Gulp: Adventures on the Alimentary Canal (33 page)

I recall riding a bus in San Francisco, years ago, and seeing a public service ad about anal cancer, “the cancer no one talks about.” I had never heard of it, and in the decade and a half since then, I haven’t come upon another reference. Until I looked it up, while writing this paragraph, I didn’t realize Farrah Fawcett had died of anal cancer. There were references to her ailment as cancer “below the colon.” It was like my mother, when I was a kid, calling the vagina “your bottom in front.” Up through 2010, anal cancer had no nonprofit society, no one to organize fund-raisers and outreach, no colored awareness ribbon. (Even
appendix
cancer has a ribbon.)
^*
Like cervical cancer, anal cancer is caused by the human papillomavirus; people get it via sex with an infected person, and that seems like something they ought to know when making decisions about using a condom.

Colonic inertia has an even lower profile than anal cancer. And I doubt you’ll be seeing bus posters about defecation-associated sudden death any time soon. I imagine the stigma discourages open talk among doctors and patients and people at risk. As Nichopoulos wrote in
The King and Dr. Nick
, “Nothing could have been more embarrassing than having people whispering about his bowel difficulties.”

But I have questions. At what point does constipation cross over from unpleasant to life-threatening? How hard would you have to be pushing? How exactly does it kill you? Should certain people be taking stool softeners the way others take baby aspirin?

I know one person who doesn’t mind talking about it.

G
EORGE
N
ICHOPOULOS LIVES
in a leafy Memphis neighborhood of widely spaced homes, on a bend in the road where once or twice a year a drunk fails to notice the curve and crashes his car in the yard of the house across the street. Elvis Presley had the house designed and built as a present for Nichopoulos and his family in the 1970s. You can see that in its day it was modish and luxe: the peaked ceiling with exposed rafters, the massive stone fireplace that divides the open floor plan of the downstairs, the backyard swimming pool.

Nichopoulos escorts me to the sofa. He and his wife, Edna, sit in armchairs to my left and right. The furniture is positioned far enough apart that I hand the doctor my tape recorder, for fear it won’t otherwise pick up his words. The coffee table is just out of reach, so that each time I pick up or set down my cup, I have to rise partway from my seat. It’s as though the family had been at a loss to fill the expanses of a home designed by someone with far more extravagant taste.

Nichopoulos is recovering from hip surgery. Although he’s in his eighties and using a mobility scooter to get around, he doesn’t appear much diminished. He’s tan and spiffed up, having just arrived home from an appearance at an Elvis Week memorial event. His hair is white, but it is not the sparse, scalp-clinging strands of the nursing-home frail. His stands firm and frames his head like an aura.

I open a folder and pass around the pictures I have of J.W. and of K.’s megacolon resting on its bed. No documents were released from Presley’s autopsy, but Nichopoulos has a photo of a similarly proportioned megacolon. He opens his laptop and turns it to face me. I get up to set down my coffee and cross the divide. In the photograph, a surgeon in blue scrubs holds a limp, bloody colon above his head in the triumphant, two-handed pose of an athlete with a trophy cup. Nichopoulos says he thought about including the photo in his book, so people would have a sense of what Presley had been dealing with. “But we knew that Priscilla was not going to allow us to put this in there.”

“She goes and puts her nose in everything.” A dispatch from the distant island nation of Edna.

I ask Nichopoulos to talk about precisely, medically, what caused Presley’s death.

“The night he died he was bigger than usual,” he begins. Depending on how long it had been since Presley had managed to empty himself, his girth fluctuated between big and stupendous. He sometimes appeared to be gaining or losing twenty pounds from one performance to the next. “He wanted to get rid of his gut that night. He was pushing and pushing. Holding his breath.” As the constipated do. The technical term is the Valsalva maneuver. Let’s have Antonio Valsalva, writing in 1704, describe it: “If the glottis be closed after a deep inspiration and a strenuous and prolonged expiratory effort be made, such pressure can be extended upon the heart and intrathoracic vessels that the movement and flow of the blood are temporarily arrested.” After a momentary spike, the heart rate and blood pressure plunge as the pressure squeezes off the flow of blood. This is followed by what one paper termed the “after-fling”—the body taking emergency measures to get things back up to speed.

