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THE DOSAGE OF DEXAMETHASONE AND TRIAMCINOLONE IN BRONCHIAL ASTHMA
257
The youngest, who had been on prednisolone for four and a half years, developed severe indigestion for the first time on transferring to dexamethasone. Scleroderma Of 2 women, aged 60 and 48, one was definitely better on dexamethasone with considerably less oedema, while the other was equally well controlled on either substance. In the former dyspeptic symptoms appeared on changing to dexamethasone. Status Asthmaticus and Ankylosing Spondylitis A man with status asthmaticus, aged 27, was equally well controlled by either substance. A man, aged 52, with a sixteen-year history of ankylosing spondylitis, had been on prednisolone for sixteen months. On transferring to dexamethasone, he improved,
becoming symptom-free, and, nisolone he relapsed.
on
returning
to
pred-
Discussion
received our first supplies of dexamethasone, When the correct dosage in man had still to be ascertained. We therefore substituted tablet for tablet, 0-4 mg. dexamethasone (this being the strength of the first tablets received) for 5 mg. prednisolone. The disastrous results obtained in the first 2 cases showed us that this dose was totally inadequate, and we therefore doubled it. On this ratio the clinical results were very similar with the two substances. Shortly afterwards, when the strength of tablet issued was increased to 0-5 mg., we maintained the 1/2 tablet ratio; each patient, therefore, now received 1 mg. where previously he had had 5 mg. prednisolone. This 1/5 ratio is perhaps slightly in favour of dexamethasone ; the true ratio may be more in the region of 1/6 or 1/7. This fact may explain the slightly increased incidence of gastric side-effects with dexamethasone. Nevertheless, from this small series of cases treated over short periods, there is little evidence that in the 5/1 dosage ratio dexamethasone was demonstrably superior to prednisolone except in a few cases. The fact that much the same clinical effect is obtained with a smaller dose (1/5th) of the new substance is of little practical importance unless the cost is reduced in the same ratio, and this is not the case. The patient on dexamethasone has in fact to take almost twice as many tablets as with any other corticosteroid. It seems likely on the existing evidence that all the same side-effects occur with dexamethasone as with prednisolone and prednisone but on this series we can say only that the most frequent and annoying, i.e., gastroduodenal irritation, is no less common. We have not had patients with rheumatoid arthritis on dexamethasone long enough to know whether the negative calcium balance reported by Bunim et al. (1958) will prove an added disadvantage; when a daily dosage of 6 mg. dexamethasone was reached these workers found that around 1-05 g. of calcium was excreted daily, mostly in the fxces. we
Summary and Conclusions steroid, dexamethasone, has been compared with prednisolone in its effect on 30 patients with rheumatoid arthritis in a dose ratio of 1/5 over periods up to twenty-four weeks. Little difference was apparent, 12 patients preferring dexamethasone, 12 preferring prednisolone, and 6 being indifferent. Dyspeptic sympA
new
appear to be no less common with dexamethasone than with prednisolone. In systemic lupus erythematosus (3 cases), scleroderma toms
(2 cases), ulcerative colitis (1 case), and status asthmaticus (1 case), little or no difference was noted in therapeutic response. 1 patient with ankylosing spondylitis improved on
dexamethasone.
