International Association for the Study of Pain®    IASP Press®

William Kenneth Livingston
1998, 268 pp, hardbound, ISBN 0-931092-24-8, Special Price: $30.00 US 
 
Table of Contents                  Order Form                   Reviews                   IASP

In this semi-autobiographical work, pioneer clinician-scientist William K. Livingston (1892-1966) guides us through critical early developments in the field of pain research and treatment. His infectious enthusiasm, inquisitive mind, and complete dedication to understanding pain provide a fascinating and informative introduction to the major problems and ideas that gave rise to what is now an independent field of practice and research.

Pain and Suffering offers much more than historical significance. Its valuable clinical material serves as a guide to those who strive constantly to improve their own clinical skills. Curiosity, compassion, and concern provide the framework for Livingston’s astute clinical observations, enabling him to improve patient treatment through deeper understanding of the neural mechanisms of pain. Above all, he relied on the patient’s reported experience, and in this book his narrative gift allows us to witness that dynamic interchange between doctor and patient. This long-neglected manuscript, the crown jewel of Livingston’s collected papers, has been in the possession of the History of Pain Collection at the Louise M. Darling Biomedical Library at UCLA since 1997 and is previously unpublished.

Livingston personifies the optimal blend of clinical and theoretical background in medicine. His clinical experiences as a surgical resident at Harvard and his wartime experiences as a naval surgeon piqued his interest in pain research. As Chair of Surgery at the University of Oregon Medical School and leader of one of the first multidisciplinary pain clinics, he gathered a team of basic scientists to study the neurobiology of pain. Additionally, he visited clinics and laboratories throughout the world in order to observe and discuss their work. Above all, Livingston sought to apply his unique clinical and scientific knowledge to the task of uncovering the fundamental nature of pain.

Table of Contents

The Interpretive Background for a Concept of Pain; Opening a Colostomy; The Problem of Visceral Sensibility; 

 The Adequate Stimulus for True Visceral Pain; "Visceral Pain" from Peripheral Blood Vessels; 

 Studies of Visceral Nerve Function; Irritative Nerve Lesions;  Glomus Tumors;  Phantom Limb Pain; 

 The Mirror Image; Tentative Interpretations; Missile Wounds of Nerves;  A Case of Major Causalgia; 

Peripheral and Central Mechanisms of Causalgia;  Procaine and Nitrous Oxide "Analgesia";  Hypnosis; 

 The Pain Project;  The Philosophers and Johannes Müller;  The "Reticular Formation"; 

Two Blind Alleys (Nerve Irritation and Zombies);  Tracing Tooth-Pulp Responses into the Cat Brain; 

The Functional Organization of the Central Nervous System;  Habituation;  Appetitive Systems in the Brain; 

Pulling the Picture Together;  Interpretations and Speculations. 

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Reviews:
 
Largely autobiographical in nature, this book explores the evolution of Livingston’s ideas in relation to scientific discoveries and his own clinical experience ... [the clinical anecdotes] serve to introduce the discussions of the major problems of pain ... Apart from its concise and interesting presentation of the history, there are two other good reasons for reading this book. First, Livingston’s anecdotes remind us that good medical science begins in clinical observation. Livingston insisted that scientists in his own department leave their laboratories to observe patients in order to gain a better understanding of the nature of pain. Second, the book introduces the reader to a warm, creative, intellectual human being, one whose life and work deserve to be remembered. Isis
 
The book is an "adventure" through Dr. Livingston’s evolving concept of pain during his career as a general surgeon ... Using patient histories he presents us with clinical scenarios followed by how he conceptualized the nervous system to explain the patient’s pain.
Dr. Livingston’s empathy for his patients and his enthusiasm for exploring the basis for their pain comes through very clearly in the text. Dr. Livingston understood the devastation that chronic pain can cause patients and has very clearly and convincingly conveyed this in his case reports. He realized the importance of "psychic" factors in the presentation of all patients with chronic pain, but also cautions the reader with examples of supposedly "psychological pain" that resolved with treatment of the underlying disorder.
There are many clinical pearls in this book for the pain physician. However, his work is also a reminder of the importance of clinical skills and physical examination if we are to understand our patients’ symptoms.
The most amazing aspect of this book is how far ahead of his time was Dr. Livingston’s concept of pain. Our understanding of peripheral and central sensitization, reverberating circuits, and descending inhibitory pathways are predicted in his concept of pain. At the time his ideas were not well accepted. His theories of a dynamic nervous system conflicted too greatly with the specificity theory of the day, and Dr. Livingston went unrecognized.
This is a fascinating book that I would highly recommend to anyone with an interest in chronic pain. It is both inspirational and instructive and serves as a model of how to approach the myriad of chronic pain problems that even today we have trouble understanding. Canadian Journal of Anesthesia

