Pain and Suffering. By William K. Livingston, M.D. Seattle, International Association for the Study of Pain, 1998. Pages: 250. Price:$31.20 (member)$48.00 (nonmember).

William Livingston was one of the giants in the conceptualization of pain. At a time when most theorists adhered to a simplistic, push-button concept of pain, Livingston realized that many of the observations he and others made in regards to patients with intractable pain problems simply were inconsistent with the popular specificity theory, which was in vogue during his early career. Livingston was a man who constantly questioned his observations and “checked them for fit” against current beliefs and dogma. He tells of his early exposure to the “pain pathway,” a view encompassing the hallowed three-neuron arc-peripheral nerve, the spinothalamic tract, and projections to the cerebral cortex as a rigid system, with pain intensity always being directly proportional to the stimulus. He then explains how this perspective was shaken when, as an intern, he painlessly opened a colostomy for a patient with a red-hot soldering iron. This spurred an interest in visceral pain and the eventual publication of a book of the topic. His ingenious experiments investigating visceral pain demonstrated to him that the adequate stimulus for visceral pain was different than for somatic pain. He takes the reader on a fascinating cognitive journey, during which he beautifully describes his experiences with patients while working as an examiner for the Oregon State Industrial Commission, which afforded him an opportunity to observe many patients with post-traumatic pain syndromes, including stump pain and phantom limb pain. As a reservist surgeon called to active duty in World War II, he had the opportunity to carefully collect information concerning more than 1,200 high-velocity missile injuries. In some of these patients, causalgia developed, as previously described by Weir Mitchell. Livingston started one of the first multidisciplinary pain clinics in this country during his tenure at the University of Oregon and published the book Pain Mechanisms . His theory of reverberating circuits within the internuncial pool of neurons in the dorsal horn was clearly prescient and one of the building blocks used in formulating more recent pain theories. He spent more 20 yr writing Pain and Suffering , in which he summarizes, in a semiautobiographic fashion, many of his most memorable patients and how they affected his evolving concept of pain.

Pain and Suffering  was truly a pleasure to read. Livingston writes well and with great clarity. His humor is quite entertaining. The book should be read by all with a sincere interest in understanding the evolution of pain concepts during the past 50 yr. Livingston's humility in evaluating patients with complex pain problems is instructional for all. He touches several issues that are as difficult to understand today as they were in his time. For example, how can a patient receive prolonged, possibly permanent relief of pain as a result of local anesthetic blockade, despite the limited duration of action of local anesthetic? Based on his observation that the summation of long-term “irritative” peripheral input can maintain a state of heightened central sensitization, he acknowledges the rationale for treating as many sources of peripheral irritative input as possible when the patient's primary problem cannot be treated directly or such treatment has failed to adequately relieve the pain. This might be considered the battle cry of interventional pain management today in which, for example, it is reasonable to attempt to relieve severe, intractable migraine headaches with procedures aimed at pain generators in the head and neck region. Throughout the book, he repeatedly reminds us that the “pain message” is subject to significant modulation at every level, from the peripheral nerve to the cerebral cortex, and that one must be careful to avoid mistaking the stimulus that causes the pain for the pain itself.

Isaac Newton once said, “If I have seen farther than others, it is because I was standing on the shoulders of giants.” There is no question that many of the current pain theorists have enjoyed the view from Livingston's shoulders. I sincerely recommend this offering of the International Association for the Study of Pain press to anyone interested in chronic pain.