The Cider House Rules

by John Irving

  "A hollow muscular organ of conical form," as Homer Wells could recite, by rote, from Gray's Anatomy, ". . . enclosed in the cavity of the PERICARDIUM." By 194_ Homer had looked at each of the hearts in the three cadavers Dr. Larch had acquired for him (each cadaver outliving its usefulness for exploratory purposes in about two years' time).

  The cadavers were female; it hardly served Dr. Larch's purpose--in the process of educating Homer Wells in obstetrical procedure and procedures of a related kind--to have his student examining male cadavers. There was always a problem getting a body (once one was delivered in water that was supposed to be ice; another had to be disposed of because the embalming fluid had clearly been old or too weak). Homer remembered the three cadavers distinctly. It was not until the third body that he developed enough of a sense of humor to give the body a name; he called her Clara after David Copperfield's wimpish mother--that poor, weak woman who'd allowed herself and young David to be so bullied by the terrible Mr. Murdstone.

  "You should call her Jane," Melony advised Homer; Melony was alternately sick of Jane Eyre and completely identified with her.

  "I could have called her Melony," Homer responded, but humor was not reliably to be found in Melony, who preferred to play her own jokes.

  Body number two provided Homer with the essential practice that prepared him for his first Caesarean section; for that one, he had felt Dr. Larch's eyes so riveted to his hands that his hands seemed not his own--they moved with such smooth purpose that Homer was sure that Dr. Larch had discovered a way to make that perfect, no-bigger-than-necessary incision in the uterus with his mind (no need for using hands, at all).

  The harangue that developed at the railroad station over the arrival of the body Homer would call Clara gave Homer his first experience with eclamptic convulsions--or puerperal convulsions, as they were called in Wilbur Larch's days at the Boston Lying-In. At the exact moment that Dr. Larch was at the railroad station arguing with the stationmaster about the release form for the unfortunate Clara, Homer Wells was at St. Cloud's trying to locate, exactly, the inferior thyroid vein on body number two. Although he didn't know it, he had a good excuse for having, momentarily, lost his way; body number two was wholly shopworn, and many things were hard to locate within it. He would have consulted his Gray's in another minute or two, but just then Nurse Edna burst upon him--shrieking (as she always did when she saw Homer with body number two; it was as if she'd caught him up to something with Melony).

  "Oh, Homer!" she cried, but she couldn't speak; she flapped her arms in an agitated, chickenlike fashion before she managed to point Homer in the direction of the dispensary. He ran there as quickly as he could, finding a woman lying on the dispensary floor--her eyes staring so wildly and so steadily unseeing that at first he mistook her for the body he knew Dr. Larch was trying to liberate from the stationmaster. Then the woman began to move, and Homer Wells knew she was quite close to becoming a cadaver; the convulsions began with a twitching in her face, but they spread rapidly through all the muscles of her frame. Her face, which had been flushed, turned a shiny blue-black; her heels struck the floor with such force that both her shoes flew off--Homer saw instantly that her ankles were hugely swollen. Her jaws were set; her mouth and chin were wet with a frothy spittle, laced with blood because she'd bitten her tongue--which was at least preferable to her swallowing it. Her respiration was hardworking; she expelled air with a hiss, and the spray splashed Homer's face with a violence he'd not felt since he stood back from the bank and watched the Winkles being swept away.

  "Eclampsia," Homer Wells said to Nurse Edna. It derives from the Greek; Dr. Larch had told him that the word refers to the flashes of light a patient sees at the onset of the puerperal convulsions. With any sensible prenatal care, Homer knew, eclampsia was usually avoidable. There was an easily detected rise in blood pressure, the presence of albumin in the urine, swelling of the feet and hands, headaches, vomiting, and of course those spots and flashes in the eyes. Bed rest, diet, reduction of fluid intake, and free catharsis usually worked; but if they didn't, the bringing on of premature labor almost always prevented the convulsions and often produced a living baby.

  But the patients Dr. Larch saw were not women who sought or even understood prenatal care. This patient was very last-minute--even by the standards of Dr. Larch's practice.

