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A. P. WALKER AND R. A. DICKSON: REFERENCES

1. Brooks HL, Azen SP, Gerberg E, Brooks R, Chau L. Scoliosis: a prospectiveepidemiological study. J Bone Joint Surg 1975; 57A: 968-72.

2. Lonstein JE. Screening for spinal deformities in Minnesota schools. Clin Orthop 1977;126: 33-42.

3. Rogala EG, Drummond DS, Gurr J. Scoliosis: incidence and natural history. J BoneJoint Surg 1978; 60A: 173-76.

4. Burwell RG, James NJ, Johnson F, Webb JK, Wilson YG. Standardised trunkasymmetry scores. A study of back contour in healthy schoolchildren J Bone JointSurg 1983; 65B: 452-63.

5. Dickson RA, Stamper P, Sharp AM, Harker P. School screening for scoliosis: cohortstudy of clinical course. Br Med J 1980; 281: 265-67.

6. Dickson RA. Scoliosis in the community. Br Med J 1983; 286: 615-18.7. Adran GM, Coates R, Dickson RA, Dixon-Brown A, Harding FM. Assessment of

scoliosis in children. Low-dose radiographic technique. Br J Radiol 1980, 53:146-47.

8. Ottander HG Simple x-ray method for measuring leg length discrepancy. TechnicalNote. Ilford X-ray Focus 1977; 15: 3

9. Whittle MW, Evans M. Instrument for measuring the Cobb angle in scoliosis, Lancet1979; i: 414.

10. Papaioannou T, Stokes I, Kenwright J. Scoliosis associated with limb lengthinequality. J Bone Joint Surg 1982; 64A: 59-62.

11. British Orthopaedic Association and British Scoliosis Society. School screening forscoliosis. Br Med J 1983; 287: 963-64.

12 Avikainen VJ, Vaherto H. A high incidence of spinal curvature. A study of 100 youngfemale students. Acta Orthop Scand 1983; 54: 267-73.

13. Adams W. Lectures on the pathology and treatment of lateral and other forms ofcurvature of the spine. London: Churchill, 1865.

14. Dickson RA, Lawton JO, Archer IA, et al Combined median and coronal planeasymmetry-the essential lesion of progressive idiopathic scoliosis. J Bone JointSurg 1983, 65B: 368.

15 Vercauteren M, Van Beneden M, Verplaetse B, Croene P, Uyttendaele D, Verdonk RTrunk asymmetries in a Belgian school population. Spine 1982; 7: 555-62.

16. Lonstein J, Bjorklund S, Wanninger MH, Nelson RP. Voluntary school screening forscoliosis in Minnesota. J Bone Joint Surg 1982; 64A: 481-88.

Clinical Sign

PRODROMAL ITCHING IN CHILDHOODASTHMA

T. J. DAVID MARIA WYBREWUTA HENNESSEN

Department of Child Health, University of Manchester

Summary In a prospective study of 79 children withasthma, 26 had prodromal itching 1-30 min

before the attack, and 17 had prodromal itching during theearly part of the attack. The sensation lasted up to about 30min. Scratch marks were seen in 5 patients. In 7 patients theitching was known to the child but had not been recognisedby the parents. The site of itching was constant for eachpatient, being the anterior part of the neck in 14 patients andthe upper part of the back in 9 patients. The pathogenesis ofprodromal itching is obscure, but its recognition may be ofdiagnostic use when taking a history and may enable an attackof asthma to be aborted or treated more promptly.

INTRODUCTION

PATIENTS with asthma sometimes experience a sensationof itching just before an attack. The site of itching is localised,being usually at the front of the neck or over the upper part ofthe back, and is usually constant for each patient. Thepatient’s response is nearly always to scratch. Prodromalitching, although often experienced by patients with asthma,is unfamiliar to most doctors. We have only been able to tracea single study of prodromal itching in asthma, and thisexcluded young children. The present study was undertakento examine the frequency of prodromal itching in childrenwith asthma.

PATIENTS AND METHODS

Children with asthma under the care of Booth Hall Children’s

Hospital were studied prospectively. Only children who had had atleast 1 attack severe enough to require admission to hospital werestudied. The parent(s) and children were interviewed, and astandard questionnaire was completed for each patient. Age,duration of asthma, number of admissions to hospital because ofasthma, type of prophylactic treatment, use of regular oral

antihistamines, and the presence of eczema were recorded. Theparents and patients were asked whether itching or scratching wasnoticed, for how long it lasted, exactly where it was located, andwhether it occurred before or during asthma attack. Prodromalitching was defined as an itching sensation (felt by the patient), orscratching (observed by the relatives), occurring just before, orduring, the early part of, an attack.