most cases, there is no obvious advantage in transferring to dexamethasone. Some patients, nevertheless, preferred it and did improve on it, and it is
Thus, in
therefore useful to have yet another potent steroid available. We are grateful to Messrs. Merck, Sharp & Dohme for supplies of dexamethasone (’ Decadron’). REFERENCES
Arth, G. E., Johnston, D. B. R., Fried, J., Spooner, W. W., Hoff, D. R., Sarett, L. H. (1959) J. Amer. chem. Soc. (In the press). Bernstein, S., Lenhard, R. H., Allen, W. S., Heller, M., Littell, R., Stolar, S. M., Feldman, L. I., Blank, R. H. (1956) ibid. 78, 5693. Boland, E. W. (1958) Calif. Med. 88, 417. Borman, A., Singer, F. M., Numerof, P. (1954) Proc. Soc. exp. Biol., N.Y. 86, 570. British Medical Journal (1959) i, 109. Bunim, J. J., Black, R. L., Lutwak, L., Peterson, R. E., Whedon, G. D. (1958) Arth. & Rheum. 1, 313. — Pechet, M. M., Bollet, A. J. (1955) J. Amer. med. Ass. 157, 311. Dubois, E. L. (1958) ibid. 167, 1590. Freyberg, R. H., Berntsen, C. A. Jr., Hellman, L. (1958) Arth. & Rheum. 1, 215 Fried, J., Sabo, E. F. (1953) J. Amer. chem. Soc. 75, 2273. Garrod, O., Nabarro, J. D. N., Pawan, G. L. S., Walker, G. (1955) Lancet, ii, 367. Hart, F. D., (1956) Ann. R. Coll. Surg. Engl. 18, 314. Clark, C. J. M. (1951) Lancet, i, 775. Golding, J. R. (1955) ibid. ii, 998. — Golding, J. R., Burley, D. M. (1958) ibid. ii, 495. Hench, P. S., Kendall, E. C., Slocumb, C. H., Polley, H. F. (1949) Proc. Mayo Clin. 24, 181. (1950) A.M.A. Arch. intern. Med. 85, 545. Herzog, H. L., Nobile, A., Tolksdorf, S., Charney, W., Hershberg, E. B., Perlman, P. L. (1955) Science, 121, 176. Hogg, J. A., Lincoln, F. H., Jackson, R. W., Schneider, W. P. (1955) J. Amer. chem. Soc. 77, 6401. Lansbury, J., Mueller, E. E. (1956) Amer. U. med. Sci. 232, 300. (1958) Arth. & Rheum. 1, 505. Liddle, G. W., Pechet, M. M., Bartter, F. C. (1954) Science, 120, 496. Slater, J. D. H., Heffron, P. F., Vernet, A., Nabarro, J. D. N. (1959) Lancet, i, 173. Williams, R. S. (1959) ibid. p. 698. —
—
—
—
—
—
—
-
THE DOSAGE OF DEXAMETHASONE AND TRIAMCINOLONE IN BRONCHIAL ASTHMA E. STRESEMANN M.D. From the Asthma
Clinic, Free University of Berlin THE discovery of cortisone was quickly followed by the development of the more potent corticoids prednisone and prednisolone, and recently dexamethasone (9&agr;-fluor16x-methylprednisolone) and triamcinolone (9x-nuor16o!-hydroxyprednisolone). The latter two substances were made available at a time when their dosage was only tentative, and therefore it seemed appropriate to determine this as quickly as possible. Fortunately in our clinic we had a number of patients with chronic bronchial asthma, whose maintenance dose of prednisone had remained fairly constant for some time. These patients were changed to dexamethasone or triamcinolone, and the maintenance dose of these substances was estimated. Method Our patients had a history of asthma for many years, and had been under outpatient observation for a long time. In every case, routine treatment had been tried at first, and prednisone had been used only if it was evident that without it either dangerous attacks would occur, or permanent incapacity for work would result. The maintenance dose of prednisone was arrived at as follows: during the first 2-3 days of treatment the patient received 25 mg. daily; during the following 10 days the dose was reduced by 5 or 2-5 mg. per day every 2nd day until it had reached 12-5 mg. per day. In most cases this period brought about a considerable improvement, with decrease of dyspnoea and cough, and an increase in vital capacity. As a rule, however, some minor symptoms remained which required symptomatic treatment. From this point onwards the daily dose of prednisone was further reduced
258
by 2-5 or 1-25 mg. As soon as symptoms increased again, as confirmed by the amount of symptomatic treatment required, we assumed that the daily dose was lower than maintenance, and it was at once increased by 5-10 mg. per day to
every week
the previous state. After 4-7 days this was reduced again to an amount one step higher than that at which increasing symptoms had developed.
restore
It is doubtful whether these two new substances offer any therapeutic advantages in comparison with the older steroids, for a lower dosage alone is no advantage, except for topical application. As to the side-effects (see table), our small number of observations does not permit definite conclusions, but the occurrence of oedema (which dis. appeared under prednisone) in 3 patients treated with dexamethasone is remarkable. There is also the possibility of a negative calcium balance caused by dexame. thasone (Slater et al. 1959).