The body’s response to this wild, Valsalvic seesawing of the vital signs can throw off the electrical rhythm of the heart. The resulting arrhythmia can be fatal. This is especially likely to happen in someone, like Elvis, with a compromised heart. Fatal arrhythmia is the cause of death listed on Presley’s autopsy report. “Probably every physician practicing emergency medicine has encountered tragic cases of sudden death in the lavatory,” writes B. A. Sikirov in “Cardio-vascular Events at Defecation: Are They Unavoidable?”

In 1950, a group of University of Cincinnati physicians documented the phenomenon—rather recklessly, I thought—by monitoring the heart rate of fifty subjects, half of them with heart disease, and asking them to “take a deep breath, hold it, and strain down vigorously as if endeavoring to have a bowel movement.” No one died, but they could have. It happens often enough that stool softeners are administered as a matter of course on coronary-care wards.

Making matters riskier: bed pans! “The notorious frequency of sudden and unexpected deaths of patients while using bed pans in hospitals has been commented upon for many years,” wrote the Cincinnati doctors. Notorious enough for a term to be coined: “bed pan death.” Lying flat is as counterproductive a posture as squatting is productive. Squatting passively increases the pressure on the rectum. It does the pushing for you. It also, Sikirov discovered in his study “Straining Forces at Bowel Elimination,” makes the task easier by straightening out the recto-anal angle, which I read as “angel.” The overall result, purrs Sikirov, is “smooth bowel elimination with only minimal straining.”

The other mode of defecation-associated sudden death is pulmonary embolism. The surge of blood when the person relaxes can dislodge a clot in a large blood vessel. When the clot reaches the lungs it can get stuck, causing a fatal blockage, or embolism. A 1991 study found that over a three-year period, 25 percent of the deaths from pulmonary embolism at one Colorado hospital were “defecation-associated.” This study’s authors took issue with Sikirov over squatting, claiming that descending and rising from a squat raises the risk of dislodging clots in the deep veins of the thighs.

Presley was given laxatives and enemas on an almost daily basis. “I carried around three or four boxes of Fleets,” Nichopoulos says, referring to the enema brand and recalling his days on tour with Presley. Getting the timing right was, he says, “a difficult balancing act.” Presley sometimes did two shows a day, and Nichopoulos had to schedule the administration such that the treatments didn’t kick in while the singer was on stage. This was the low point of Presley’s career: the bulky jumpsuit and isosceles sideburns era. His colon had expanded so dramatically that it crowded his diaphragm and had begun to compromise his breathing and singing. Beneath the polyester and girth, it was hard to see the man who had performed on the stage of the Ed Sullivan Theater, his moves so loose and frankly sexual that the producers had ordered him filmed from the waist up. Now there was a different reason to do so. “Sometimes right in the middle of the performance, he’d think, ‘I’m passing a little gas,’ and it wouldn’t be gas,” Nichopoulos says quietly. “And he’d have to get off stage and change clothes.”

People who saw the Graceland master bathroom would remark on its extravagance—a TV set! Telephones! A cushioned seat!—but the décor was in equal part a reflection of how much time was spent there. “He would be thirty minutes, an hour, in there at a time,” Nichopoulos says. “He had a lot of books in there.” Constipation ran Presley’s life. Even his famous motto TCB—“Taking Care of Business”—sounds like a reference to bathroom matters. (The TCB oath touched on self-respect, respect for fellow men, body conditioning, mental conditioning, meditation, and, according to a group tell-all by Elvis’s entourage, “freedom from constipation.”)

When Nichopoulos’s book came out, a colorectal surgeon named Chris Lahr contacted him. Lahr’s specialty is the paralytic colon.
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He has excised, in part or in whole, more than two hundred of them, and he surmised that Presley had had one too. When I spoke to Lahr by phone he told me Johnny Cash, Kurt Cobain, and Tammy Wynette had also struggled with obstinate constipation, and he was convinced that they too had stretches of paralyzed colon. But these were also people who struggled with obstinate drug addictions. Opiates, whether they’re in the form of heroin or prescription painkillers, drastically slow colon motility (as do, by varying degrees, antidepressants and other psychiatric drugs).