  "Doctor Larch is at the railroad station," Homer told Nurse Edna calmly. "Someone has to get him. You and Nurse Angela should stay to help me."

  In lifting the woman and carrying her to the delivery room, Homer felt the woman's moist, cold skin and was reminded of body number one and body number two (the latter, he recalled, had been left on the examining table in the room now used for his anatomical studies, near the boys' division kitchen). In the last century, Homer Wells knew, a doctor would have given this patient an ether anesthesia and would have dilated the mouth of the womb to effect a forcible delivery--a method that usually caused the patient's death.

  At the Boston Lying-In Wilbur Larch had learned to fortify the heart muscle with doses of digitalis, which helped prevent the development of fluid in the lungs. Homer listened to the woman's watery breathing and realized he might be too late, even if he correctly remembered the procedure. He knew that one had to be conservative with eclampsia; if he was forced to deliver the woman prematurely, he must allow the labor to develop as naturally as possible. The woman just then moaned; her head and heels whacked the operating table in unison, her pregnant belly seemed to levitate--and one of her arms, without will, without purposeful direction, flew up and hit Homer in the face.

  He knew that sometimes a woman had only one puerperal convulsion; it was recorded that a few patients had survived as many as a hundred. What Homer didn't know, of course, was whether he was observing this woman's second convulsion or her ninetieth.

  When Nurse Edna returned to the delivery room with Nurse Angela, Homer instructed the nurses to administer morphine to the patient; Homer himself injected some magnesium sulphate into a vein, to lower her blood pressure at least temporarily. In the interval between her last and what Homer knew would be her next convulsion, he asked Nurse Edna to take a urine sample from the woman and he asked Nurse Angela to examine the specimen for traces of albumin. He asked the woman to tell him how many convulsions she had already suffered; but although the woman was coherent and could even answer questions intelligently, she couldn't pinpoint the number of convulsions. Typically, she remembered nothing of the convulsions themselves--only their onset and their draining aftereffects. She estimated she was at least a month away from expecting her baby.

  At the onset of her next convulsion, Homer gave the woman a light ether sedation, hoping he might reduce the violence of the fit. This fit was different in character from the last, though Homer doubted it was any less violent; the woman's motion was slower, but--if anything--more powerful. Homer lay across her chest, but her body abruptly jackknifed--lifting him off the operating table. In the next interval, while the woman was still relaxed under the ether sedation, Homer's investigations showed him that the neck of the patient's womb was not shortened, its mouth was not dilated; labor hadn't begun. He contemplated beginning it, prayed that he wouldn't have to make this decision, wondered why it was taking so long to find Dr. Larch.

  An orphan with a bad cold had been assigned to locate Larch at the railroad station; he returned with a thick rivulet of snot in each nostril and strung across one cheek, like a welt from a whiplash. His name (Nurse Angela's, of course) was Curly Day, and he wetly announced that Dr. Larch had boarded the train to Three Mile Falls--in order to chase down and capture the body that the stationmaster (in a pique of perversity prompted by religious outrage) had forwarded to the next stop. The stationmaster had simply refused to accept the cadaver. Larch, in a rage now surpassing the stationmaster's, had taken the next train after it.

  "Oh-oh," Nurse Edna said.

  Homer gave his patient her first dose of digitalis; he would repeat this periodically
until he could see its effects on the woman's heartbeat. While he waited with the woman for her next seizure, he asked her if she had decided to put her baby up for adoption, or if she had come to St. Cloud's only because it was the nearest hospital--in short, was this a baby she very much wanted, or one she didn't want?

  "You mean it's going to die?" the woman asked.

  He gave her Dr. Larch's best "Of course not!" kind of smile; but what he thought was that it was likely the baby would die if he didn't deliver it soon, and likely the woman would die if he rushed the delivery.

  The woman said she had hitchhiked to St. Cloud's because there was no one in her life to bring her, and that she didn't want to keep the baby--but that she wanted it, very much, to live.

  "Right," Homer said, as if this decision would have been his own.