This method has been found to work well. It has the advanas defined here is the smallest amount possible for continuous treatment, and thus will produce only a minimum of harmful corticoid effects. Moreover it allows of easy recognition of a relapse provoked by external factors, such as superinfection or exposure to allergens. Inpatients are not included in our series, and the influence of entering hospital can therefore be excluded. Our average maintenance dose of prednisone was 10-0 mg. per day, and varied from 7-5 to 12-5 mg. per day. When this level had been reached, prednisone was replaced by either 2 mg. of dexamethasone or 6 mg. of triamcinolone. If the asthma became worse, this dose was doubled and then slowly reduced until a maintenance dose was reached. If the asthma did not become worse, the dose was gradually reduced until the maintenance dose could be recognised. To avoid misunderstandings it should be stated that by the expression maintenance dose is understood that amount of corticoid substance the decrease of which will lead to a definite deterioration within 3-6 days. Sometimes there are patients who appear to be maintained with 5 mg. of prednisone or even less. Such cases, which have also been described by Irwin and Burrage (1958) and Arnoldsson (1958), are usually patients with moderate or mild asthma, in whom corticoid treatment induces an improvement lasting for weeks or months. In these patients corticoids can often be gradually omitted without an immediate relapse; nevertheless deterioration usually occurs some weeks or months later, either spontaneously or after an upper respiratory infection, and necessitates resumption of corticoid therapy. Such patients are not included here as it is difficult to find out their true maintenance
tage that the maintenance dose
Summary
corticoids, dexamethasone and investigated in 29 patients suffering from chronic bronchial asthma and compared with that of prednisone. The mean ratio of the maintenance dose of prednisone to dexamethasone was 5-4/1, that of pred. nisone to triamcinolone 16/1. The effect of two
triamcinolone,
new
was
indebted to Prof. H. Herxheimer for reading the manu. Messrs. E. Merck (Darmstadt), Messrs. Stern (Hamburg, and Messrs. Lederle (Munich) for trial amounts of dexamethasone and triamcinolone. I
am
script,
to
REFERENCES
Arnoldsson, H. (1958) Acta allerg., Kbh. 12, suppl. VI. Irwin, J. W., Burrage, W. S. (1958) J. Allergy, 29, 233. Epstein, I., Sherwood, H. (1958) Conn. St. med. J. 22, 822. Sherwood, H., Cooke, R. A. (1957) J. Allergy, 28, 97. Segal, M. S., Duvenci, J. (1958) Bull. Tufts N. Engl. med. Centre, 4, 71. Slater, J. D. A., Heffron, P. F., Vernet, A., Nabarro, J. D. N. (1959) Lancet, i, 173.
INTUBATION OF THE CARDIA FOR INOPERABLE CARCINOMA ARNOLD GOUREVITCH M.C., M.B. Birm., F.R.C.S. SURGEON, UNITED BIRMINGHAM HOSPITALS
ANY interference with the mechanism of swallowing makes life difficult enough, but inability to swallow even saliva makes it intolerable. Advanced carcinoma of the lower end of the oesophagus or the fundus of the stomach may result in severe dysphagia or complete inabilityto swallow. Naturally if resection of the lesion offers any prospect of cure or even long-continued relief, then this is the treatment of choice. In some patients; however, the growth is so advanced or the clinical condition so poor that resection may be either technically
dosage. Results and Discussion
Both dexamethasone and triamcinolone were found to be, weight- for weight, more effective than prednisone, the former being about 5 times, the latter about 1-6 times more active. Some workers with triamcinolone have, in the meantime, estimated its efficacy as 12-25 times that of prednisone (Sherwood and Cooke 1957, Epstein and Sherwood 1958, Segal and Duvenci 1958). In our observations the individual variation in this ratio is rather small (1-4-1-9); in those of Sherwood and Cooke (1957) it is between 1-2 and 2-5. The variations with dexamethasone, however, are considerably greater, the ratio to prednisone varying from 3-0 to 8-0. With dexamethasone the maintenance dose in an individual patient cannot therefore be predicted with a similar probability as with triamcinolone.
impossible or too dangerous. Gastrostomy in such cases has been universally condemned. After gastrostomy the patient can be fed but cannot swallow, and one has only to see these
people continually spitting out frothy saliva
poor
NUMBER OF PATIENTS SHOWING SIDE-EFFECTS ON PREDNISONE, TRIAMCINOLONE, AND DEXAMETHASONE
realise that gastrostomy has nothing to offer and that there is
to
no
acceptable
alternative
to
swallowing. A bypass operation such
as
an
oesophagojeju_
nostomy may be
Fig. 1-A, Symonds’ tube; B, C, flexometallic tube.