... [This book] is astonishingly fresh and lively.
Livingston’s writings and especially this book stand out for a combination of superb craftsmanship and luminous intelligence. I have never read a book in which clinical case histories were brought so much to life with simplicity and power. Ideas flow from them and grip the reader’s attention. The human drama becomes a starting point for trains of ideas treated with enthusiastic objectivity. Theories never get in the way of facts being stated and awkward evidence is invariably mentioned. Yet, it is all informed with fun, insight, humor, sympathy and a consistent concern to increase knowledge and understanding.
If you want to think with interest and fresh information about peripheral pain, sensory nerve lesions, phantom pain, causalgia and a critical period in the development of our knowledge of the nervous system, you will find all of those things in Livingston. The book is sensitively and helpfully edited and very nicely produced. Pain Research & Management
 
This is a wonderful book, written by one of the great thinkers in the birth of the field of pain medicine … Howard Fields did a superb job of editing the uncompleted manuscript so that it reads coherently and in the tone of Dr. Livingston’s prose. Nicely published by IASP Press, the book has a useful index and includes many, if not all, of the references used by Livingston in his manuscript.
Livingston … was conceptually years ahead of his peers, both within [neurosurgery] and in medicine in general … It is my belief that few of those who practice pain medicine at the present time have incorporated Livingston’s ideas into their thinking. He was a man ahead of his time.
I urge you to buy and read [this book]. Give it to your trainees and make them pass a test to demonstrate their mastery of its concepts. APS Bulletin
 
This book is an unusual book and is published for the benefit of those interested in the broader aspects of pain.
To believe this book is only of historical value would be wrong, although it provides a fascinating insight of the beginnings of pain management as a specialty in the USA.
Dr Livingston’s contributions to an understanding of the perception of pain were to relate the carefully observed clinical picture with the neural mechanisms. Yet he fully recognized the importance of psychology in pain perception.
This book is a valuable contribution to our heritage but significantly adds to our knowledge of some of today’s most difficult clinical problems. It is written in an easy style and for me had the ‘unable to put down’ characteristic of a good thriller. I can strongly recommend it to all who have an interest in chronic pain. British Journal of Anaesthesia
This book, which is disarmingly autobiographical in tone, recounts the evolution of Livingston’s ideas about how pain is represented in the brain. It reads more like a good novel than a scientific text. The driving force for his ideas was always the clinical manifestations of pain—phantom limb pain, visceral pain, complex regional pain syndromes—and the adequacy and inadequacies of treatment. Throughout the book one is always aware of the struggle to uncover the fundamental nature of pain in order to alleviate suffering. All of the ideas current in pain research—the concepts of central sensitization, role of inflammation in the activation of "silent" nociceptors, central modulation of nociceptive input,, and different roles for multiple ascending pain pathways—are thoughtfully developed in a germinal manner in this remarkably anticipatory book.
…although completed more than 30 years ago, this is a very special and timely book. Livingston was a model clinician-scientist. This book, his final work, is enriching and informative in its historical overview, but above all it remains inspiring in its compassion for the pain sufferer and its belief that a better understanding of pain mechanisms is a prerequisite to improved treatment outcomes. Anaesthesia and Intensive Care
Livingston’s theories regarding inhibitory reflexes at neuraxial level preceded Melzack and Wall’s spinal gate theory by over a decade. One of the most inspiring parts of the manuscript is the suggestion that pain has a major psychosocial component. Dr Livingston opposed the concept that pain, without physical findings, is hysterical and part of a malingering syndrome. The theories proposed by the author have now been proven by the discovery of the opioid and NMDA receptors in the neuraxis.
It is not the high-tech nature of this book that makes it a treasure, but the workings of a brilliant mind that was so far ahead of its time that even the author was unsure of the validity of his conclusions. Clinicians, research workers, students of medical history and caregivers involved in the discipline of pain management will find this work spellbinding.
There is an excellent bibliography listing the early research papers on the pathophysiology of pain. South African Medical Journal

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This page was updated on August 7, 2002