CORRESPONDENCE

this article cast doubt on the value of its content and tend to discredit the efficacy of the editorial review procedures. The real question that this article raises is "What, if any- thing, could have been done in this case to have prevented this outcome?" Neither Darvon nor spinal manipulative therapy was therapeutic in this case of apparent frank neu- ronal tissue damage resulting from whiplash trauma. It would be instructional for colleagues to have presented here the entire post-accident medical history of this patient so that its relation to established protocol may be examined.

Frederick F Cochran Sunnyvale, California

In Reply: I wish to thank Mr Cochran for correcting the gram-

matical errors he lists. The correct terms should be "chi- ropractic" and "foramina." As noted in the article, informa- tion regarding the history of chiropractic was obtained from an individual at the Michigan Chiropractic Association and apparently was not accurate. The article clearly states, how- ever, that this patient was "previously in good health" and that this catastrophe occurred "in a previously healthy young man." Obviously the treating chiropractor disagreed

with Mr Cochran as to the indications for manipulation in this case.

Mr Cochran apparently misses the point of this article and the others listed as references by asking the question, "What, if anything, could have been done in this case to prevent this tragic outcome?" The important facts are:

1) Chiropractors performing manipulations of the cervical spine can cause devastating cerebral vascular accidents re- sulting in death or paralysis through injury to the vertebral arteries.

2) It may be impossible to ascertain which patients are at risk for such injury.

3) The only way to prevent such injuries in the future is to discontinue the practice of manipulating the cervical spine.

As to whether chiropractic mt~lipulation constitutes a disease, I would defer such judt!:~x~ent to the patient, his family, and my colleagues. It i:~ ~,~'ncouraging to hear that this report has been read by a f~ture practitioner of chi- ropractic.

Sherman W Horn II, MD Hayes-Green-Beach Hospital Charlotte, Michigan

TAC Minus A

To the Editor: In his article, "Clinical Comparison of TAC Anesthetic

Solut ions With and Wi thou t Coca ine" [November 1985; 14:1077-1080], Dr Schaffer quite rightly pointed out the theoretical concem of increased infection rate and toxic sys- temic effects with TAC {tetracaine, adrenalin, and cocaine}. The systemic effects alluded to involved episodes of excit- ability possibly related to systemic absorption of the TAC solution. In our emergency department we dispensed with the adrenalin in the TAC solution some years ago for just these theoretical reasons. It was our subjective finding that a solution of tetracaine and cocaine was at least as effective

as TAC. By eliminating the adrenalin the likelihood of the two possible side effects of systemic excitability and in- creased infection from excessive vasoconstriction were re- duced. As Dr Schaffer showed, both the cocaine and tetra- caine are important active ingredients in a topical anes- thetic. It has been our impression that adrenalin is not.

Mark Feldman, MD Emergency Department Waynesboro Hospital Waynesboro, Pennsylvania

Ts and Blues

To the Editor: I read with interest the article 'IKn Acute Hypertensive

Response After Intravenous Use of a New Pentazocine For- mulation" by Reinhart and Barrett [June 1985;14:591-593.] This drug combination is quite popular in the Cincinnati area and our emergency department frequently treats pa- tients with many of the typical sequelae of IV drug abuse which occur from abusing Talwin ®, especially the infec- tious complications. We have not seen the hypertensive re- sponse described in this report.

It is my observation that the addition of naloxone to the pentazocine formula has done little to discourage "T and B" abuse in our area. In fact, the addicts that I have inter- viewed have noted no significant change in the quality of the "high" which they experience when Injecting the Tal- win Nx formulation, and abuse is as common as ever. Reuitch and Weiss 1 have reported a narcotic-like effect of

tripelennamine alone when the drag is injected IV by pris- oners. It is possible that the euphoric effects of the reformu- lated Ts and Blues may be due solely to the tripelennamme, a substance that is not blocked by naloxone. Interestingly, my patients do not describe withdrawal with the IV pen- tazocine-naloxone preparation, despite using 10 to 20 tab- lets per day for extended periods and despite the fact that naloxone is supposed to precipitate Talwin * withdrawal in addicts. It is possible that there may be some of the original formula of Talwin ® still available on the street, because when I question my patients they are unaware of the new formulation. It is also possible that the added naloxone somehow blocks true addiction to the repeated use of pen- tazocine.

I can offer two reasonable explanations for the clinical findings in this patient. The cause of the acute hypertensive episode could easily have been due to an amphetamine or

154/606 Annals of Emergency Medicine 15:5 May 1986