The Cider House Rules

by John Irving

  When young Dr. Larch first set out from the South Branch of the Boston Lying-In to deliver babies in the poor districts of the city, he had a place in his mind where the peace of ether resided. Although he carried the ether can and the gauze cone with him, he didn't always have time to anesthetize the patient. The woman's labor was often too far advanced for the ether to help her. Of course he used it when he had the time; he would never share the opinion of some of his elder colleagues that ether was a deviation from the given--that children should be brought forth in pain.

  Larch delivered his first child to a Lithuanian family in a coldwater, top-floor apartment--the surrounding streets littered with squashed fruit and tattered vegetables and horse droppings. There was no ice to put on the abdomen, over the uterus, in case of postpartum hemorrhage. There was a pot of water already boiling on the stove, but Larch wished he could sterilize the entire apartment. He sent the husband out for ice. He measured the woman's pelvis. He mapped out the fetus. He listened to its heartbeat while he watched a cat toying with a dead mouse on the kitchen floor.

  There was a would-be grandmother present; she spoke Lithuanian to the woman in labor. To Dr. Larch she spoke a strange language of gestures, which suggested to him that the would-be grandmother was feebleminded. She indicated that a large mole on her face was either a source of hysterical pleasure or hysterical pain--Larch couldn't tell which; perhaps she simply wanted him to remove it, either before or after he delivered the baby. She found several ways to exhibit the mole--once by holding a spoon under it, as if it were about to fall; once capping it with a teacup and revealing it suddenly, as if it were a surprise or a kind of magician's trick. But the zeal she brought to each revelation of the mole suggested to Wilbur Larch that the old woman simply forgot that she had already shown him her mole.

  When the husband returned with the ice, he trod on the cat, which voiced its disapproval in tones that made Wilbur Larch think the child was being born. Larch was grateful not to have to use the forceps; it was a short, safe, loud delivery, following which the husband refused to wash the baby. The grandmother offered, but Larch feared that her combination of excitement and feeblemindedness would cause an accident. Indicating (as well as he could, without the benefit of Lithuanian) that the child should be washed in warm water and soap--but not boiled in the pot on the stove, and not held head down under the coldwater tap--Larch turned his attention to the afterbirth, which refused to come away. The way the patient kept bleeding, Larch knew he would soon be faced with serious hemorrhage.

  He begged the husband to hack him some ice--the strong fellow had brought a whole block, borrowing the ice company's tongs for this purpose and standing in the kitchen with the tongs on his shoulder in a menacing fashion. The block of ice could cool the uteri of several bleeding patients; to apply it whole, to a single patient, would likely crush the uterus, if not the patient. At this moment the grandmother lost her grip on the soapy child and dropped it among the dishes soaking in the coldwater sink; this happened the instant that the husband again trod upon the cat.

  Seizing the moment, when he saw that the grandmother and the husband were distracted, Larch grasped the top of his patient's uterus through her abdominal wall and squeezed hard. The woman screamed and grabbed his hands; the grandmother, abandoning the baby among the dishes, tackled Larch at the waist and bit him between the shoulder blades. The husband retrieved the child from the sink with one hand, but he raised the ice tongs over Larch with the other. Whereupon, lucky Wilbur Larch felt the placenta separate. When he calmly pointed to its appearance, the grandmother and the husband seemed more in awe of it than of the child. After washing the baby himself and giving the mother some ergot, he bowed a wordless good-bye. Leaving the apartment, he was surprised to hear a commotion almost the instant he closed the door: the grandmother, the iced patient, the husband--all shouting in Lithuanian--and the baby giving forceful voice to its first family quarrel. It was as if the delivery, and Dr. Larch's entire appearance, had been only a brief interruption to a life of unintelligible turmoil.

  Larch navigated the dark stairs and groped his way outside; he stepped on a rotting head of lettuce, which gave under his foot with the disquieting softness of a newborn baby's skull. This time he did not confuse the cat's terrible yowl with the sounds a child can make. He looked up in time to see the object flying through the window of the Lithuanian apartment. He was in time to dodge it. It had clearly been hurled at him, and Larch wondered what particular, perhaps Lithuanian, offense he had caused these poor people. Larch was shocked to see that the object thrown from the window--and now dead on the ground at his feet--was the cat. But he was not that shocked; for a passing second, he feared it might have been the child. He had been told by his professor of obstetrics at Harvard that "the tensile strength of the newborn" was "a marvel," but Larch knew that the tensile strength of a cat was also considerable and he noted that the beast had failed to survive its fall.

