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.”