  "You seem kinda young," the woman said. "I'm not going to die, am I?" she asked.

  "That's right, you're not," said Homer Wells, using Dr. Larch's smile again; it at least made him look older.

  But in twelve hours, when Dr. Larch had not returned and when the woman was arching her body on the operating table, suffering what was her seventh seizure, Homer Wells could not remember the exact expression that produced the reassuring smile.

  He looked at Nurse Angela, who was trying to help him hold the woman, and he said, "I'm going to start her labor. I'm going to rupture the bag of waters."

  "I'm sure you know what's best, Homer," Nurse Angela said, but her own imitation of Dr. Larch's confidence-inspiring smile was very poor.

  In twelve more hours the patient's uterine contractions commenced; Homer Wells would never remember the exact number of convulsions the woman experienced in that time. He was beginning to worry more about Dr. Larch than about the woman, and he had to fight down his fear of something happening to Dr. Larch in order to concentrate on his job.

  Another ten hours after the onset of the woman's contractions, she delivered herself of a boy--four pounds, eleven ounces, in good condition. The mother's improvement was rapid--as Homer had expected. There were no more convulsions, her blood pressure returned to normal, the traces of albumin in her urine were minimal.

  In the evening of the day after the morning when he had gone to the station to retrieve the body that the stationmaster would neither keep nor relinquish, Wilbur Larch--together with the rescued cadaver soon to be called Clara--returned tired and triumphant to St. Cloud's. He had followed the body to Three Mile Falls, but the stationmaster there had registered such horror that the body was never unloaded from the train; it had traveled on, and Larch had traveled after it, arriving at the next, and at the next station, always a train behind. No one wanted Clara, except to put her in the ground, and it was thought that this should not be the responsibility of a stationmaster--who would surely not accept, at his station, a body that no one came forward for. Clara was a body clearly not intended for the ground. The unearthly sloshing sound of the embalming fluid, the leathery skin, the outer-space colors of the occasionally exposed arteries and veins--"Whatever that is, I don't want it here," said the stationmaster in Three Mile Falls.

  And so Clara went from Three Mile Falls to Misery Gore, to Moxie Gore, to East Moxie--on and on. Larch got in a terrible row with the stationmaster in Harmony, Maine, where Clara had stopped for a few minutes--giving the railroad personnel the fright of their lives--before she'd been sent on.

  "That was my body!" Larch screamed. "It had my name on it, it is intended for the instruction of a student of medicine who is training with me in my hospital in Saint Cloud's. It's mine!" Larch yelled. "Why are you sending it in the wrong direction? Why are you sending it away from me?"

  "It came here, didn't it?" the stationmaster said. "It didn't get taken at Saint Cloud's, it appears to me."

  "The stationmaster in Saint Cloud's is crazy!" Larch hollered; he gave a little hop--a little jump, which made him appear a little crazy, too.

  "Maybe he is, maybe he isn't," said the stationmaster in Harmony. "All I know is, the body come here and I sent it on."

  "For Christ's sake, it's not haunted!" Larch said with a wail.

  "Didn't say it was," said the stationmaster. "Maybe it is, maybe it isn't--wasn't here long enough to tell."

  "Idiots!" Larch shouted, and took the train. In Cornville (where the train didn't stop), Wilbur Larch screamed out the window at a couple of potato farmers who were waving at the train. "Maine is full of morons!" he yelled, riding on.

  In Skowhegan, he asked the stationmaster just where in Hell he thought the damn body was going. "Bath, I suppose," the Skowhegan stationmaster said. "That's where it came from, and if nobody wants it at the other end, that's where it's going back to."

  "Somebody does want it at the other end!" screamed Wilbur Larch. "I want it."

  The body had been sent to the hospital in St. Cloud's from the hospital in Bath; a woman who was a willing body-donor had died, and the pathologist at Bath Memorial Hospital knew that Wilbur Larch was looking for a fresh female.

  Dr. Larch caught up with Clara in Augusta; Augusta was very sophisticated, for Maine, and the stationmaster simply saw that the body was going the wrong way. "Of course it's going the wrong way!" Wilbur Larch cried.

