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THE SKIN AS AN ORGAN OF SENSES WITH SPECIAL

REFERENCE TO THE ITCHING SENSATION*t
GEORGE H. BISHOP, PH. D.

Of all the structures of the body the skin is the most appropriate structure on
which to hold a symposium. In a most real sense it is itself a symposium of
structures, with correspondingly integrated functions. We may view the skin
both its chemically and physically resistant epithelial surface and its tough
fibrous dermal layer, as an envelope, a container for the bodily organs, chiefly
dedicated to protecting these from physical, chemical and bacterial injury.
Into this envelope the nervous system, an entirely separate tissue, has projected
feelers, the sensory nerve endings, not so much to obtain information concerning
the state of the skin as to explore the environment through and beyond it. The
skin as the intermediary between the nervous system and the environment then
becomes itself the sense organ, and for pain endings we find no other specialized
organ than the skin tissue surrounding the endings. These are typically excited,
short of skin damage, by bending sharply the epithelial layer; and through
mechanical skin distortion, tension is put on nerve terminals. For other sensory
endings the skin has developed special containers for nerve endings whose
function is to exclude certain forms of energy, as well as to transform others into
nerve stimuli. The skin, in other words, acts as a filter through which various
forms of environmental energy are sorted out for the nervous system. The
skin protects sense organs, as it protects other structures, against inappropriate
influences.
Into the skin are also built excretory organs, having some of the functions of
the kidney, though with a somewhat less elegant disposal system for their
excreta. Again the nervous system invades the protective layer to coordinate
the activity of this system with the over-all economy of the body, this time with
motor fibers. The circulatory system, necessary of course for maintaining the
metabolism of the skin as of other organs, has undergone here an enormous
hypertrophy to become useful for the regulation of the temperature of internal
organs; the temperature resulting in the skin itself is relatively incidental.
Again the nervous system projects its motor fibers into the skin for the operation
of a system itself an intruder there. Finally the skin has adopted hair shafts,
the remnants in the human animal of a thermal protective coat, to an entirely
different function, to serve as mechanical levers by which physical stresses are
transmitted to deep-lying touch endings.
The present discussion deals with skin sensation, but several facts need
emphasis. First, no sensation is experienced in the skin. Sensation is a function
* From
the Laboratory of Neurophysiology, Department of Neuropsychiatry, Washing-
ton University School of Medicine, Saint Louis, Missouri.
Received for publication May 5, 1948.
f Presented as part of the Symposium on the Skin at the annual meeting of the American
Academy of Dermatology and Syphilology, Chicago, Dec. 8, 1947.
143
144 THE JOURNAL OF INVESTIGATIVE DERMATOLOGY

of certain higher nervous structures, brain cortex and thalamus, and the same
sensations are induced by stimulating cut skin nerves centrally as by stimulating
skin sense organs. Since only the most peripheral segment of the sensory
pathway lies in the skin, the "sensory" elements there are not the only factors
that determine the sensations experienced. What the skin contains are certain
mechanisms for transforming environmental energy into nerve impulses. Sec-
ond, sensation is an almost incidental concomitant of the excitation of skin
endings; most of the activity of sense organs so-called is shunted to other path-
ways than the sensory. Sensation is the apical florescence on the afferent tree
of which the lower branches, at reflex levels, bear most of the fruit. Some of
these activities are irrepressibly carried to consciousness; some can be registered
there by attention; some are incapable of reaching it. We may include all these
in the sensory or afferent system. Presumably anyone sitting through a lecture
is experiencing a persistent stimulation of pressure and contact endings in the
region euphemistically referred to as the seat of his pants; until mention of this,
perhaps five per cent would experience a sensation from it. After attention is
called to it, the percentage will probably have risen to 99. Yet a periodic shift
of position gives evidence that afferent stimulation has registered below the
sensory level.
Thirdly, the state of the skin itself modifies the action of its sensory endings,
largely in terms of altering thresholds. Temperature thresholds depend on the
temperature of the skin; touch and pain thresholds on its moisture content and
hence its flexibility; and various irritation and inflammatory processes are
designated irritative chiefly because they increase the excitability of skin sensory
endings. The skin as a metabolic and structural matrix for specialized endings
becomes itself a part of its contained sense organs.
Each of the conventionally differentiated layers of the skin contains sensory
endings. The most superficial epithelium is invaded by unencapsulated touch
endings; pain is encountered only when a razor cut for instance reaches the
dermis (1). The upper boundary of its papillary layer however is richly supplied
with free pain endings. These mediate the familiar pricking pain, variants of
which are the only painful sensations which the skin is capable of initiating (2).
Few if any pain endings lie below the papillary layer. In the sub-epithelial
nerve net lie many tactile endings, including both encapsulated Meissner's
corpuscles and free terminals. Within or at the lower margin of the plexiform
layer cold endings are located. The terminals for warmth have not been
located accurately, or in fact definitely identified, but they presumably also lie
deep in the dermis. Finally, beneath the skin proper, in the subcutaneous
layer, are endings which are effectively insensitive to ordinary stimuli until
inflammation enhances their excitability. Most of the pain associated with
inflammatory states of the skin arises in these endings, although the sensitivity
of superficial prick-pain endings may also be increased. Also projecting into
the subcutaneous layers are the endings for hair-touch at the bases of follicles
protruding through the plexiform, but the tissue carried down about the follicular
base is a dipping in of the papillary layer (3).
 SKIN AS ORGAN OF SENSES 145

