors, sufferers, pharmaceutical companies, politicians, the federal government, the states, lawyers, or judges? Even as pain medicine has emerged and grown as a clinical specialty during the past seven decades, physicians were never in true control and always looked to others—the drug enforcement agencies, police, courts, disability activists—for guidance. Thus, while it is tempting to see the history of pain relief as a medical story in which ascendant doctors and scientists (rather than the courts) should have authority and control
over the question of who was in pain, in truth, the politics of pain has always been deeply contested. Doctors, as we shall see, have played critical roles—advocating for sufferers, inventing new theories of pain, endorsing relief practices, and bridling against legal constraints. But these experts have largely conformed to the cultural trends of their time. In the politics of pain, politicians and ideologues have often led the way, creating new rules about whether pain should count as disability. Often, it has been the courts, not scientists or physicians on their own professional terrain, that have settled questions about the validity of chronic pain, the criteria of disability, and the citizen's right to relief. As we shall see in the pages ahead, these ambiguities over who owns the topic (and over whether it was a moral problem, a political challenge, a legal question, a personal dilemma, a pharmaceutical opportunity, or a medical problem) made pain a fraught and contentious field.

But come now … and sing of the building of the horse of wood … led up into the citadel as a thing of guile … So there it stood, while the people talked long as they sat about it, and could form no resolve.

BOOK 9,
ODYSSEY

F
or Lieutenant Colonel Henry Beecher, soldiers' pain was a paradox. Treating men gravely wounded on the Italian war fronts in the mid-1940s and at the Anzio beachhead, Beecher, a medic who later became a renowned pain specialist, marveled at how “strong emotion can block pain.” Gravely wounded GIs (in fact, as many as three-quarters of them) did not request morphine, he found, despite being in severe pain and often near death. What allowed these badly injured men, subjected to almost uninterrupted shellfire for weeks, to show surprising optimism and even cheerfulness? With this question fresh in mind, the war doctor came home understanding that pain was far more complicated than most people thought and that the capacity of men to withstand wrenching anguish was a profound mystery. In time, pain would become not merely a bodily paradox but also a profound political one.

A decade later, Louis Orr viewed the GI through a different lens. Orr insisted that, once safely at home, the veteran had become a whiner, a complainer, and “a Trojan horse” opening the way for socialized medicine. As a prominent physician in the American Medical Association hierarchy, his pronouncements carried political force. The medical organization had successfully opposed President Harry Truman's plan for national health insurance in the late 1940s, and it remained alarmed about any proposals to expand insurance and benefits—both to veterans and to the general population. Writing in the late 1950s, Orr saw the veteran's complaint in this
political light, as an excuse for government encroachment into private health care. In the years since the war ended, he insisted, the GIs' complaints of disability had grown out of proportion to their actual injuries. Orr alleged that the trend had been encouraged by veterans' groups (such as the American Legion) lobbying Congress to liberalize disability benefits. The result was incessant coddling and crippling dependence on government, particularly within the Veterans Administration health-care system. These developments, Orr feared, were leading America to the brink of socialism.
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What had happened to shift the profile of the GI and his pain so dramatically from the hardened fighter on the Anzio beachhead in 1946 to the chronic complainer on the VA ward in 1957? Had the soldier's marvelous endurance on the front lines been converted into a societal weakness by life at home? Was it true, as Orr and the American Medical Association contended, that expanding government benefits; creeping, coddling liberalism; and social indulgence were to blame? It was not just that memories of the soldiers' heroism had faded in the intervening twelve years: the disability and pain debate of the 1950s concealed within it an ideological skirmish about liberalism and the legacy of New Deal policies, about social accommodations and postwar citizenship, about disability provisions for the general population, and about the future of the nation itself. The case of these soldiers (and the civilians they would become) sits at the core of this chapter in American pain and politics. As we shall see, the debate on the soldier's complaint was a battle in the larger social conflict, one that would expand and transform beyond veterans per se and become a raging political war shaping American society for decades to come.

Context mattered in assigning a meaning to pain; Henry Beecher knew this. There was something in war's setting that gave a man a strange ability to tolerate long-bone fractures, penetrated abdomens, head wounds, and other severe injuries. For a civilian similarly injured in a car crash on his way to work, Beecher reasoned, the accident marked the “beginning of a grave disaster.” But war wounds were different. At first, fighters barely even notice injuries. Why? The soldier downplayed his torment because “his wound suddenly releases him from an exceedingly dangerous environment, one filled with fatigue, discomfort, anxiety, fear and
real danger of death, and gives him a ticket to the safety of the hospital,” Beecher speculated. “His troubles are about over, or he thinks they are.” Removed from the immediate threat of death, “it is not difficult to understand their relief on being delivered from this area of danger,” Beecher observed.
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However traumatized, soldiers' minds now turned to thoughts of going home, and thus they seldom asked for morphine, Demerol, or other painkillers.

The case of a husky nineteen-year-old soldier with a lacerated spine from a mortar shell gave Beecher his first view of these paradoxes of pain and social setting. The soldier “complained bitterly” about the pain, appearing to be wild from it, convinced that he was still being driven through with his own rifle. In reality, his back was gravely wounded. In the unruly triage procedure, the man was not given morphine—the most commonly used opiate—but whatever was at hand (in this case, a strong barbiturate sedative, sodium amytal). The sedative, which did nothing at all for pain, had a striking effect: “his color improved,” the young man relaxed, his blood pressure rose, and he “turned for the better.” His manic state had not been due to pain, Beecher concluded. Once sedated, a euphoric state set in; this was its own painkiller. Interviewing many such men, Beecher found that pain ranked low among their worries. In shock or euphoria or perhaps dreading death, they complained of strange things like unquenchable thirst, which usually “rose to first place as a cause of suffering.”
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But what would happen with a change of context? How long would a body's ability to relieve itself in this way last? What would happen to these men at home if the torment returned, if it persisted, or if the scars did not heal?