  "Here in St. Cloud's," Dr. Larch would write, "I am constantly grateful for the South End of Boston." He meant he was grateful for its children and for the feeling they gave him: that the act of bringing them into this world was perhaps the safest phase of their journey. Larch also appreciated the blunt reminder given him by the prostitutes in the South End. They recalled for him the painful gift of Mrs. Eames. He could not see the prostitutes without imagining their bacteria under the microscope. And he could not imagine those bacteria without feeling the need for the giddy warmth of ether--just a sniff; just a light dose (and a light doze). He was not a drinking man, Dr. Larch, and he had no taste for tobacco. But now and then he provided his sagging spirits with an ether frolic.

  One night, when Wilbur was dozing in the South End Branch of the Boston Lying-In, he was informed by one of the doctors that there was an emergency arrival, and that it was his turn. Although she had lost a lot of weight and all of her youthfulness since Larch had last seen her, he had no trouble recognizing Mrs. Eames. She was so frightened, and in such intense pain, that she had difficulty catching her breath, and more trouble telling the nurse-receptionist her name.

  "Rhymes with screams," said Dr. Larch helpfully.

  If Mrs. Eames recognized him right away, she didn't let on. She was cold to the touch, her pulse was very fast, and her abdomen was as hard and white as the knuckles of a tight fist; Larch could detect no signs of labor, and he couldn't hear the heartbeats of the fetus, which Larch couldn't help imagining as having features similar to Mrs. Eames's sullen teen-age daughter. How old would she be now? he wondered. Still about his own age--that much he had time to remember before attending to his diagnosis of Mrs. Eames: hemorrhage within the abdomen. He operated as soon as the house officer could locate the necessary donors for the transfusion.

  "Missus Eames?" he asked her softly, still seeking some recognition from her.

  "How's your father, Wilbur?" she asked him, just before he operated.

  Her abdomen was full of blood; he sponged away, looking for the source, and saw that the hemorrhage issued from a six-inch rupture in the back of the uterus. Larch performed a Caesarean section and delivered a stillborn child--the pinched, scornful face of which forcibly reminded him of the cigar-smoking daughter. He wondered why Mrs. Eames had come here alone.

  To this point in the operation, young Larch felt in charge. Despite his memories of the woman opened up before him--and his memories of her transmitted disease, which he was only recently rid of--he felt he was handling a fairly manageable emergency. But when he tried to sew up Mrs. Eames's uterus, his stitches simply pulled through the tissue, which he noticed was the texture of a soft cheese--imagine trying to put stitches in Muenster! He had no choice then; he had to remove the uterus. After all the transfusions, Larch was surprised that Mrs. Eames's condition seemed pretty good.

  He conferred with a senior surgeon in the morning. At the Boston Lying-In it was standard that an obstetrician's background was surgical--Larch had interned in surgery at Mass General--and t
he senior surgeon shared young Larch's bafflement with the disintegrating consistency of Mrs. Eames's uterus. Even the rupture was a puzzle. There was no scar of a previous Caesarean section that could have given way; the placenta could not have weakened the wall of the uterus because the afterbirth had been on the other side of the uterus from the tear. There had been no tumor.

  For forty-eight hours Mrs. Eames did very well. She consoled young Wilbur on the death of his parents. "I never knew your mother, of course," she confided. She again expressed her concern that Wilbur consider her reputation, which Wilbur assured her he would (and had--by refraining from expressing his fears to the senior surgeon that the condition of Mrs. Eames might somehow be the result of gonorrhea). He briefly wondered which story Mrs. Eames was using at the moment, regarding her reputation: whether she was claiming to live a proper life in Portland or in Boston; whether a third city was now involved and necessarily a third fictitious life.

  On the third day after the removal of her strange uterus, Mrs. Eames filled up with blood again, and Wilbur Larch reopened her wound; this time he was quite afraid of what he'd find. At first, he was relieved; there was not as much blood in her abdomen as before. But when he sponged the blood away, he perforated the intestine, which he had hardly touched, and when he lifted up the injured loop to close the hole, his fingers passed as easily through the intestine as through gelatin. If all her organs were this same fragile jelly, Larch knew Mrs. Eames wouldn't live very long.