Souttar’s tube
The youngest, who had been on prednisolone for four and a half years, developed severe indigestion for the first time on transferring to dexamethasone. Scleroderma Of 2 women, aged 60 and 48, one was definitely better on dexamethasone with considerably less oedema, while the other was equally well controlled on either substance. In the former dyspeptic symptoms appeared on changing to dexamethasone. Status Asthmaticus and Ankylosing Spondylitis A man with status asthmaticus, aged 27, was equally well controlled by either substance. A man, aged 52, with a sixteen-year history of ankylosing spondylitis, had been on prednisolone for sixteen months. On transferring to dexamethasone, he improved,
becoming symptom-free, and, nisolone he relapsed.
on
returning
to
pred-
Discussion
received our first supplies of dexamethasone, When the correct dosage in man had still to be ascertained. We therefore substituted tablet for tablet, 0-4 mg. dexamethasone (this being the strength of the first tablets received) for 5 mg. prednisolone. The disastrous results obtained in the first 2 cases showed us that this dose was totally inadequate, and we therefore doubled it. On this ratio the clinical results were very similar with the two substances. Shortly afterwards, when the strength of tablet issued was increased to 0-5 mg., we maintained the 1/2 tablet ratio; each patient, therefore, now received 1 mg. where previously he had had 5 mg. prednisolone. This 1/5 ratio is perhaps slightly in favour of dexamethasone ; the true ratio may be more in the region of 1/6 or 1/7. This fact may explain the slightly increased incidence of gastric side-effects with dexamethasone. Nevertheless, from this small series of cases treated over short periods, there is little evidence that in the 5/1 dosage ratio dexamethasone was demonstrably superior to prednisolone except in a few cases. The fact that much the same clinical effect is obtained with a smaller dose (1/5th) of the new substance is of little practical importance unless the cost is reduced in the same ratio, and this is not the case. The patient on dexamethasone has in fact to take almost twice as many tablets as with any other corticosteroid. It seems likely on the existing evidence that all the same side-effects occur with dexamethasone as with prednisolone and prednisone but on this series we can say only that the most frequent and annoying, i.e., gastroduodenal irritation, is no less common. We have not had patients with rheumatoid arthritis on dexamethasone long enough to know whether the negative calcium balance reported by Bunim et al. (1958) will prove an added disadvantage; when a daily dosage of 6 mg. dexamethasone was reached these workers found that around 1-05 g. of calcium was excreted daily, mostly in the fxces. we
Summary and Conclusions steroid, dexamethasone, has been compared with prednisolone in its effect on 30 patients with rheumatoid arthritis in a dose ratio of 1/5 over periods up to twenty-four weeks. Little difference was apparent, 12 patients preferring dexamethasone, 12 preferring prednisolone, and 6 being indifferent. Dyspeptic sympA
new
appear to be no less common with dexamethasone than with prednisolone. In systemic lupus erythematosus (3 cases), scleroderma toms
(2 cases), ulcerative colitis (1 case), and status asthmaticus (1 case), little or no difference was noted in therapeutic response. 1 patient with ankylosing spondylitis improved on
dexamethasone.