Through the subcutaneous tissues run nerve trunks and their branches, the
smaller branchings forming a subcutaneous plexus. From this coarse network
twigs rise to supply hair follicles, pain and touch spots (4). On the arm surface
at least, on which this account is chiefly based, one pain twig rises near each hair
follicle to a corresponding pain spot. It may or may not contain touch fibers.
Many separate twigs for touch also rise to the surface layer; structurally then
there are two types of touch in the skin, that from the subepithelial nerve endings
and that from the bases of hair follicles lying in the subcutaneous tissue. Touch
and pain twigs spread out in a branching network that appears continuous
because of spatial overlap of the distributions of these two senses. Their
specific surface sensory "spots" are unitary, but the unit areas for pain and for
touch overlap indiscriminately.
What appear on mechanical, and particularly on electrical stimulation, to be
unit touch spots, though each is doubtless supplied by several fibers, consist of
irregularly shaped areas up to five millimeters across on the arm arranged in a
mosaic. The areas vary in size over the body surface, being smaller over the
areas of more acute discrimination. A unit spot may or may not have a central
point more sensitive than its surroundings; when it has such a point, its sensitivity
may be assigned to specialized encapsulated endings rather than to a hair-follicle
ending, although some hair follicles at any one time may have temporarily lost
their hairs and thus be unrecognizable from the surface. The reason for this
inference is that touch elicited by electrical stimulation has a low threshold at
these more sensitive points, while the touch recognizable as that of a hair ending
has a higher threshold, due to its deeper position in the skin. Over palmar and
non-hairy surfaces these central points of high sensitivity may also sometimes be
detected. To adequate stimuli, the touch areas determine the limit of two-point
discrimination; within a given area two simultaneous stimuli are not differ-
entiated (5). Two-point discrimination, however, also depends so much on.
strength of stimulation that this may be the controlling factor in casual tests.
The stronger the stimulation, the less the distance between two points that
can be discriminated. The dimensions of the unit touch spot appear to deter-
mine the irreducible minimum of spatial discrimination; not of course of temporal.
Cold spots are easily located by means of a cold instrument; their precise
distribution is easier to detect by electrical stimulation to which they are very
sensitive. However, due to their depth in the skin relatively strong stimuli are
required, and certain points react to a cold object which are not found by
electrical stimulation of a strength below that which masks cold sensation by
pain. They may be conveniently localized by electrical stimulation after
removal of the epithelium and papillary layer. They occur in groups of three to
eight in the arm area, the groups spaced 10 mm. apart, the separate points
l—2 mm. apart in the group. These points are irritable to mechanical and even
to heat stimuli if sufficiently localized, but to all adequate stimuli give a sensation
of cold.
Warmth spots on the other hand are not consistently localizable and do not
respond to electrical stimuli. Warmth sensation has been assigned to endings
146 THE JOURNAL OF INVESTIGATIVE DERMATOLOGY