  She lived three more days. The night she died, Larch had a nightmare--his penis fell off in his hands; he tried to sew it back on but it kept disintegrating; then his fingers gave way in a similar fashion. How like a surgeon! he thought. Fingers are valued above penises. How like Wilbur Larch!

  This helped to strengthen Larch's conviction regarding sexual abstinence. He waited for whatever had destroyed Mrs. Eames to claim him, but the autopsy, which was performed by a distinguished pathologist, seemed off the track.

  "Scurvy," the pathologist said.

  So much for pathologists, thought Wilbur Larch. Scurvy indeed!

  "Missus Eames was a prostitute," Larch told the pathologist respectfully. "She wasn't a sailor."

  But the pathologist was sure about it. It had nothing to do with the gonorrhea, nothing to do with the pregnancy. Mrs. Eames had died of the sailor's curse; she had not a trace of Vitamin C, and, the pathologist said, "She had destruction of connective tissue and the tendency to bleed that goes with it." Scurvy.

  Though this was a puzzle, it convinced Larch that it wasn't a venereal puzzle and he had one good night's sleep before Mrs. Eames's daughter came to see him.

  "It's not my turn, is it?" he sleepily asked the colleague who roused him.

  "She says you're her doctor," the colleague told him.

  He did not recognize Mrs. Eames's daughter, who had once cost less than Mrs. Eames; now, she would have charged more than her mother could get. If, on the train, she had seemed only a few years younger than Wilbur, now she seemed several years older. Her sullen teen-age quality had matured in a brash and caustic fashion. Her makeup, her jewelry, and her perfume were excessive; her dress was slatternly. Her hair--in a single, thick braid with a sea-gull feather stuck in it--was so severely pulled back from her face that the veins in her temples seemed strained, and her neck muscles were tensed--as if a violent lover had thrown her to her back and held her there by her strong, dark pigtail.

  She greeted Wilbur Larch by roughly handing him a bottle of brown liquid--its pungent odor escaping through a leaky cork stopper. The bottle's label was illegibly stained.

  "That's what did her in," the girl said with a growl. "I ain't having any. There's other ways."

  "Is it Miss Eames?" Wilbur Larch asked, searching for her memorable cigar breath.

  "I said there's other ways!" Miss Eames said. "I ain't so far along as she was, I ain't quick."

  Wilbur Larch sniffed the bottle in his hand; he knew what "quick" meant. If a fetus was quick it meant the mother had felt it move, it meant the mother was about half through her gestation period, usually in her fourth or fifth month; to some doctors, with religion, when a fetus was quick it meant it had a soul. Wilbur Larch didn't think anyone had a soul, but until the middle of the nineteenth century, the common law's attitude toward abortion was simple and (to Wilbur Larch) sensible: before "quickening"--before the first, felt movement of the fetus--abortion was legal. More important, to the doctor in Wilbur Larch, it was not dangerous to the mother to perform an abortion before the fetus was quick. After the third month, whether the fetus was quick or not, Wilbur Larch knew it had a grip on the uterus that required more force to break.

  For example, the liquid in the bottle Wilbur Larch was holding had not provided sufficient force to break the grip that Mrs. Eames's fetus had on her--although, apparently, it had exerted enough force to kill the fetus and turn Mrs. Eames's insides to mush.

  "It's gotta be pure poison," Mrs. Eames's tough daughter remarked to Wilbur Larch, who dabbed a little of his beloved ether on the bottle's stained label, cleaning it up enough to read.

  FRENCH LUNAR SOLUTION

  Restores Female Monthly Regularity!

  Stops Suppression!

  (Suppression, young Larch knew, was a euphemism for pregnancy.)

  Caution: Dangerous to Married Women!

  Almost Certainly Causes Miscarriages!

  the label concluded; which, of course, was why Mrs. Eames had taken it and taken it.

