The Cider House Rules (92 page)

But chiefly, for his education, he would peruse (and linger over every word of)
A Brief History of St. Cloud’s.
In this pursuit, he would have Nurse Angela’s and Nurse Edna’s and Mrs. Grogan’s and Nurse Caroline’s tireless company, for by this pursuit they would keep Wilbur Larch alive.

Not that everything was clear to Homer: the later entries in
A Brief History of St. Cloud’s
were marred by shorthand inspirations and the whimsy conveyed to Larch through ether. For example, what did Larch mean by “rhymes with screams!”? And it seemed uncharacteristically harsh of Larch to have written: “
I
put the pony’s penis in her mouth!
I
contributed to that!” How could he have thought that? Homer wondered, because Homer never knew how well Dr. Larch had known Mrs. Eames’s daughter.

And as he grew older, Homer Wells (alias Fuzzy Stone) would take special comfort in an unexplained revelation he found in the writings of Wilbur Larch.

“Tell Dr. Stone,” Dr. Larch wrote—and this was his very last entry; these were Wilbur Larch’s last words: “There is absolutely nothing wrong with Homer’s heart.” Except for the ether, Homer Wells knew there had been very little that was wrong with the heart of Wilbur Larch.

To Nurse Edna, who was in love, and to Nurse Angela, who wasn’t (but who had in her wisdom named both Homer Wells and Fuzzy Stone), there was no fault to be found in the hearts of either Dr. Stone or Dr. Larch, who were—if there ever were—Princes of Maine, Kings of New England.

Author’s Notes

The pagination of this electronic edition does not match the edition from which it was created. To locate a specific passage, please use your ebook reader’s search tools.

(pp. 37–38) Anthony Trollope, who visited Portland, Maine, in 1861, and wrote about it in his
North America,
was mistaken—in the manner of Wilbur Larch’s father—about the intended future of the
Great Eastern.

(p. 41) I am indebted to my grandfather Dr. Frederick C. Irving for this information regarding Dr. Ernst, the curve-ball pitcher—and for the particularly medical language in this chapter. My grandfather’s books include
The Expectant Mother’s Handbook, A Textbook of Obstetrics,
and
Safe Deliverance.
Dr. Ernst’s studies of bacterial infections drew the attention of a Dr. Richardson of the Boston Lying-In Hospital, the maternity hospital where Wilbur Larch served an internship and later joined the staff. Dr. Richardson’s article “The Use of Antiseptics in Obstetric Practice” would surely have caught the attention of that eager student of bacteriology, clap-sufferer Wilbur Larch.

The interest in antiseptics among obstetricians was due to their effect in preventing the most deadly puerperal infection of that day, childbed fever. In 188_, in some maternity hospitals, the death rate among the mothers was about one in eight. In 189_, when Wilbur Larch was still at the Boston Lying-In, a mother’s odds were better; the doctors and their patients were washed with a solution of bichloride of mercury. Before Larch would leave the Boston Lying-In, he would see the antiseptic technique advance to the aseptic—the latter meaning “free from bacteria,” which meant that everything was sterilized (the sheets, the towels, the gowns, the gauze sponges); the instruments were boiled.

(p. 42) On the use of ether: most historians of anesthesia agree with Dr. Sherwin B. Nuland that surgical anesthesia began at Massachusetts General Hospital on October 16, 1846, when William Morton demonstrated the effectiveness of ether. Dr. Nuland writes: “Everything that led up to it was prologue, everything that was tangential to it was byplay, and everything that followed it was amplification.”

According to Dr. Nuland, ether in proper hands remains one of the safest inhalation agents known. At a concentration of only 1 to 2 percent it is a light, tasty vapor; in light concentration, even thirty years ago, hundreds of cases of cardiac surgery were done with light ether and partially awake (even talking) patients.

Some of Dr. Larch’s colleagues, at the time, would have preferred nitrous oxide or chloroform, but Larch developed his preference for ether through self-administration. Someone would be crazy to self-administer chloroform. It is twenty-five times more toxic to heart muscle than is ether and has an extremely narrow margin of safety; a minimal overdose can result in cardiac irregularity and death.

Nitrous oxide requires a very high (at least 80 percent) concentration to do the job and is always accompanied by a degree of what is called hypoxia—insufficient oxygen. It requires careful monitoring and cumbersome apparatus, and the patient runs the risk of bizarre fantasies or giggling fits. Induction is very fast.