on vessel walls (6), responding to dilatation or constriction as mechanical

receptors only during actual change of vessel response to heat. This interpreta-
tion corresponds nicely with the adaptation that occurs after temperature change,
but other factors that dilate or constrict vessels do not necessarily cause tem-
perature sensations.
The endings for pricking pain of the skin lie just below the epithelium in the
sub-epithelial nerve net. Each surface pain spot is found over a corresponding
twig from the sub-epithelial plexus, and in general there is one such twig adjacent
to each hair follicle, hair touch ending and pain spot (4). Each pain spot has a
central point of extreme sensitivity over the region at which a nerve twig reaches
the nerve net; movement of the stimulating instrument as little as a tenth of a
millimeter here gives evidence of a sharp drop in sensitivity. Excitability of
pain endings decreases toward the peripheral margin of the unit area where the
threshold may be ten or more times higher than at the center. In fact, blank
spaces occur between these roughly hexagonal areas which are wholly insensitive
to pain. Even at the adjoining margins of two pain spots the sensitivity may be
so low that a hypodermic needle may be inserted with little discomfort. In fact
it is so easy to find, by gentle pricking with the point of such a needle before
insertion, a region where its penetration will cause a minimum of pain that
this maneuver is worthy of clinical consideration in routine hypodermic injections.
Even the central foci of pain spots vary widely in sensitivity, and this may be
correlated with the number of fibers in the twig supplying the spot. This
number may vary from two or three to perhaps twenty, although the fact that
all fibers lose their myelin sheathes above the plexiform layer, and cannot be
distinguished on the basis of size, leaves the possibility that some of the fibers
of a twig serve touch instead of pain. The higher sensitivity of the central
point is probably assignable to the greater number of fibers that can be stimulated
here, the effect being due to summation. In the cornea, however, where the
distribution of single fibers has been followed (7), the main fiber before branching
is more sensitive than its branches, and this may also be a factor in the skin.
Not only is a pain spot innervated by several distinct fibers, but partial anaesthe-
sia of some spots after blocking of only one nerve branch indicates that one spot
may be innervated by fibers from different branches of a nerve, or from different
nerves. The distribution of each main branch of a cutaneous nerve overlaps
with that of its neighbor, so that a given area may be supplied by any one or
more of three branches. In addition, overlap occurs between the distribution of
quite different nerves, so that the innervation of any one pain spot may be from
multiple sources. Some correlation must have developed therefore between
peripheral innervation and central cortical representation of a pain locus such
that recognition of locus is a more complicated process than simple unit pathway
conduction (8).
Localization at the marginal overlap region after section ol one of the nerve
branches supplying it is impaired and the character of the sensation may be
changed to so-called protopathic pain, the hot or burning pain also characteristic
of causalgia and of thalamic injury. This change in character is probably
 SKIN AS ORGAN OF SENSES 147

assignable to impairment of complete representation of pain spots in the higher

centers (9, 10), for there is no evidence that different fibers are involved than
those serving normal pain sensation. Localization and two-point discrimination
of pain, as of touch, depends on the intensity of stimulus employed in its meas-
urement. Weak stimulation of two spots near each other for instance is sum-
mated and referred to the more sensitive of the two, or to the one more effectively
stimulated (11). Stronger stimulation may permit recognition of the two as
distinct, and with such recognition of separateness the stimulation effect is
markedly reduced, as if summation of sensory affect and summation of spatial
locus were intimately connected. That is, to the extent that two points of
stimulation are interpreted by the brain as one, or added spatially, their intensi-
ties are also added to give a stronger sensation of pain.
Some of these phenomena can be demonstrated more effectively during
regeneration, after removal of the papillary layer of the dermis. As nerve
fibers grow back into the newly regenerated surface, their growing tips become
extremely sensitive to either mechanical or electrical stimuli (3); these endings
have same of the properties of normal sensory endings, even before they reach
the epithelial surface. At this stage the sensory spots are virtually points,
one to each growing twig, with non-sensory areas between them. In tissue
excised at this stage and stained for nerve elements, nerve twigs may be ac-
curately identified with previously located sensitive points. The characteristic
of a sense organ which such endings manifest is that even a brief single stimulus
has a persistent after-effect which means that a single shock to the ending sets
up a repetitive series of nerve impulses in the fiber. This is in contrast to the
action of normal nerve fibers, when a single shock sets off a single impulse in each.
This raises the point of the character of a sense organ's response, that is, the
pattern of impulses which it sets off in its nerve fiber. it is worth emphasizing
that the only information which the central nervous system receives from the
periphery must come over afferent fibers in a code of which the dots and dashes
are nerve impulses. The brain decodes these messages and translates them
into sensations. Each modality of sense presumably sends its fibers to a different
set of receptor cells in the brain, giving the same modality of sense, however the
fibers are activated. But within one modality the pattern of activation, both
spatially in terms of location on the body surface of sense organ activation, and
temporally in terms of the frequency and duration of activity in each fiber,
causes this message to vary within wide limits. Furthermore we find in different
sense organs different combinations of properties suited to the type of function
they perform such that sense organs at the periphery may be said to be separated
into modalities quite as definitely as are their central projections. The properties
referred to are of two kinds, those which make sense organs differentially excit-
able to different forms of energy, and those which enable them to respond in the
most advantageous pattern when they are activated at all, by any agent.
How sense organs perform these functions we do not know, but it can be said
that position in the layers of the skin, and the protection afforded by the skin
against certain forms of energy play a part, as do presumably the specialized
148 THE JOURNAL OF INVESTIGATIVE DERMATOLOGY