most cases, there is no obvious advantage in transferring to dexamethasone. Some patients, nevertheless, preferred it and did improve on it, and it is
Thus, in
therefore useful to have yet another potent steroid available. We are grateful to Messrs. Merck, Sharp & Dohme for supplies of dexamethasone (’ Decadron’). REFERENCES
Arth, G. E., Johnston, D. B. R., Fried, J., Spooner, W. W., Hoff, D. R., Sarett, L. H. (1959) J. Amer. chem. Soc. (In the press). Bernstein, S., Lenhard, R. H., Allen, W. S., Heller, M., Littell, R., Stolar, S. M., Feldman, L. I., Blank, R. H. (1956) ibid. 78, 5693. Boland, E. W. (1958) Calif. Med. 88, 417. Borman, A., Singer, F. M., Numerof, P. (1954) Proc. Soc. exp. Biol., N.Y. 86, 570. British Medical Journal (1959) i, 109. Bunim, J. J., Black, R. L., Lutwak, L., Peterson, R. E., Whedon, G. D. (1958) Arth. & Rheum. 1, 313. — Pechet, M. M., Bollet, A. J. (1955) J. Amer. med. Ass. 157, 311. Dubois, E. L. (1958) ibid. 167, 1590. Freyberg, R. H., Berntsen, C. A. Jr., Hellman, L. (1958) Arth. & Rheum. 1, 215 Fried, J., Sabo, E. F. (1953) J. Amer. chem. Soc. 75, 2273. Garrod, O., Nabarro, J. D. N., Pawan, G. L. S., Walker, G. (1955) Lancet, ii, 367. Hart, F. D., (1956) Ann. R. Coll. Surg. Engl. 18, 314. Clark, C. J. M. (1951) Lancet, i, 775. Golding, J. R. (1955) ibid. ii, 998. — Golding, J. R., Burley, D. M. (1958) ibid. ii, 495. Hench, P. S., Kendall, E. C., Slocumb, C. H., Polley, H. F. (1949) Proc. Mayo Clin. 24, 181. (1950) A.M.A. Arch. intern. Med. 85, 545. Herzog, H. L., Nobile, A., Tolksdorf, S., Charney, W., Hershberg, E. B., Perlman, P. L. (1955) Science, 121, 176. Hogg, J. A., Lincoln, F. H., Jackson, R. W., Schneider, W. P. (1955) J. Amer. chem. Soc. 77, 6401. Lansbury, J., Mueller, E. E. (1956) Amer. U. med. Sci. 232, 300. (1958) Arth. & Rheum. 1, 505. Liddle, G. W., Pechet, M. M., Bartter, F. C. (1954) Science, 120, 496. Slater, J. D. H., Heffron, P. F., Vernet, A., Nabarro, J. D. N. (1959) Lancet, i, 173. Williams, R. S. (1959) ibid. p. 698. —
—
—
—
—
—
—
-
THE DOSAGE OF DEXAMETHASONE AND TRIAMCINOLONE IN BRONCHIAL ASTHMA E. STRESEMANN M.D. From the Asthma
Clinic, Free University of Berlin THE discovery of cortisone was quickly followed by the development of the more potent corticoids prednisone and prednisolone, and recently dexamethasone (9&agr;-fluor16x-methylprednisolone) and triamcinolone (9x-nuor16o!-hydroxyprednisolone). The latter two substances were made available at a time when their dosage was only tentative, and therefore it seemed appropriate to determine this as quickly as possible. Fortunately in our clinic we had a number of patients with chronic bronchial asthma, whose maintenance dose of prednisone had remained fairly constant for some time. These patients were changed to dexamethasone or triamcinolone, and the maintenance dose of these substances was estimated. Method Our patients had a history of asthma for many years, and had been under outpatient observation for a long time. In every case, routine treatment had been tried at first, and prednisone had been used only if it was evident that without it either dangerous attacks would occur, or permanent incapacity for work would result. The maintenance dose of prednisone was arrived at as follows: during the first 2-3 days of treatment the patient received 25 mg. daily; during the following 10 days the dose was reduced by 5 or 2-5 mg. per day every 2nd day until it had reached 12-5 mg. per day. In most cases this period brought about a considerable improvement, with decrease of dyspnoea and cough, and an increase in vital capacity. As a rule, however, some minor symptoms remained which required symptomatic treatment. From this point onwards the daily dose of prednisone was further reduced
258
by 2-5 or 1-25 mg. As soon as symptoms increased again, as confirmed by the amount of symptomatic treatment required, we assumed that the daily dose was lower than maintenance, and it was at once increased by 5-10 mg. per day to
every week
the previous state. After 4-7 days this was reduced again to an amount one step higher than that at which increasing symptoms had developed.
restore
It is doubtful whether these two new substances offer any therapeutic advantages in comparison with the older steroids, for a lower dosage alone is no advantage, except for topical application. As to the side-effects (see table), our small number of observations does not permit definite conclusions, but the occurrence of oedema (which dis. appeared under prednisone) in 3 patients treated with dexamethasone is remarkable. There is also the possibility of a negative calcium balance caused by dexame. thasone (Slater et al. 1959).