  "Damndest thing," the stationmaster said. "Don't they speak English up in your parts?"

  "They don't hear English!" Larch yelled. "I'd like to send a cadaver to every damn one of those towns--one a day!"

  "That sure would rile up a bunch of folks," the stationmaster said dryly, wondering how "riled up" Dr. Larch was going to get.

  On the long ride back to St. Cloud's with Clara, Dr. Larch didn't calm down. In each of the towns that offended him--in Harmony, especially, but in East Moxie and in Moxie Gore, and in all the rest of them, too--he offered his opinions to the respective stationmasters while the train paused at the stations. "Moronville," he told the stationmaster in Harmony. "Tell me one thing that's harmonious here--one thing!"

  "It was pretty harmonious before you and your damn body got here," the stationmaster said.

  "Moronville!" Larch shouted out the window as the train pulled away. "Idiotsburg!"

  To his great disappointment, when the train arrived in St. Cloud's, the stationmaster was not there. "Lunch," someone told Dr. Larch, but it was early evening.

  "Perhaps you mean supper?" Dr. Larch asked. "Perhaps the stationmaster doesn't know the difference," he said nastily; he hired the help of two louts to lug Clara up the hill to the boys' division.

  He was surprised by the disarray in which Homer Wells had left body number two. In the excitement of the emergency, Homer had forgotten to put body number two away, and Larch ordered the two oafs to carry Clara in there--not preparing the simpletons for the shopworn cadaver exposed on the table. One of the clods ran into a wall. Terrible crying out and jumping around! Larch went shouting through the orphanage, looking for Homer.

  "Here I am, running after a new body for you--across half the damn state of Maine--and you leave a mess like that just lying out in the open where any fool can fall upon it! Homer!" Dr. Larch yelled. "Goddamn it," he muttered to himself, "there is no way a teen-ager is going to be an adult ahead of his own, good time--no way you can expect a teen-ager to accept adult responsibilities, to do an adult's Goddamn job!" He went muttering all over the boys' division, looking for Homer Wells, but Homer had collapsed on Larch's white-iron bed in the dispensary and had fallen into the deepest sleep. The aura of ether surrounding that spare bed under that eastern window might have enhanced Homer's drowsiness, but he scarcely needed ether to sleep; he had been up for nearly forty hours with the eclampsia patient--delivering her and her child.

  Nurse Angela interrupted Dr. Larch before he could find Homer Wells and wake him up.

  "What's happening around here?" Larch demanded to know. "Is no one the least bit interested in where in Hell I've been? And why has that boy left his body looking like a war casualty? I go away overnight and just look at this place."

  But Nurse Ange
la straightened him out. She told him it had been the worst case of puerpural convulsions she'd ever seen, and she had seen some--in her time. Wilbur Larch had seen some, too. In his days at the Boston Lying-In, he'd lost a lot of women to eclampsia, and even in 194_, about a quarter of the deaths in childbirth were credited to these convulsions.

  "Homer did this?" Larch asked Nurse Angela and Nurse Edna; he was reading the report; he had examined the mother, who was fine, and the premature baby boy, who was normal and healthy.

  "He was almost as calm as you, Wilbur," Nurse Edna said admiringly. "You can be real proud of him."

  "He is an angel, in my opinion," Nurse Angela said.

  "He looked a little grim when he had to break the water," Nurse Edna remembered, "but he did everything just right."

  "He was as sure as snow," Nurse Angela said.

  He did almost everything right, Wilbur Larch was thinking; it really was amazing. Larch thought it was a slight error that Homer had failed to record the exact number of convulsions in the second twelve-hour period (especially after correctly counting them in the first twelve hours), and Homer had not mentioned the number or the severity of the convulsions (or if there were any) in the ten-hour period after the patient's labor contractions began and before she delivered. Minor criticism. Wilbur Larch was a good teacher; he knew that this criticism was better withheld. Homer Wells had performed all the hard parts correctly; his procedure had been perfect.