capsules which the dermis builds about certain nerve endings. These factors
assist in making sense organs act as selective filters to energy from the environ-
ment. The second set of properties, those determining the type of response,
may be functions of the nerve endings themselves. The latter characteristics
of sense organs may be described in terms of two general properties of excitable
tissue. One is usually designated as adaptation, or rapid adjustment, to a
change of state such that activity occurs chiefly at the start and at the end of an
applied stimulus. Its opposite is summation, or the addition of effect through-
out a continued steady state of excitation. A second property is after-discharge,
the continuation of response after the stimulus has ceased. These properties are
represented in the nerve fibers which sense organs activate by characteristic
patterns of impulses.
For instance, tension recorders such as stretch endings in muscle or lung
(12, 13) need to follow accurately and continuously the degree of stretch in the
tissue. The frequency of response of a nerve fiber from one of these endings
starts abruptly when the stretch is applied, ceases promptly when it is relaxed,
continues at a constant rate during constant stretch, and increases or decreases
with change of tension. Persistent or changing tensions are thus transformed
into appropriate frequency patterns. These sense organs do not adapt, and
show no after-discharge. Tactile endings at the opposite extreme respond
chiefly to a change of pressure. They give a short burst of a few impulses as the
pressure is applied, which then decrease in frequency or stop entirely during its
continued application. At the removal of pressure they again induce a brief
burst of impulses which promptly ceases without persistent after-discharge.
This renders these organs particularly serviceable for recording movement, and
everyone recognizes the superior tactile effectiveness of patting or stroking over
mere contact. It also allows tactile or pressure endings to record vibration so
effectively as to lead to the inference of a special vibratory sense. Cold and
warm endings first show summation, probably because it takes time to warm the
tissues to the depth of the endings, but then adapt remarkably, and tend to
record only changes of temperature. The stability of internal temperature is
maintained by other temperature organs, the heat center of the hypothalamus
for instance, which presumably does not adapt at all. A residual activity must
persist in skin temperature organs, however, because sufficiently intense stimula-
tion gives a persisting sensation. The sense of hot or burning is evidently
composite, consisting of the fusion of the effects of stimulation of warm and of
pain endings. Heat has been demonstrated to be one of the more effective
stimuli for pain endings (14).
Pain endings remain to be considered, one pattern of the activation of which
appears to result in itch. Pain endings show summation during the start of a
constant stimulus, the opposite to the adaptation of touch, and lack the ability
to adjust promptly as tension receptors do. They also exhibit after-discharge
following even brief stimuli. There is, however, no increase of sensation on
removal of the stimulus as there is for touch. Thus in both respects they are
sluggish in their action, although they lie in a position at the surface of the skin
 SKIN AS ORGAN OF SENSES 149