Ether is a perfect drug addiction for a conservative.

(pp. 42–44) The source of this story is, again, my grandfather, who graduated from Harvard Medical School in 1910. He became chief of staff of the Boston Lying-In Hospital and was William Lambert Richardson Professor of Obstetrics at Harvard for a number of years. I remember him as a good storyteller and an occasional bully—of the other members of his family. As a young doctor, he had many experiences delivering babies to Boston’s poorer immigrant families, and to read him is to understand that he had as many opinions and prejudices as he had experiences and talents.

(p. 44) Ether was first synthesized in 1540 by a twenty-five-year-old Prussian botanist. People have been having ether frolics—and later, laughing-gas parties—ever since. In 1819, John Dalton published his study of the compound’s physical and chemical properties. Coleridge was a laughing-gas man—a party sniffer, and a frequenter of the experiments with nitrous oxide conducted by Humphrey Davy. The poet was certainly familiar with ether; it was a pity—for him—that he apparently preferred opium.

(p. 45) A Caesarean section is, today, a relatively calm operation: the abdominal incision is small because the uterus is opened inside the abdominal cavity. But in Dr. Larch’s days at the Boston Lying-In, in 188_ and 189_, the incision made in the abdominal wall was nearly a foot long; the uterus was lifted through the incision and placed upon the patient’s abdomen. “The slashing of this great, plum-colored organ produced a dramatic gush of liquid and blood,” my grandfather wrote. The uterus was then sutured with silk and returned to the abdominal cavity; the abdomen was closed in the same way. Considerably more discomfort followed such an operation than follows a Caesarean section now. The operation, in Larch’s time—and without complications—would require nearly an hour.

(p. 48) This death by scurvy is based on an actual case: “The Strange Case of Ellen Bean,” as told by my grandfather. “A spinster of thirty-five years and of New England stock,” Grandfather wrote of Ms. Bean, whose condition (and cause of death) was the same fate I awarded to the unfortunate Mrs. Eames. As my grandfather wrote: “The pregnant state does not engender in all women the rapturous joy traditionally associated with this condition; indeed there are some who view their future with a sour visage and a jaundiced eye. This much may be assumed from the case of Ellen Bean.”

(p. 49) In Wilbur Larch’s own state, in dear old Maine, performing an abortion was punishable by a year in jail or a one-thousand-dollar fine, or both—and, if you were a doctor, you might lose your license to practice. The Eastman-Everett Act of 1840 described the attempted abortion of any woman with child as an offense, “whether such child be quick or not”—and regardless of the method.

(p. 49) Instead of red merthiolate Dr. Larch might have used Dakin’s solution, although it’s likely he would have learned more about its uses during his short visit to France in World War I. That is where my grandfather learned of the many uses of Dakin’s solution and where he learned how to
débride
—that is, to cut away all the devitalized tissue surrounding a wound; the French were good teachers of this, he said.

(p. 52) In order for Dr. Larch to find the music in the 189_ abortion palace “remindful of Mahler’s
Kindertotenlieder,
” he would have to be gifted with a little precognition; Mahler’s song cycle was written in 1902. That is implied in the line, “Of course they could not have been singing Mahler’s
Songs on the Death of Children,
but those were the songs Wilbur Larch had heard.”

(p. 58) This is my grandfather’s description of the condition of an actual patient, an extremely small woman named Edith Fletcher—upon whom a Caesarean section was performed (Boston Lying-In Hospital; July 13, 1894). A pelvis this small is rare.

(p. 59) Mrs. W. H. Maxwell’s
A Female Physician to the Ladies of the United States: Being a Familiar and Practical Treatise of Matter of Utmost Importance Peculiar to Women
(“Adapted to Every Woman’s Own Private Use”) was published in New York in 1860. Mrs. Maxwell treated “all diseases peculiar to women, or which they may have unfortunately incurred through the dissipations or wanton unfaithfulness of husbands, or otherwise.” (In short, she treated venereal diseases.) Mrs. Maxwell also wrote that she gave her attention, as well, “to women . . . who are forced by the malfunction of their genital organs, or other cause, to resort to premature delivery.” (In short, she performed abortions.)

(p. 94) The New England Home for Little Wanderers was originally The Baldwin Place Home for Little Wanderers; the charter was granted by the Commonwealth of Massachusetts in 1865. The name was changed to The New England Home for Little Wanderers, its present name, in 1889—more than a decade before Wilbur Larch founded the orphanage in St. Cloud’s.