RESULTS

79 patients, 53 boys and 26 girls, were studied. They wereaged from 2 to 16years(mean7-75±3-62). 27 patients (34%)had atopic eczema. The mean number of admissions to

hospital because of asthma attack was 5 - 81. 71 patientsreceived regular prophylactic treatment, which consisted oforal or inhaled beta2-stimulants in 48 patients, oral slow-release theophylline preparations in 9, inhaled disodiumcromoglycate in 16, inhaled corticosteroids in 28,intramuscular corticotropin in 2, and oral prednisolone in 1.10 patients received antihistamines nightly as part of thetreatment for atopic eczema. The mean length of time sincediagnosis of asthma was 2-52 years.Prodromal itching was reported in 32 patients (41%). In 7

of these, the itching sensation was known to the child but hadnot been recognised by the parents. In 1 case neither mothernor child (aged 7) had noticed itching, but a 13-year-old sistersharing the patient’s bedroom said that she had often noticedher sister rubbing her neck just before an attack. There wasno statistically significant difference between the agedistribution of those with or without prodromal itching. 23(72%) of the 32 patients with prodromal itching and 30 (64%)of the 47 without prodromal itching were boys. The excess ofboys in the former group was not significant. The occurrenceof prodromal itching was unrelated to any particularprophylactic treatment or antihistamine use. The frequencyof eczema was the same in those with or without prodromalitching. In 4 patients, recognition of prodromal itching madeit possible to abort some attacks of asthma by the early use ofbronchodilators.

Prodromal itching occurred in a constant location in eachpatient, but in some patients it was seen in more than 1 site.The most common site was the anterior neck in the midline

(14 patients), followed by the upper part of the back in themidline (9), the upper sternal area (4), the vertex (3), the sideof the neck (2), the umbilical area (2), the epigastrium (1), theback of the neck (1), the left shoulder and left upper arm (1),the right side of the cheek and both legs (1), and the left side ofthe cheek (1).26 of the 32 patients had itching before the attack-in 22 it

began 1-2 min, and in 4, 10-30 min, before wheezing andcoughing. In 17 patients, the itching was noticed during theearly part of the attack itself. Many parents and children haddifficulty in being precise about the duration of itching, but10 said it lasted less than 5 min, 1 said it lasted 5-10 min, and4 said it lasted 30 min or more. 5 said that it lasted untiltreatment had begun to work, and 3 said that it stopped assoon as wheezing or coughing started. Scratch marks were notsystematically sought but were noticed in 5 patients withprodromal itching; in each, the scratch marks were over theupper part of the back.

155

DISCUSSION

The inquiry about itching before an attack was clearly aleading question. However, in each case the parent or patientwas able to locate precisely the scratching movements oritching sensation without any prompting from theinterviewer. Prodromal itching was mainly confined to theneck and back, and only occurred before or at the beginningof an attack.The patients in this study were selected on the basis of

severity and were not necessarily representative of allasthmatic children. By selecting patients with severe asthma,we anticipated that the general level of concern would be suchthat if prodromal itching was present, it would not beoverlooked by the parents. Nevertheless, in 7 of the 32 cases(22%) of prodromal itching, the parents were unaware of thesymptom. Whether the frequency of prodromal itchingwould be as high in milder cases is difficult to predict. In aseries of 50 presumably mild asthmatic patients, mainlyadults, seen in an Armed Forces general practice, the

prevalence of prodromal itching was 70%.’ 1Prodromal itching in asthma is not described in most

paediatric textbooks. The passage: "Sudden onsets are oftenushered in by a spell of coughing, which may be associatedwith itching of the chin, anterior part of the neck or chest"from the 10th edition of Nelson’s Textbook of Pediatrics, hasbeen omitted in the 11 th edition.3 The present study showsthat prodromal itching usually precedes early features of anattack, as well as accompanying them.The pathogenesis of prodromal itching is obscure.

Anorectal itching and burning after intravenous

hydrocortisone sodium phosphate4 in asthmatics may be arelated phenomenon. These symptoms appear to be a specificside-effect of the phosphate corticosteroid, and do not occurwith hydrocortisone sodium succinate.4 They begin in 10 s to4 min after injection, and last between 30 s and 6 min. Thepathogenesis of anorectal itching and burning is also obscure.Itching is associated in a reflex way with diverse triggers.Facial itching is an unexplained side-effect of intraspinallyadministered opiates.s This itching can be reversed withintravenous naloxone and is thought to result from an

enkephalinergic reflex relayed at a central level by a

medullary itch centre having a close functional link with thespinal nucleus of the trigeminal nerve. Ferocious itching ofthe nostrils is a specific sign of a cerebral tumour that hasinfiltrated the floor of the 4th ventricle,6 and in some animalsthere is evidence of a "scratch centre" in the caudal part of thefloor of the 4th ventricle. About 1 person in 4 or 5 isconscious that scratching an itchy area of skin may produce anitch elsewhere.8 These referred itch (Mitempfindungen)sensations are localised, ipsilateral, and transient. They canbe repeatedly provoked, and as with asthmatic prodromalitching each person seems to have his own pattern of itchreferral. The cause of referred itch is obscure, but it has beensuggested that it may result from a spread of excitation in thethalamus.8 The occurrence of prodromal itching cannot besatisfactorily explained by any of the physiologicalabnormalities found in the atopic stated Atopic eczema wasequally common in children with or without prodromalitching, and two thirds of subjects with prodromal itching didnot have eczema.Prodromal itching occurs in 40-70% of patients with

asthma, though it is not mentioned in books about asthmalO,ll 1or a major review of all aspects of itching.l2 The symptommay be of diagnostic use when taking a history, and whenrecognised by an asthmatic or his relatives it may enable anattack of asthma to be treated more promptly or even aborted.