where, unlike the temperature senses, mechanical factors will least account for
this. Pain does adapt slightly; but less completely, the stronger the stimulus.
Especially important is the cumulative central effect of pain summation; pain
becomes unbearable when long continued, even at an intensity that can be born
with equanimity for a brief time. This central factor of cumulative effect,
what Wolff (15) refers to as the reaction as contrasted to the discrimination of
pain, more than compensates for the slight adaptation shown by sense organs
and becomes the factor of major importance in pathological states.
Touch and pain obviously differ in the degree of mechanical distortion of the
skin necessary to arouse their sensations, but it is not so obvious that the type
of distortion is also a factor. Touch responds to slight pressure, even without
bending of the skin surface. Pain responds to acute bending or indentation
of the epithelium, as is apparent from its association with mechanical prick.
'While heat and other forms of energy excite these endings, their commonest
response is to sharp objects. Since a convenient measure of sharpness of such
an object as a needle point is curvature, a quantitative examination of the excit-
ability of pain endings can be made in terms of the pressure required to reach
threshold of sensation by objects which differ in bluntness, i.e., curvature.
Such instruments may be made by impaling small round droplets of solder on
needle points, and applying them to sensitive spots by means of a lever which
registers the pressure (16). The plot of the pressure required for threshold
prick against the square of the diameter, or cross sectional area of the ball
points employed, gives a curve which is approximately horizontal over a range
from 0.4 to 1.5 mm. diameters of curvature, but rises sharply at either extreme.
The rise in pressure per unit area for smaller or sharper curvatures is easy to
account for. The cornified layer of the skin is stiff enough to distribute the
weight over a larger area than that directly in contact with the needle. If a
really sharp needle is employed it may penetrate the epidermis and the pressure
per area of point for threshold prick then falls.
The rise in pressure required with larger balls has a more significant explana-
tion. It is found that as pressure increases, the skin indents to follow the curva-
ture of the point, and at threshold, it feels as if a fine grain of sand were lying
under a smooth object. Above 2 mm. in diameter round objects do not cause
any such sensation until pressures are reached that cause deep pain in fascia or
periosteum. The curvature is insufficient to stimulate at any reasonable
pressure. On the other hand, objects with fiat ends stimulate pain at their
sharp corners only, which is the only place at which bending of the skin occurs.
The conclusion is that bending, or the stretch caused by acute deformation, and
not pressure, is the particular form of stress to which pain endings are designed
to react. This is consistent with the fact that scratches or cuts which weaken
the surface layer make the cut region liable to stimulation by slight stretching
of the skin.
The comparison of touch and pain stimulation in the human subject permits
one to infer, on the basis of the results of animal experimental recording, what the
resultant pattern of nerve fiber action is following different patterns of stimula-
150 THE JOURNAL OF INVESTIGATIVE DERMATOLOGY

tion. The results of such studies lead to the inference that two much debated
sensations, tickle and itch, are not separate modalities or mediated over specific
fibers, but are varieties respectively of tactile and painful sensations (9). It is
not obviously unreasonable to state that tickle has the character of a tactile
sensation, but to talk of painful stimuli which do not cause pain is nonsense.
Therefore, we may state the proposition more technically by saying that those
nerve fibers whose adequate stimulation arouses painful sensation, may also be
activated in other patterns which are interpreted as sensation other than pain.
These other sensations are tactile, prick and itch, all to be included in the pain
modality. The reasons for inferring this will be stated presently, and since the
variation of sensation with pattern of activation is somewhat more obvious in
the case of tickle, we may consider it first.
The most easily tickled surface of the body is the margin of the mucosa of the
upper lip. Tickling is readily elicited by brushing this surface with a wisp of
cotton wool. The most effective contact for tickle is so light that no question of
pain ending stimulation need be raised. Either touch endings are the effective
organs, or separate endings specific for tickle exist. That tickle endings do not
exist seems evident from the fact that if a larger mass of cotton wool is brushed
across the whole lip, even lightly, tickle is not induced, or is much less than with a
smaller contact, or is only present at the margin of contact. In other words,
the more sense organs stimulated, and the more constantly, the less is tickle
aroused. Tickle is transformed with the greatest facility to touch by increase
of amount of stimulation.
Further variants of this procedure demonstrate that tickle results from
threshold stimulation of touch; that it adapts like touch to persisting stimulation;
that the peculiar pattern necessary for its production is movement. This
means that one adjacent touch ending is stimulated momentarily after another
in succession across the surface. The large mass of cotton wool is less effective
than a small wisp because, except at the margins, it maintains contact over
adjacent touch endings and abolishes the feature of successive activation, and
keeps the endings adapted. Tickle thus appears to result from the combined
action of spatial and temporal summation of touch, successive spatial activation
being temporally summated. It apparently requires a high density of touch
spots, that is, a surface extremely sensitive to touch for its elicitation.
Another such sensitive surface is the palm, and tickle of less poignant a
character can be induced there. A hair cemented to one arm of an electrically
driven tuning fork gives a suitable stimulus, again below threshold for prick
over the heavy epithelium. When such a stimulus is applied at one spot, only
repetitive touch results. When it is moved rapidly across the surface so that
successive vibrations stimulate adjacent touch spots successively, a distinct
tickling sensation is added. The same sensation is of course induced here by
light stroking with a small soft object. The difference in pattern of impulses
arriving at the brain, which is all the brain receives as a means of knowing
whether it is itself being tickled or merely touched, can be inferred from our
knowledge of the type of response which touch endings induce in their nerve
fibers.
 SKIN AS ORGAN OF SENSES 151

