CORRESPoI DENC Drug-Induced Dystonic Reactions To the Editor: In ~Drug-Induced Dystonic Reactions" ( J A C E P , August, 1977), Dr. Lee h a s o r g a n i z e d his m a t e r i a l well, w i t h a nice catalogue of e x t r a p y r a m i d a l symptoms. A l t h o u g h I agree w i t h Dr. F a u m a n ' s e d i t o r i a l ( J A C E P , A u g u s t , 1977) t h a t B e n a d r y l is a f a s t e r t r e a t m e n t for this problem, t h e r e is n o t h i n g w r o n g with Dr. Lee's therapy. However, I would ask t h a t patients who p r e s e n t at an emergency d e p a r t m e n t w i t h phenothiazine side-effects not be a u t o m a t i c a l l y t a k e n off t h e i r drugs. In some chronic patients, a g r e a t deal of t i m e has been spent convincing t h e m to t a k e t h e i r medications, a n d d e v e l o p m e n t of d y s k i n e s i a r e p r e sents a r e a l crisis. They need reassurance, not a physician t e l l i n g t h e m to step t h e i r medications.

James F. Hooper, MD Georgetown, South Carolina

Author's Reply The selection of a specific a g e n t for the t r e a t m e n t of drug-induced dystonic reactions often depends on the t r e a t i n g physician's clinical experience. I l i s t e d ten agents t h a t can be used to relieve drug-induced dystonic reactions. In m y experience, B e n a d r y l often causes m a r k e d drowsiness. P a t i e n t s t r e a t e d w i t h Benadryl seem to require longer e m e r g e n c y d e p a r t m e n t observation t h a n those t r e a t e d w i t h Congentin. A comparative s t u d y of B e n a d r y l a n d Congentin is in progress at t h e E m e r g e n c y D e p a r t m e n t of D e t r o i t G e n e r a l Hospital. Note t h a t the cases p r e s e n t e d in m y article were not u n d e r g o i n g t r e a t m e n t for acute or chronic m e n t a l illness. The p a t i e n t s were e i t h e r abusing major t r a n quilizers, or t h e s e d r u g s were p r e s c r i b e d i n a p p r o priately. I a g r e e w i t h Dr. Hooper t h a t the e m e r g e n c y physician should not u n i l a t e r a l l y advise a m e n t a l pat i e n t to d i s c o n t i n u e h i s a n t i p s y c h o t i c m e d i c a t i o n . However, it is m y opinion t h a t a short "medication holiday" m a y be helpful in r e l i e v i n g a painful dystonic crisis, b u t will not interfere with the t h e r a p e u t i c effect of long-term p h e n o t h i a z i n e t r e a t m e n t .

An Shih Lee, MD Emergency Department Detroit General Hospital Detroit, Michigan

Conservaf~ Managementof

Fingertip Amputa~ons To the Editor: The article, ~Conservative Management of F i n g e r t i p A m p u t a t i o n s , " (JACEP, J u n e 1977) is in-

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t e r e s t i n g but s o m e w h a t misleading. The authors are to be commended for t h e basic premise t h a t surgery does not lead to a u n i v e r s a l l y good result and more consideration should be given to conservative m a n a g e m e n t of the fingertip injuries. There are, however, a n u m b e r of criticisms to be leveled. The i n i t i a l criticism is t h e n u m b e r of cases and t h e i r selection. S e v e n t e e n consecutive p a t i e n t s were followed in the study. S u r e l y some of these patients, especially those w i t h exposed bone and a n excessive loss of p u l p s p a c e , w o u l d h a v e b e n e f i t e d f r o m a K l e i n e r t flap a d v a n c e m e n t technique which m a i n t a i n s l e n g t h a n d u s u a l l y provides i n t a c t sensation to the tip. S i m i l a r l y , I expect some would q u a l i f y more for a band-aid than the more elaborate treatment s u g g e s t e d . A n o t h e r c o n s i d e r a t i o n is the r e l a t i v e l y small t o t a l n u m b e r of tips. The second criticism is t h e i r selection of pictures to i l l u s t r a t e the h e a l i n g . The i n i t i a l set i l l u s t r a t e s h e a l i n g of a n a i l bed i n j u r y which was obviously wellt r e a t e d conservatively. The second s e t of photos shows an injury in a 70-year-old m a n who likewise would appreciate the conservative versus the surgical t r e a t ment. The t h i r d set, I believe, r e p r e s e n t s more accur a t e l y w h a t is suggested by the title. W i t h conservative t r e a t m e n t , t h e s e i n j u r e d fingers are l i k e l y to l e n g t h e n slightly and also pull sensitive skin surface over the tips. I agree e n t i r e l y t h a t m a n y fingertip a m p u t a t i o n s should be t r e a t e d conservatively, b u t would not endorse s u c h w i d e s p r e a d a p p l i c a t i o n as t h e a u t h o r s suggest.

Robert D. Pickering, MD Lecturer, Department of Surgery Queen's University, Kingston, Canada

Autt~or's Reply C o n c e r n i n g Dr. P i c k e r i n g ' s c o m m e n t on t h e n u m b e r and selection of cases, our s t u d y was designed to test the effectiveness and a p p r o p r i a t e n e s s of conservative t r e a t m e n t for a wide r a n g e of fingertip amp u t a t i o n s over a o n e - y e a r period in our own clinical setting. The most effective approach in view of these l i m i t a t i o n s was to t r e a t each a m p u t a t e d finger seen d u r i n g the study by the same s t a n d a r d protocol without selecting out cases for other forms of therapy. Over one year, 17 consecutive p a t i e n t s w i t h 21 a m p u t a t i o n s were seen in our e m e r g e n c y d e p a r t m e n t and t r e a t e d by the protocol. None of t h e s e cases r e q u i r e d a n y l a t e r surgical revision. Dr. Pickering's second point mentions the use of a K l e i n e r t flap a d v a n c e m e n t for c e r t a i n t y p e s of injuries. I would like to d r a w his a t t e n t i o n to the concluding p a r a g r a p h of our article. ~There is need for f u r t h e r comparison of conservative m a n a g e m e n t w i t h

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