This method has been found to work well. It has the advanas defined here is the smallest amount possible for continuous treatment, and thus will produce only a minimum of harmful corticoid effects. Moreover it allows of easy recognition of a relapse provoked by external factors, such as superinfection or exposure to allergens. Inpatients are not included in our series, and the influence of entering hospital can therefore be excluded. Our average maintenance dose of prednisone was 10-0 mg. per day, and varied from 7-5 to 12-5 mg. per day. When this level had been reached, prednisone was replaced by either 2 mg. of dexamethasone or 6 mg. of triamcinolone. If the asthma became worse, this dose was doubled and then slowly reduced until a maintenance dose was reached. If the asthma did not become worse, the dose was gradually reduced until the maintenance dose could be recognised. To avoid misunderstandings it should be stated that by the expression maintenance dose is understood that amount of corticoid substance the decrease of which will lead to a definite deterioration within 3-6 days. Sometimes there are patients who appear to be maintained with 5 mg. of prednisone or even less. Such cases, which have also been described by Irwin and Burrage (1958) and Arnoldsson (1958), are usually patients with moderate or mild asthma, in whom corticoid treatment induces an improvement lasting for weeks or months. In these patients corticoids can often be gradually omitted without an immediate relapse; nevertheless deterioration usually occurs some weeks or months later, either spontaneously or after an upper respiratory infection, and necessitates resumption of corticoid therapy. Such patients are not included here as it is difficult to find out their true maintenance
tage that the maintenance dose
Summary
corticoids, dexamethasone and investigated in 29 patients suffering from chronic bronchial asthma and compared with that of prednisone. The mean ratio of the maintenance dose of prednisone to dexamethasone was 5-4/1, that of pred. nisone to triamcinolone 16/1. The effect of two
triamcinolone,
new
was
indebted to Prof. H. Herxheimer for reading the manu. Messrs. E. Merck (Darmstadt), Messrs. Stern (Hamburg, and Messrs. Lederle (Munich) for trial amounts of dexamethasone and triamcinolone. I
am
script,
to
REFERENCES
Arnoldsson, H. (1958) Acta allerg., Kbh. 12, suppl. VI. Irwin, J. W., Burrage, W. S. (1958) J. Allergy, 29, 233. Epstein, I., Sherwood, H. (1958) Conn. St. med. J. 22, 822. Sherwood, H., Cooke, R. A. (1957) J. Allergy, 28, 97. Segal, M. S., Duvenci, J. (1958) Bull. Tufts N. Engl. med. Centre, 4, 71. Slater, J. D. A., Heffron, P. F., Vernet, A., Nabarro, J. D. N. (1959) Lancet, i, 173.
INTUBATION OF THE CARDIA FOR INOPERABLE CARCINOMA ARNOLD GOUREVITCH M.C., M.B. Birm., F.R.C.S. SURGEON, UNITED BIRMINGHAM HOSPITALS
ANY interference with the mechanism of swallowing makes life difficult enough, but inability to swallow even saliva makes it intolerable. Advanced carcinoma of the lower end of the oesophagus or the fundus of the stomach may result in severe dysphagia or complete inabilityto swallow. Naturally if resection of the lesion offers any prospect of cure or even long-continued relief, then this is the treatment of choice. In some patients; however, the growth is so advanced or the clinical condition so poor that resection may be either technically
dosage. Results and Discussion
Both dexamethasone and triamcinolone were found to be, weight- for weight, more effective than prednisone, the former being about 5 times, the latter about 1-6 times more active. Some workers with triamcinolone have, in the meantime, estimated its efficacy as 12-25 times that of prednisone (Sherwood and Cooke 1957, Epstein and Sherwood 1958, Segal and Duvenci 1958). In our observations the individual variation in this ratio is rather small (1-4-1-9); in those of Sherwood and Cooke (1957) it is between 1-2 and 2-5. The variations with dexamethasone, however, are considerably greater, the ratio to prednisone varying from 3-0 to 8-0. With dexamethasone the maintenance dose in an individual patient cannot therefore be predicted with a similar probability as with triamcinolone.
impossible or too dangerous. Gastrostomy in such cases has been universally condemned. After gastrostomy the patient can be fed but cannot swallow, and one has only to see these
people continually spitting out frothy saliva
poor
NUMBER OF PATIENTS SHOWING SIDE-EFFECTS ON PREDNISONE, TRIAMCINOLONE, AND DEXAMETHASONE
realise that gastrostomy has nothing to offer and that there is
to
no
acceptable
alternative
to
swallowing. A bypass operation such
as
an
oesophagojeju_
nostomy may be
Fig. 1-A, Symonds’ tube; B, C, flexometallic tube.
Souttar’s tube