Uta Hennessen is a medical student at the University of Bern, Switzerland.

We thank Dr J. Couriel, Dr J. H. Keen, and Dr V. Miller for allowing us tostudy their patients, and ProfR. D. H. Boyd, Dr R. J. Newton, and Dr BarbaraM. Phillips for their help. Mrs C. Sanders typed the manuscript.

Correspondence should be addressed to T. J. D., Booth Hall Children’sHospital, Charlestown Road, Blackley, Manchester M9 2AA.

REFERENCES

1. Orr AW. Prodromal itching in asthma. J R Coll Gen Pract 1979; 29: 287-88.2. Vaughan VC, McKay RJ, eds. Nelson’s textbook of pediatrics. Philadelphia: WB

Saunders, 1975: 505.3. Vaughan VC, McKay RJ, Behrman RE, eds. Nelson’s textbook of pediatrics.

Philadelphia: WB Saunders, 1979.4. Novak E, Gilbertson TJ, Seckman CE, Stewart RD, Di Santo AR, Stubbs SS.

Anorectal pruritus after intravenous hydrocortisone sodium succinate and sodiumphosphate. Clin Pharmacol Ther 1976; 20: 109-12.

5. Scott PV, Fischer HBJ. Intraspinal opiates and itching: a new reflex? Br Med J 1982;284: 1015-16.

6. Andreev V, Petkov I. Skin manifestations associated with tumours of the brain. Br JDerm 1975; 92: 675-78.

7. Koenigstein H. Experimental study of itch stimuli in animals. Arch Derm Syphil 1948;57: 828-49.

8. Evans PR. Referred itch (Mitempfindungen). Br Med J 1976; ii: 839-41.9. Sly RM, Heimlich EM. Physiologic abnormalities in the atopic state: a review. Ann

Allerg 1976; 25: 192-210.10. Jones RS. Asthma in children. London: Edward Arnold, 1976.11. Clark TJH, Godfrey S, eds. Asthma. London: Chapman and Hall, 1983.12. Savin J. Itching. In: Rook A, Savin J, eds. Recent advances in dermatology, No 5.

Edinburgh: Churchill Livingstone, 1980: 221-35.

Round the World

From our CorrespondentsSoviet Union

ASBESTOS IN THE SOVIET UNION

THE Soviet Union is the world’s largest producer of asbestos, so itwas interesting, during a visit for some other reason, to have theopportunity of discussing asbestos with Soviet doctors. For securityreasons I could not visit Sverdlovsk, the centre of the asbestosmining area, but the Minister of Health arranged a meeting inMoscow, at which I met, amongst others, a community physicianfrom the Sverdlovsk region, clinicians interested in asbestosis, anepidemiologist, an oncologist, a radiologist, an ENT specialist, andan expert on asbestos with whom I have had a lively correspondenceover the years.

I gave them a brief resume of the situation regarding asbestos inWestern countries, in particular how both general public andmedical profession have been influenced by the high emotionaltemperature generated by the media because of the rising incidenceof mesothelioma. It was impressed upon me that there was no mediapublicity, and no fear or panic, in the Soviet Union aboutasbestos-that the term asbestos meant little to the man in the street,and to doctors also. Asbestosis had become considerably lesscommon. The clinicians who had worked in Sverdlovsk for 30 yearssaw so few cases of asbestosis that they had difficulty in obtainingX-rays of asbestosis to show students. New cases identified at theannual medical check-ups were among those who had started workin the industry more than 20 years ago, before the present standardof 2 mg/m total dust was imposed. (Incidentally dust bronchitis isalso recognised as an occupational disease.) In most cases evidenceof asbestosis appears after retirement. No case of cancer had beendetected at annual examinations though the incidence amongasbestos workers is greater than that in the general population. Theincidence of cancer has not dropped in the same way as that ofasbestosis. Those in whom lung cancer developed had been exposedto asbestos for longer than had the non-cancer cases. There was noepidemiological evidence of a multiplicative effect of asbestos

exposure and smoking, though it was thought that this might exist.There are regulations governing the use of asbestos for all

industries using the material, such as those dealing with asbestostextiles, asbestos cement products, asbestos-bakelite and asbestosrubber materials, thermal insulation materials, and asbestos