At home, these soldiers in anguish looked entirely different and would come to occupy an important place in American politics. How the soldier-civilian handled his pain became not just a medical problem but a challenge for government. If such men did not recover fully, they came to the VA—a once small, but now growing, branch of the postwar federal establishment—for help. With the VA's expansion, the notion that the veteran's chronic complaints and his lingering health troubles might be legitimate disabilities that warranted social compassion and long-term compensation quietly crept into American political consciousness. War kept these issues in the foreground. Memories of the world war faded but the Korean War erupted in the early 1950s, and the logic of pain and disability
became surely tied to injury abroad and the growth of government care for returning soldiers.

For a nation on constant war footing, veterans' disability and pain were morally and fiscally troubling. What form of public and medical accommodations would the ailing GI receive? When was injury truly disabling? When was pain too much for a normal man to tolerate? While ongoing care for injured veterans might today seem uncontroversial, at the time, it was a continuing source of public debate. “Never before in history had a Nation assumed so inclusive a responsibility for its veterans … disabled in battle,” noted one commentator. In time, these obligations became a burden, and for some observers it also became a severe threat to the country's well-being. “It was inevitable,” this same writer noted, “that this burden would undergo a rapid increase as soldiers were returned to civilian life.” In 1945, disability claims totaled $336,000. By 1963, expenditures would near $1.7 billion, with almost two million veterans receiving disability compensation. The numbers would continue to rise; the staff of the VA hospitals doubled and doubled again to meet the demand.
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In the meantime, Beecher would make a career of such mysteries of pain—writing on the placebo effect, on soldiers reporting “phantom” pains in limbs long lost, and so on.

Pressured by veterans' groups to liberalize benefits, the Truman and Eisenhower administrations waded into these dangerous waters, fully aware that charges of socialism might follow. But could disability benefits be limited to soldiers alone? Shouldn't the benefits accorded them be more widely shared? Over the war years, a series of laws had incrementally expanded disability services for soldiers who had service-connected disabilities. Opponents like Orr on the political Right believed that the veterans' case for relief was overstated. Moreover, they feared that this case stealthily laid the groundwork for another liberal agenda: establishing government disability benefits for the general population. The outlines of an American debate emerged, with the soldier's suffering and slow readjustment sitting at the critical nexus. For soldiers and civilians, the issues of chronic illnesses and pain were particularly charged. Were they or were they not related to wartime service? How, if at all, should they be compensated and cared for? How should pain and disability be measured? The state had long been concerned with disability compensation, measured in relation to normative notions of able-bodied citizenship; the medico-political
issue carried legal implications for what Barbara Welke called the “borders of belonging.”
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The cost, complexity, and stakes of pain and disability assessment, which had always been large for government, grew exponentially in the post–World War II years.

When Eisenhower came to office in 1953, he faced pressure to liberalize benefits on two fronts—for veterans and for citizens. The “great and growing body of veterans” sat squarely at the center of disability policy debates. America “has traditionally been generous in caring for the disabled—and the widow and the orphan of the fallen,” said the president. These commitments would continue, he promised, but they must remain commensurate with injury. Trying hard to bridge the political divide between liberal Democrats' continuing New Deal principles and his own Republican Party's anxiety about the growth of government, Eisenhower hoped the issue would be resolved with such pronouncements—but it was not. Throughout the early 1950s, he faced constant pressure from the Left to expand disability benefits for the general population; in 1956, he succumbed, signing legislation establishing Social Security disability insurance (SSDI).
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That concession created a new disability benefit within the social retirement system, sparked outrage among conservatives like Orr, and generated an ideological criticism that would last for decades and inform their views on all disability matters; for many critics, such initiatives were Trojan horses, stealthily ushering in socialism under the guise of compassionate relief.

The veteran returning from the theater of war was an unknown quantity—a heroic man but also a tightly wrapped bundle of anxiety, depletion, and dependence. The view of many experts in psychology and social adjustment was summed up by Wilma Donahue and Clark Tibbits, who wrote in a volume on disability in 1945, “Whatever military life may have signified in the way of boredom, discomfort, pain, and suffering, for many men it has also meant security and solidarity of purpose.” Released now from the constraints of military discipline, what would the soldier become? Some contributors to the same volume worried that the soldier had become a permanent dependent—that many years of being fed, housed,
and cared for in the military had done significant damage to his psyche and sense of independence. Many psychiatrists shared the view of Chicago psychiatrist Roy Grinker, who said that the soldier “comes back not a strong hero, but physically and psychologically depleted.” If it is true that “angry, regressed, anxiety-ridden, dependent men” were returning to civilian life in large numbers, the future appeared dark indeed. Would they cripple society?
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For Orr and his fellow conservatives, this was not a narrow clinical question. The future of the nation now hung in the balance, hinging to a large extent around the ideal of what able-bodied men should be and the reality of how war and hardship had altered them. As legal scholar Charles Reich later observed, the public sector's expansion was creating a new kind of property in the form of social entitlements—built upon a new relationship between citizens and the state.
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In time, pain would become a precondition of these entitlements. To understand how chronic pain emerged as a political flashpoint, we will take a closer look at U.S. society in Beecher's and Orr's time (from 1945 to the late 1950s), at evolving theories about people in pain, at how the soldier's and the citizen's cases for relief were constructed, at how pain therefore gravitated slowly to the center of American politics, and finally at how by the late 1950s the broad outlines of a liberal pain standard began to emerge.