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Studies on Pain. Observations on Pain Due to Local Cooling and on Factors Involved in the “Cold Pressor” Effect

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Studies on Pain. Observations on Pain Due to Local Cooling and on Factors Involved in the “Cold Pressor” Effect STUDIES ON PAIN. OBSERVATIONS ON PAIN DUE TO LOCAL COOLING AND ON FACTORS INVOLVED IN THE “COLD PRESSOR” EFFECT Stewart Wolf, James D. Hardy J Clin Invest. 1941;20(5):521-533. https://doi.org/10.1172/JCI101245. Research Article Find the latest version: https://jci.me/101245/pdf STUDIES ON PAIN. OBSERVATIONS ON PAIN DUE TO LOCAL COOLING AND ON FACTORS INVOLVED IN THE "COLD PRESSOR" EFFECT By STEWART WOLF AND JAMES D. HARDY (From the Russell Sage Institute of Pathology, in affiliation with the New York Hospital and the Departments of Medicine and Psychiatry, Cornell University Medical College, New York City) (Received for publication May 6, 1941) When a subject's hand is immersed in cold aid of a thermostatic device. The left hand of the sub- water two phenomena are known to occur. The ject was plunged into the water up to the wrist. The an time of onset of pain was recorded and an attempt was subject experiences pain and elevation of blood made to estimate the intensity of pain being suffered at pressure. The latter phenomenon has been used a given moment. as the basis for the Hines-Brown " cold pressor " WVhile these observations were being made, the blood test (1). The occurrence of pain has received pressure in the opposite arm was estimated by means of little attention, and is alluded to only incidentally a mercury sphygmomanometer at as frequent intervals as " " possible. The skin temperature of the immersed hand in the articles on the cold pressor test. Pain, was determined continuously by the use of a copper and however, has been suspected of being concerned in constantan thermocouple fixed to the pad of the terminal the production of the hypertension (2). In the phalanx of the middle finger. The amplitude of pulsa- present work on pain due to local cooling, we tions of the digital artery was also recorded by using a have found direct correlation between the degree small glass plethysmograph fitted to the index finger of the immersed hand. The plethysmograph was connected of cooling, the intensity of pain induced by the by an air system to a tambour on which was mounted a cold, and the height to which the blood pressure small mirror. Movements of the latter were recorded on rises. a camera by reflecting a beam of light on the moving Lewis (3), in an analysis of the vascular reac- film. Extraneous factors which are known to influence tion to cold, noted that in fingers immersed in the amplitude of pulsation of the digital artery (5 to 13) were all carefully controlled. cold water from 0° C. to 18° C. a painful aching The results of a series of 54 experiments which pro- occurred " soon " after immersion. No attempt vide 121 observations are reported. The observations was made to study the nature of the pain. The were made mainly by the authors upon one another, since burning pain produced on the skin of the arm by uninterested subjects could scarcely be called upon to a dry ice stimulator has been studied (4). The undergo the necessary amount of physical discomfort. pain was shown to be adaptable and, contrary to OBSERVATIONS Goldseheider's theory that pain is an exaggerated pressure sensation, it was shown to be a separate I. Sensations induced by local cooling sensory function. The mechanism of production A. Deep aching pain and its "'adaptation ". of the pain, however, was not investigated. Immersing the hand in water warmer than 180 C. The aim of this communication is to report on caused no pain, but at 180 C., and slightly below, a study of the phenomenon of pain due to local there was a fleeting deep ache which occurred cooling, which, for convenience, we call "cold after the hand had been immersed about 60 sec- pain ". The pain is conveniently produced and, onds, and then promptly ceased. At progressively owing to its predictable character, lends itself to lower temperatures the pain had its onset sooner analysis. and was more intense, always reaching its maxi- mum at about 1 minute. It then began to subside, METHOD and in 4 to 5 minutes was no longer perceived. The subject was placed in a reclining position on a The character of the pain was aching; there was cot beside an earthenware crock holding 20 liters of a feeling as if the hand had been water which was stirred vigorously by a propeller at- crushed. The tached to a small motor. Because of the large volume, distribution was generalized and deep throughout the bath could be maintained at constant temperature for the immersed hand, and the pain was