(p. 104) In a 1928 gynecology textbook (Howard Kelly—the standard at that time), the term D and C is used. I think it’s safe to assume that the term was in common use in 192_.

(p. 104) My grandfather said that he needed to use his
Gray’s Anatomy
in France in World War I as a “navigational chart.”

(p. 112) This is the exact description of a D and C as viewed by Dr. Richard Selzer (Yale School of Medicine), a general surgeon and author (
Mortal Lessons: Notes on the Art of Surgery
and
Rituals of Surgery
are among his books). I’m grateful for his reading of the manuscript of this novel and his generous advice—especially his introducing me to Dr. Nuland, who was the overseer of all the medical aspects of this novel.

(p. 119) The source of my information concerning the physical and mental manifestations of Alzheimer’s disease is
The Journal of the History of Medicine and Allied Sciences,
Volume XXXIV, Number 3, July 1979: the article by Dr. Sherwin B. Nuland, “The Enigma of Semmelweis—An Interpretation.” Dr. Nuland first presented his material in a lecture at the Yale School of Medicine (the annual History of Surgery Series). His thesis is that Ignac Semmelweis, the tortured discoverer of the sources of puerperal fever, suffered from Alzheimer’s disease and not from neurosyphilis; furthermore, Dr. Nuland believes that Semmelweis died of injuries received in a mental institution—i.e., he was beaten to death by his keepers. The records of Bedlam and of other institutions for the insane show that this was common as late as the early part of this century, and occasional reports still appear.

(pp. 124–25) The source of the description of Homer Wells’s first eclampsia patient is my grandfather’s book
Safe Deliverance
—the chapter on puerperal convulsions. Grandfather examines the case of a Lucy Nickerson, who died in 1880 of an eclamptic condition that was further aggravated by a forced delivery—the only method known to physicians of the unfortunate Mrs. Nickerson’s day.

(p. 125) The source of this treatment is again my grandfather, Dr. Frederick C. Irving (he was called Fritz). Grandfather describes this as the correct and life-saving treatment given to one Mrs. Mary O’Toole in 1937.

(p. 130) As of 1942, these are my grandfather’s findings. Syphilis—although a great source of agitation to the public-health officials of the day—afflicted only 2 percent of the pregnant women of Boston. The incidence of eclamptic convulsions was much higher. The disease developed in 8 percent of the country’s childbearing women.

(p. 147) Spring would be considered too early to bother waxing the press boards; the first press wouldn’t be until September, when you’d be pressing the early McIntoshes and the Gravensteins. The press boards, or racks, are wooden slats, over which the cider cloths (or press cloths) are folded. The press boards—they are stacked seven-high—take quite a beating, and the wax protects them. The mash, which is also called the pomace, is squeezed between these boards under a pressure of two thousand pounds. It takes eight hours to squeeze a thousand gallons of cider out of the press—about three gallons per bushel of apples.

The reason you wax the press boards before the first press is that you don’t want to take the time to do it once the harvest has begun. And you’re running the cider mill during the harvest maybe as much as every other night, and every day that it rains—when you can’t pick apples. In the 1940s and the 1950s, the last good press would have come in January.

I’m indebted to my old friends Ben and Peter Wagner and to their mother, Jean, for this and other apple-farming information. The Wagners run the Applecrest Farm Orchards in Hampton Falls, New Hampshire, where I worked when I was a boy; Jean and her late husband, Bill, gave me my first job.

(p. 148) All orchards have names; it is common practice, too, for farmers to name their buildings. This is necessary for the shorthand language of simple directions, as in: “The Deere has a flat and needs fixing in the Frying Pan”; or, “I left the Dodge in Number Two because Wally is spraying in the Sanborn and he’ll need a ride back.” In the orchard where I worked, there was a building called Number Two—although there was no Number Three and I don’t remember a Number One. Many of the orchards were named after the families who’d been the original homesteaders on that particular piece of land (Brown, Eaton, Coburn, and Curtis are some local names I remember). There was an orchard called Twenty Acres and another one called Nineteen, and there were the plainer names—an orchard called the Field, one called the Fountain, one called the Spring, and one called Old-New (because it was half old trees and half newly planted). The Frying Pan is also called Frying Pan—without the article.