Letters to the Editor

To the Editor

I recently read the article about the death of Huey P. Long by Dr Trotter in The Ochsner Journal (Volume 12, Number 1).

As author of Accident and Deception: The Huey Long Shooting, I did considerable research on the subject.

I personally heard Dr Edgar Hull state that he was next to Dr Kahle when he aspirated Long's renal area and said, and I quote, “This man is not bleeding around the kidney.” Dr Hull insisted that Long died of peritonitis. In my research, I met an elderly nurse in a Clinton [LA] nursing home who had been in training at the time and brought many bottles of infusions to Long's room.

Enclosed you will find my sketch of the operating room, which was initially drawn by the scrub nurse (Figure).

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Figure.

Diagram of Huey Long's operating room.

The respected Dr Cook initiated the operation. During the procedure, Dr Lorio, a state senator and confidant of Long's, came into the procedure. At that time, Dr Cook left the operation and sat behind Dr Lorio on the stretcher. Dr Vidrine was the assistant surgeon.

My feeling is that Long died from fluid overload, peritonitis, and an unknown amount of blood loss.

In my book, the reporter who witnessed the shooting feared for his life, having been threatened not to expose the truth. Could this have happened to the doctors as well?

Donald A. Pavy, MD

Lydia, LA

P.S. I welcome, at no cost, an opportunity to appear before any group to present my finding and even debate this issue.

Author's Reply

I appreciate Dr Pavy taking the time to write. His book is the first reference in the article and is recommended reading for anyone interested in this subject. His comments add more information to a controversial subject that will likely never be definitively answered.

I would offer the following regarding his comments. The issues of whether or not blood was aspirated from the perinephric space and of the contribution of peritonitis as a cause of death were both recognized and delineated in the article. While valid, opinions vary as to the role of both. His diagram of the operating room that night is a welcome addition to the body of information about this subject. Unfortunately, he did not include it in his book. His comments regarding the positions of surgeon/first assistant are exactly as I described them in the article as is the role of the relief surgeon. Likewise, his opinion of the cause of death does not diverge with that described in the article. Semantics aside, an abdominal gunshot wound causing shock and peritonitis (hypovolemic, septic, or with components of both) coupled with inadequate surgery and inadequate or overly aggressive resuscitation that was crudely monitored at best led to multiple organ systems failing and a fatal outcome. As a cardiothoracic and vascular surgeon with 30 years' experience caring for surgical and critically ill patients, this scenario is fairly straightforward to envision. As to the nonmedical details of witnesses being threatened, I will defer to those with expertise in that area.

Again, I appreciate Dr Pavy's comments and interest.

Michael C. Trotter, MD, FACS

Greenville, MS

mdatrotter{at}gmail.com

To the Editor

The number of studies supporting the use of probiotics is beginning to stack up. The majority have found probiotics to be an effective therapy, but consensus is lacking on exactly what organisms to use. The general conclusion is that further studies are needed.

The 2012 review by Dinleyici et al¹ published in Expert Opinion in Biological Therapy joins numerous other metaanalyses published in the past year advocating the probiotic use of Saccharomyces boulardii as effective treatment for reducing the duration of diarrheal disease.

Another large review published recently in JAMA supports their findings.² This study similarly concluded that probiotics were effective, but the focus of the review was limited to a multitude of randomized controlled trials utilizing Lactobacillus-based interventions.

In a sweeping review of metaanalyses published in the British Medical Journal, the authors honed in on the lack of head-to-head comparison studies as the key problem with existing research.³ At this point in time, it would be prudent to move beyond studying the effectiveness of treatment and begin comparing different species and delivery modalities directly, as well as determining which target populations benefit most.

Doctors can routinely recommend probiotics now, but the safety of these treatments cannot be assumed by looking at short-term findings. What are the long-term ramifications of such a paradigm shift? The complications of treatment with Lactobacillus spp. and S boulardii, while rare, do exist and pose a risk if large-scale therapy is to begin. Although no cases of systemic spread have been reported in any of the metaanalyses reviewed, numerous cases of probiotic-induced bacteremia and fungemia have been reported in the literature.^3,4

Although these cases have been confined to immunocompromised patients and those with comorbidities such as cancer and diabetes, several potential problems must be addressed:

• • How will the increasing presence of a readily transmitted potential pathogen, such as an airborne fungus, affect a hospital environment with increasing immunosuppression?

• • What happens if, or perhaps when, these introduced inhabitants develop antibiotic resistance or virulence?

• • Are we then just harboring a lethal agent waiting to exert its systemic effects when our defenses wane?

We must also consider how altering the bacterial flora of the gut affects the larger system as a whole. The complex interplay between the central and enteric nervous system is illustrated in the review article by Konturek et al.⁵ Their paper draws attention to the fact that stress and emotional stimuli have been shown to influence the composition of enteric microbiota and that the functioning of our immune and digestive systems in turn can be altered by the flora living within. The impact of tampering with such a complex balance has the potential to create complications that we are only now beginning to understand the magnitude of and that should not be overlooked.

We simply do not know enough about these issues to endorse probiotic therapy en masse. More directed studies are needed to answer these questions, and we should proceed cautiously in the meantime to avoid any unintended consequences of introducing new species into an already complex milieu of microorganisms, lest we forget the lessons learned from the cane toad, kudzu, or numerous other introduced species causing havoc on local ecosystems.

Miles Landry, BA, BS

Ochsner Clinical School, New Orleans, LA

miles.landry{at}uqconnect.edu.au