This finding, if acceptable, should make it easier to envisage the somewhat

moie complicated situation with respect to itch. While methods of inducing
itch are more numerous than we might prefer, the method of electrical stimula-
tion has certain advantages of specific control and localizability. It has a
further critical advantage, that to electric currents pain endings have a lower
threshold than touch endings (17); itch aroused electrically cannot be due to
overstimulation of touch, whatever the effect of understimulation of pain.
It is first obvious that no movement is required for itch; nothing is more per-
sistently local than a mosquito bite. Second, itch is elicited electrically most
easily at the most sensitive central points of pain spots (4); not of touch spots.
Further there is a distinct after-effect of itch following a single shock which first
elicits sharp prick or pain. Correspondingly, if a sharp needle is applied to the
most sensitive region of a pain spot, with very gentle pressure, the effect just
below pain threshold is itch rather than prick. There is thus a general cor-
respondence between itch and pain, spatially and functionally; itch results from
pain stimulation below threshold for pain, but only provided the stimulating
effect is sufficiently persistent in time. In fact there is no such thing as a
momentary itch. The brief stimulus of a strength to induce itch is interpreted
as a slight prick if felt at all.
This is not the only variety of sensation which pain ending stimulation is
capable of inducing. By close attention a tactile or contact sensation which is
not even pricking can be recognized following single shocks to pain spots. This
must be pain without the "dolorous affect"; too little pain to be recognized as
such. The same contact sense is obtained on threshold electrical stimulation of a
tooth through a metal filling (18). No tactile organs have been demonstrated in
teeth. Mechanical contact is registered through pressure endings in the gums.
No pricking sense follows stronger stimulation; toothache pain is the only other
result. Certain analgesics raise the threshold for this painful affect, without
altering the threshold for contact sense. Pain might thus be designated as a
contact sense with an aura of dolorous effect.
Above this contact sense of the skin, a stronger shock induces mild prick which
no one would call painful, and as the stimulus is increased pain is added pro-
gressively to increasing prick. Rapidly repeated shocks, one of which causes
sharp prick but no pain, summate to distinct pain. Prick may thus be designated
as pain of too brief a duration to be recognized as painful. If painful shocks are
repeated the result more resembles ache, and if the frequency is sufficiently high
the pricking character is decreased. Frequencies of direct shock stimulation to
pain fibers in a sensory nerve may be recognized as repetitive up to at least
30 per second, touch up to at least 60 (19). Above 30 per second pricking pain
is transformed into aching pain. Thus a variety of sensory affects is induced
within the modality of pain depending apparently only on the pattern, spatial
and temporal, of the impulses in nerve fibers induced by various patterns of
stimulation.
Itch, as experimentally produced, appears to fall into this category, being the
result of a temporally persistent excitation too low in intensity to cause pain,
and too continuous to register as prick. As pain can be induced by the sum-
152 THE JOURNAL OF INVESTIGATIVE DERMATOLOGY