perhaps the duration of an experimental observation without the most intense on the radial side. It was continu- 521 522 STEWART WOLF AND JAMES D. HARDY ous and non-pulsatile. Exercise of the fingers or 3 +, however, there occurred a radiation of the movement of the hand did not influence the char- ache up the inner aspect of the arm. At 4 + acter or intensity of the pain. There was no pain was felt in the axilla. At this intensity the tenderness in the hand since it could be struck subjects usually showed a reaction to the stimulus against the side of the bath without altering the characterized by rapid irregular respirations, as sensation of pain. Sixty seconds after immersion well as by adventitious movements of the feet. the peak of pain intensity was reached. This was At 5 + the restlessness was replaced by writhing followed by amelioration, and finally cessation of movements and the subject's face betrayed suf- the pain. The disappearance of pain while the fering. From 6 + to 8 + the pain provoked hand is still immersed in the water we have called perspiration and approached the unbearable level. "adaptation During the first minute after immersing the hand A barely perceptible painful sensation experi- in cold water it was quite clear that the pain was enced as a deep ache in the immersed hand was becoming more and more severe. Each time a designated as threshold pain. Additional incre- definite increase in pain intensity was felt the ments in pain intensity were indicated in terms subject called out an additional plus. Similarly, of pulses, 8 + being used for the pain of greatest as adaptation occurred after one minute and the intensity experienced. The distribution of pain pain was dearly becoming less intense, the subject as high as 2 + was confined to the hand. At called out one less plus at each perceptible de- INTENSilY OF PAIN $4+- -2 6- / 5+- / 4+- 3+- 2+- 1+ - O-- I I HAND IMMERSED PINS 4+ - 3+ - 2+ - 1+- In. I I I I I I I I I I I I I I 0 60 120 180 240 300 360 TIME IN SECONDS FIG. 1. THE COURSE OF THE ESTIMATED INTENSITY OF PAIN AND " PINS AND NEDLES " SEN- SATION EXPEINCED WITH VARIOUS STRENGTHS OF COLD STIMULUS PAIN DUE TO COOLING 523 PAIN 8+ 0 7+ o o 0 o o 5+ 0 0 4+ 0 01 3+ 0 2+ I |. O-l 0 I I l I I 20° 15 10 5 0 -2°C. TEMPERATURE OF WATER FIG. 2a. THE ESTMATD PEAK OF PAN INTENSITY PLOTTED AGAINST THE STRENGTH OF THE COLD STIMULUS crease in pain intensity. The values thus estab- of interest that the line points directly at 180 C. lished were roughly reproducible at any time. A which, as noted above, was found to be the high- subject immersing his hand in water of unknown est temperature at which this variety of pain oc- temperature consistently called out the same num- curs. In Figure 2b the total area under the pain ber of pluses as had been previously assigned to curves at various temperatures is plotted against that particular temperature. Therefore, although the temperature of the bath. The total amount of not precise, this method has proved useful here pain experienced also increases uniformly with as in other studies of sensation (14, 15). Figure the strength of stimulus. 1 shows the course of estimated pain intensity in B. " Pins and Needles" sensation. The sensa- the hand immersed in water at different tempera- tion of " pins and needles" occurred only in water tures. Figure 2a shows maximal pain intensity colder than 120 C. The sensation was felt in the plotted against water temperature. It is apparent entire immersed hand from 60 to 90 seconds after that pain intensity as estimated increases uni- immersion. This sensation, occurring shortly formly with the strength of stimulus measured in after the peak of the aching pain, steadily in- terms of temperature of the water bath. It is also creased in intensity as the pain decreased. The AREA BENEATH PAIN CURVE SQ UNITS 0 30- 0 20- 10- 0; I I 0-I I I I 20 C. 15 10 5 0 -2C .. TEMPERATURE OF WATER FIG. 2b. THE TOAmL AREA BENEATH THE CURVES OF PAIN INTENSITY IN FIGURE 1 PormD AGAINST STRENGTH.~~~~OF COLD STIMULUS 524 STEWART WOLF AND JAMES D. HARDY lower the bath temperature, the more intense was C. "Adaptation ". If the hand were withdrawn the prickling. Like pain, this sensation ran a before the pain had reached its maximum inten- cycle of aggravation and then adaptation, until at sity, there was a momentary twinge of extra pain the end of 8 to 10 minutes the immersed hand felt immediately after withdrawal. If the hand were only the cold of the water (Figure 1). The sen- withdrawn at any time before complete " adapta- sation of touch and of pain to pin prick, however, tion" had taken place and then at once re-im- as well as motor power in the fingers, remained mersed, the pain would recur with nearly as great intact.
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