  Larch had studied the abuse of aborticides in medical school. Some--like the ergot Larch used to make the uterus contract after delivery, and pituitary extract--directly affected the uterus. Others ruined the intestines--they were simply drastic purgatives. Two of the cadavers Larch had worked with in medical school had been victims of a rather common household aborticide of the time: turpentine. People who didn't want babies in the 1880s and 1890s were also killing themselves with strychnine and oil of rue. The French Lunar Solution Mrs. Eames had tried was oil of tansy; she had taken it for such a long time, and in such amounts, that her intestines had lost their ability to absorb Vitamin C. Thus did she turn herself into Muenster. She died, as the pathologist had correctly observed, of scurvy.

  Mrs. Eames could have chosen several other ways of attempting to abort the birth of another child. There were stories that a rather notorious abortionist in the South End was also the district's most successful pimp. Because he charged nearly five hundred dollars for an abortion, which very few poor women could afford, in their indebtedness they became his whores. His quarters--and others like his--were called, simply, "Off Harrison"--appropriately vague, but not without meaning. One of the facilities of the South Branch of the Boston Lying-In was established on Harrison Street, so that "Off Harrison," in street language, correctly implied something unofficial--not to mention, illegal.

  It did not make much sense to have an abortion "Off Harrison," as Mrs. Eames, perhaps, had reason to know. Her daughter also knew the methods of that place, which was why she gave Wilbur Larch a chance to do the job--and gave herself a chance to have the job done well.

  "I said I ain't quick," Mrs. Eames's daughter told young Larch. "I'd be easy. I'd get out of here in just a couple of minutes."

  It was after midnight at the South Branch. The house officer was asleep; the nurse-practitioner, an anesthesiologist, was also asleep. The colleague who had woken Larch--he'd gone to sleep, too.

  The dilation of the cervix at any stage of pregnancy usually leads to uterine contractions, which expel the contents of the uterus. Larch also knew that any irritant to the uterus would usually have the desired effect: contraction, expulsion. Young Wilbur Larch stared at Mrs. Eames's daughter; his legs felt rocky. Perhaps he was still standing with his hand on the back of Mrs. Eames's seat on that swaying train from Portland, before he knew he had the clap.

  "You want an abortion," Wilbur Larch said softly. It was the first time he had spoken the word.

  Mrs. Eames's daughter took
the sea-gull feather out of her pigtail and jabbed Larch in the chest with the quill end. "Shit or get off the pot," she said. It was with the words "shit" and "pot" that the sour stench of cigar reached him.

  Wilbur Larch could hear the nurse-anesthesiologist sleeping--she had a sinus condition. For an abortion, he wouldn't need as much ether as he liked to use for a delivery; he would need only a little more than he routinely gave himself. He also doubted it was necessary to shave the patient; patients were routinely shaved for a delivery and Larch would have preferred it for an abortion, but to save time, he could skip it; he would not skip ether. He would put red merthiolate on the vaginal area. If he'd had a childhood like Mrs. Eames's daughter, he wouldn't have wanted to bring a child into the world, either. He would use the set of dilators with the Douglass points--rounded, snub-nosed points, they had the advantage of an easy introduction into the uterus and eliminated the danger of pinching tissue in withdrawal. With the cervix dilated to the desired size, he doubted that--unless Mrs. Eames's daughter was well along in her third or fourth month--he would need to use forceps, and then only for the removal of placenta and the larger pieces. A medical school textbook had referred, euphemistically, to the products of conception: these could be scraped from the wall of the uterus with a curette--perhaps with two different-sized curettes, the small one to reach into the corners.

  But he was too young, Wilbur Larch; he hesitated. He was thinking about the time for recovery from ether that he would need to allow Mrs. Eames's daughter, and what he would say to his colleagues, or to the nurse if she woke up--or even to the house officer if it turned out to be necessary to keep the girl until the morning (if there was any excessive bleeding, for example). He was surprised by the sudden pain in his chest; Mrs. Eames's savage daughter was stabbing him with the sea-gull feather again.

  "I ain't quick! I ain't quick, I said!" the Eames girl screamed at him, stabbing him again and again, until the feather bent in her hand; she left it stuck in his shirt. In turning away from him, her heavy braid brushed his face--the braid's odor overwhelmingly conveying smoke. When she was gone and Larch plucked the sea-gull feather from his breast, he noticed that the oil of tansy--the French Lunar Solution--had spilled on his hands. Its smell was not unpleasant, but it momentarily overpowered the smell Larch liked and was used to--it overpowered the ether; it put an end to his peace of mind.