Treatment of the Chronic Alimentary Enteric Carrier
Authors: R. G. Main
Journal: BMJ (1961)

The problem of the enteric carrier has exercised many penetrating minds and has evoked a large amount of work, thought, discussion, and compassion, and a sizable literature over the last half-century.Many conflicting views have been put forward in recent years regarding the efficacy of treatment.In Scotland, where standards of health and hygiene are high, the relatively small nidi of enteric carriers probably represent the last stronghold of a disease which in former years has taken its toll of human life and suffering.In the world at large, however, and particularly in the relatively underdeveloped countries, the problem must still be a vast one.The carrier's condition is a danger not only to the community but to himself in the form of restriction, anxiety, and painful and even potentially fatal disease.Present Investigation My attention was first drawn to the carrier problem in the course of surgical practice in Bellsdyke Hospital, Larbert, in 1954, by Dr. Alan P. Russell.There was a nidus of nine alimentary enteric carriers-eight faecal excretors of Salmonella paratyphi B and one mixed alimentary carrier excreting intermittently Salm.typhi and Salm.paratyphi B. Eight of them had been discovered during an intensive investigation in 1951, and in May, 1956, a ninth carrier was transferred from another hospital.These carriers were kept in isolation and therefore were excluded from communal social intercourse, group therapy, and rehabilitation.Their restriction was responsible for considerable anxiety and frustration, and prevented advancement in their status within the hospital community.In addition to this, they formed a pocket of potential disease, not only within the hospital but also outside its walls.Indeed, one of the nursing assistants developed overt enteric fever while on leave in Ireland.In 1954 the question of surgical treatment for the carrier group was discussed, but a study of the recent literature and some of the standard works left one with mixed feelings about the possible benefits of surgery, and no action was taken.In 1956, however, one of the patients developed an acute illness which necessitated surgical treatment as a matter of urgency. Treatment of Case 1The patient had an episode of cholecystitis in October, 1956, and in the following January again complained of abdominal pain and developed jaundice, which gradually deepened.Murphy's sign was positive, but the gall-bladder was not palpable.Bile was present in the urine.A plain x-ray film showed no evidence of stone.Liver-function tests indicated that the jaundice was of obstructive type, and, as it was persistent, laparotomy was undertaken on February 22, 1957.The gall-bladder and bile-duct system were found to be distended; fibrotic, subacutely inflamed, and buried *This paper represlents a brief synopsis of a thesis submitted for the degree of Ch.M. of the University of Glasgow.in dense adhesions.When the adhesions were being freed it was noted that the duodenum was firmly fixed to the gall-bladder wall.In separating the necrotic duodenum a perforation occurred.This was sutured in two layers.Cholecystectomy and choledochostomy were performed with considerable difficulty.Convalescence was rather stormy.After operation this patient showed positive stool.sfor four months.Thereafter the stools became persistently negative and have remained so up to the present.