mated effect of repetitive prick, so itch can be induced by the summated effect
of weak shocks, one of which by itself is below threshold for prick. It can iii fact
be induced most readily by weak constant currents, which might be compared to
shocks of infinite frequency. Shocks at a lower frequency, each below threshold
for prick, may summate to repetitive prick rather than itch. One of the essen-
tials of itch and perhaps its most exasperating one is continuity.
Thus with no evidence for separate fibers or sense organs for itch, and with the
many coriespondences between the members of the series prick, itch and pain,
and with the analogous example of the relation of touch and tickle, it is con-
sidered highly probable that itch belongs in the pain modality rather than the
tactile. Itch then seems to result as the temporal summation of continued
mild prick; pain as that of continuous stronger prick; aching pain is the effect of
temporally summated pricking pain. Pricking pain is painful because the
after-discharge of strong prick amounts to the same thing as continued stimu-
lation.
If this interpretation seems too ingenious to be trusted, there are other evi-
dences of modification of sensation with pattern of stimulation to support it.
The addition of cool to smooth contact may be felt as wet; repetitive touch gives a
vibrating sensation; some irregularity of pattern differentiates rough from
smooth, and movement of a rough object across the sensory surface assists in its
recognition by increasing the irregularity of stimulation. Contact sense fuses
with muscle and joint sense to give us form or shape, etc. Scratching the skin
too ]ightly to cause pain gives touch of a sharper character apparently determined
by weak stimulation of pain endings. Light contact to an already itching spot
may accentuate the itch; firmer contact may reduce it; and scratching an itch
gives a relief too familiar to require elaboration, if too little understood to merit
discussion. At least it may be noted that scratching an itch with a violence that
would cause pain elsewhere may be experienced as one of the most exquisite of
pleasures. "Parting is such sweet sorrow" says the poet, "that I would say
good night till it be morrow". Here Shakespeaie has given us the perfect
emotional analog for the scratching of a mosquito bite.
But scratching, however satisfying as a momentary expedient, is no more
illuminating as an explanation than it is effective as a remedy. It may be
significant that the causes of pathological itch are characteristically mildly
toxic or irritating substances which have the persistent stimulating character
of other agencies capable of inducing itch. Agencies that induce itch in weak
application such as acids cause a stinging sensation in stronger concentration,
and finally pain. Stinging sensation is similar enough to the prick sensation
to be considered a variety of it, and in some respects seems to bridge the interval
between itch and pain. Itch elicited by electrical stimulation often has the
stinging character reminiscent of prick. On the other hand a stinging sensation
does not typically accompany inflammation, and this may seem to compromise a
close relationship between sting and itch or pain. But the pain of inflammation
is usually due to activation of endings deeper in the tissues than those giving
pricking pain of the skin, and deep sensations in general lack the qualities of
itch, sting and prick.
 SKIN AS ORGAN OF SENSES 153

From the standpoint of sense organ activation, itch has then the following
characteristics. It is elicited from pain spots, rather than from touch areas.
It follows as the after-effect of prick, which is itself a mild form of pain. Its
effective stimulus is one which persists at one spot, rather than requiring move-
ment like tickle. Like prick or pain it may follow from summation of rapidly
repeated stimuli, any one of which may be relatively ineffective. It does not
show adaptation as does touch. Its central effect is cumulative like that of
pain. Further excitation of an itching spot by scratching to cause frank pain
relieves itch, which returns as the pain recedes. This is at least consistent with
the inference that itch arises from a liminal stimulation of pain endings to a
persisting weakly summated state.
From these functional analogies to painful sensation it may be inferred that
itch either has special endings whose mode of activation is strikingly similar to
that of pain endings, and which are similarly distributed, or that it follows from
activation of pain endings themselves. An attempt at further differentiation
between itch and prick and sting for instance might be profitably pursued by
means of chemical rather than electrical agencies capable of arousing one or
more of these sensations
SUMMARY

Various aspects of the physiology of sensation are reviewed, with special

reference to the variety of subjective sensations following different patterns of
stimulation of a given modality of sense organ.
Structure and distribution of sensory spots by area and depth can be observed
after removal of the papillary layer of the dermis, and during its regeneration.
The sensory spot is a multiply innervated area rather than a single sense organ,
and its interpretation as a unit is apparently a phenomenon of the higher centers.
The pattern of impulses in nerve fibers set up by a given stimulation of their
sense organs differs for different senses, and is in general optimally adapted to
the functional utility of the sensory information to be conveyed.
Tickle seems to result from a certain pattern of stimulation of touch endings,
and itch from pain endings respectively, touch and pain endings being defined
as those capable of arousing tactile and painful sensations when adequately
stimulated.
The relation of prick, itch, sting and various qualities of pain, all of which
seem to arise from one or another pattern of activation of skin endings capable
of mediating pain, are differentiated in terms of the pattern of stimulation
required to arouse these sensations.
This pattern of sense organ stimulation determines the pattern of nerve
impulses in fiber paths reaching the cortex from the periphery, and the message
reaching the cortex must consist entirely of such spatial and temporal patterns
in nerve fibers.
It might still be argued whether itch is aroused by stimulation of the identical
endings that are also capable of mediating painful sensations, or whether they
only have so many physiological characteristics in common as to be difficult to
differentiate by present methods. The variety of sensory quality which the
154 TEE JOURNAL OF INVESTIGATIVE DERMATOLOGY

pain modality exhibits under various conditions of stimulation supports the

possibility of the former interpretation.
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