To know which is right—whether it was drugs or genetics behind the King’s condition—you’d need some information about his childhood. Most people with Hirschsprung’s—the main cause of megacolon—are diagnosed as infants or young children. As Mike Jones put it, “They come out of the box that way.” If there were truth to the story Adrianne Noe had heard, about Presley’s mother having to use her finger on him, that would suggest a hereditary condition like Hirschsprung’s. I ask Nichopoulos whether he’d heard the business about manual disimpaction. Edna volunteers that she’d read that in one of the many Elvis biographies.

Nichopoulos says he looked into it himself. “We were trying to figure out if it was there from birth or whether it was something that came on later. But his mother was gone.” Gladys Presley died when Elvis was twenty-two. Presley’s father wasn’t around the house much when Elvis was a child.

“I wanted to talk to Priscilla about it,” he says. Presumably Elvis would have discussed his medical issues with his wife. Nichopoulos shifts his weight. The hip still causes him pain. “She didn’t want to discuss it.”

It surprises me that Presley’s condition didn’t dampen his enthusiasm for food. He so appreciated Edna Nichopoulos’s Greek hamburgers that he gave her a ring he’d commissioned, with each of the recipe’s ingredients represented by a different-color diamond. “Green for parsley,” says Nichopoulos when I ask about it, “white for the onion, brown is the hamburger, and yella . . .” Some words are born for the Memphis accent.
Yellow
is one.

“Yella is the onion,” says Edna.

Nichopoulos considers this. “Wasn’t that the white?”

“No, white’s the bread.”

“Elaine!” Nichopoulos shouts toward the upstairs. “Can you get the hamburger ring!” Elaine Nichopoulos has been living with her parents, helping out since her father broke his hip.

A few minutes pass before Elaine appears on the stairs. She crosses the living room with a crooked gait, the combined aftermath of a car crash and a fall from a ladder. “Sorry, I was in the bathroom,” she says. “I’m sure
y’all
can understand”—
y’all
meaning the freaks down in the living room talking about bowel health.

Elaine sits down on her dad’s mobility scooter. She shows me where the pins stuck out of her ankle as it healed. Then she pulls down the shoulder of her shirt. I expect more medical hardware, but it’s a tattoo. “Do you like monkeys?” I almost say, but then I get it: There’s a monkey on her back. Oxycontin, fentanyl, drugs for chronic pain. On top of everything else, she has fibromyalgia.

“. . . and bipolar,” her dad chimes in.

She makes a face at him. “No,
you
are.”

I ask permission to try on the hamburger ring. “Go ahead,” Nichopoulos says. “We’ve got finger cutters.” It’s a fabulous object. I love the mix of diamonds and hamburger, glamour and trash. I feel like Elizabeth Taylor and Larry Fortensky at the same time.

E
LVIS
P
RESLEY’S COLON
is not on display in a glass case, but you can get a good sense of what it looked like by reading the autopsy section of
The Death of Elvis
. “As Florendo cut, he found that this megacolon was jam-packed from the base of the descending colon all the way up and halfway across the transverse colon. . . . The impaction had the consistency of clay and seemed to defy Florendo’s efforts with the scissors to cut it out.”

Nichopoulos was at the autopsy and remembers the moment. The clayey material, he says, was barium, administered to prep Presley for a set of X-rays—taken four months earlier. “That barium was . . .” He gestures toward the fireplace. “Just like a rock.” He says the impaction obstructed at least 50 to 60 percent of the diameter of Presley’s colon.

In the 1600s, the venerable English physician Thomas Sydenham advocated horseback riding as a remedy for an impacted bowel. I mention this to Nichopoulos, noting that Presley had liked riding well enough to have had a stable built at Graceland.

“That’s interesting,” he says. “It would certainly loosen it up.” Elaine turns the scooter and drives away.

Thomas Sydenham was an uncommonly gentle practitioner. Another of his treatments for intestinal obstruction featured mint water and lemon juice, as if all that were needed to make a man right was a refreshing summertime beverage. “I order, too,” he continued, “that meanwhile a live kitten be kept continually lying on the naked belly.” The kitten was to remain in place for two to three days, whereupon a dram of something unrecognizable but presumably stronger was prescribed. “The kitten is not to be taken off before the patient begins with the pills.”