The Cider House Rules

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 debride--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-hi

gh--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.

(p. 155) Anyone who grew up near the ocean, as I did, could detect a sea breeze in Iowa (if one was blowing).

(p. 210) The prayer that Mrs. Grogan recites is credited to John Henry (Cardinal) Newman, the English theologian and author (1801-90); I'm told that the prayer was originally part of one of Cardinal Newman's sermons. It was also what served my family as a family prayer and was spoken at the graveside of my maternal grandmother--it was her favorite. Her name was Helen Bates Winslow, and she died just a month short of her hundredth birthday; the festivities the family had planned for that event would doubtlessly have killed my grandmother, had she lived until then. Cardinal Newman's prayer must be a very good one, or at least it worked very well--and for a very long time--for my grandmother, who was devoted to it. I was devoted to her.

(pp. 226-27) Alzheimer described the disease he called presenile dementia in 1907. "Deterioration in cognition" occurs relatively early in the disease and is marked by a disturbance of recent memory and a loss of the ability to learn new things. Dr. Nuland of Yale also states that some patients are more likely to begin with personality changes and some with intellectual changes. The advance of the disease, in either case, is marked by a lowering threshold of frustration. Dr. Nuland notes that the sequence in which certain small jobs need to be done would be difficult to follow and that complex ideas are hard to comprehend and impossible to explain to others. It is a rapid deterioration that advances in Alzheimer victims: the average life-span, from the time of diagnosis, is approximately seven years; there are patients who live much longer, and many who die within a few months. In recent years, it has been recognized that Alzheimer's is not only an uncommon disease that affects people in midlife, but also a relatively frequent cause of mental and physical degeneration in the elderly--many of whom were previously thought to have simple hardening of the arteries (arteriosclerosis).

(p. 276) The famous Paris edition of 1957 (which was privately printed) collected seventeen hundred examples of the limerick. This limerick, which is categorized as an "organ limerick," originated in print in 1939; it may have been in spoken circulation earlier. In 194_, when Senior and Wally are saying it to each other, it would have been only a few years old.

(p. 292) Benjamin Arthur Bensley's Practical Anatomy of the Rabbit is a real book, published by the University of Toronto Press in 1918. Bensley is a clear, no-nonsense writer; his book, which he calls "an elementary laboratory textbook in mammalian anatomy," employs the anatomy of the rabbit as an introduction to an understanding of human anatomy. Bensley's is not Gray's, but Practical Anatomy of the Rabbit is a good book of its kind. As a very "elementary" student of anatomy, I learned a lot from Bensley--his book made reading Gray's much easier for me.