by John Irving
For this reason I made Larch an ether addict.
Ether was first synthesized in 1540 by a twenty-five-year-old Prussian botanist. People have been having ether
6190_Irving_02_js.qxd 8/23/99 5:00 PM Page 13
M Y
M O V I E
B U S I N E S S
1 3
frolics—and later, laughing-gas parties—ever since. In the proper hands, ether remains one of the safest inhalation agents known.At a concentration of only 1 or 2 percent, it is a light, tasty vapor; some forty years ago, hundreds of cases of cardiac surgery were done with ether and partially awake (even talking) patients.
Some of Dr. Larch’s colleagues would have preferred
nitrous oxide or chloroform, but Larch developed his preference for ether through self-administration. You would have to be crazy to self-administer chloroform. It is twenty-five times more toxic to the heart muscle than is ether, and it 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 it 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. Coleridge was a laughing-gas man, although the poet was certainly familiar with ether, too. It was unfortunate for Coleridge that he preferred opium. Ether is a kinder drug addiction to bear. But no drug addiction is without risk—and no self-administered anesthesia is safe. After all, in both the novel and the film, Dr. Larch accidentally kills himself with ether.
When I first thought about the grounding for Dr.
6190_Irving_02_js.qxd 8/23/99 5:00 PM Page 14
1 4
J O H N I R V I N G
Larch’s character, I kept one principle foremost in mind: he goes to extremes. In the novel, he has sex just once, with a prostitute who gives him gonorrhea. He starts taking ether to numb himself to the pain of the gonococci; by the time the bacteria burns itself out, Larch is addicted to the ether. I thought that he should be no less extreme as a doctor.
In the movie, Larch’s onetime experience with the
prostitute, his case of the clap, and his subsequent sexual abstemiousness are gone.What remains is his ether addiction; without a history, it seems more desperate, more extreme. Homer defends Larch’s reasons for taking ether by saying that Larch needs it to help him sleep (“He’s too tired to sleep”), but the ether numbs Larch’s overall pain. He takes it to relieve his angst, his Weltschmerz.
My grandfather’s predecessor—the founding father of
the Boston Lying-In, Dr. Walter Channing—was the first physician to use ether to relieve the pains of childbirth.
Thus Dr. Channing became the founding father of obstetric anesthesia in America. Dr. Channing was one of my grandfather’s heroes, just as one of Dr. Channing’s heroes was the great Benjamin Rush. It was Rush who wrote that
“pain does not accompany child-bearing by an immutable decree from Heaven.”
But in Dr. Irving’s day, there were still those obstetricians and midwives who believed that pain was a neces-
6190_Irving_02_js.qxd 8/23/99 5:00 PM Page 15
M Y
M O V I E
B U S I N E S S
1 5
sary, even a sacred part of the birthing process. The popular return of midwifery in the United States today, and the practice of so-called natural childbirth—indeed, the dis-dain for making any kind of anesthesia a part of the childbearing process—would doubtless have been greeted with contempt by my grandfather, who saw nothing “natural”
(not to mention “sacred”) in a mother’s pain in childbirth, and who was old enough to remember when male physicians in obstetrics were looked upon with abhorrence.
“Those days of false modesty,” Grandfather called them,
“when females had limbs rather than legs; and pelvic examinations, if made at all, were often conducted under a sheet, which only increased the uncertainty already existing in the mind of the doctor.” Like Dr. Larch, Dr. Frederick C. Irving was used to being in conflict—not only with prudish public opinion but also with his more conservative brother practitioners.
6190_Irving_03_js.qxd 8/23/99 5:00 PM Page 16
3
R U B B E R G L O V E S
My father, Colin Franklin Newell Irving, is
named after another mentor of my grand-
father’s, Dr. Franklin Newell, who pioneered
the change from the antiseptic to the aseptic technique at the Boston Lying-In Hospital, introducing the use of rubber gloves in 1903. Before then, even when physicians washed their hands, a death rate of about one in thirty (among obstetrical patients at lying-in hospitals) was regarded as standard—and, in Grandfather’s words, “ac-
cepted almost with equanimity.” It was of the utmost importance, my grandfather wrote, to rescue obstetrics from what he called “the relics of barbarism.”
Prenatal clinics were established at the Boston Lying-In in 1911; to cite only the example of eclampsia and eclamp-
6190_Irving_03_js.qxd 8/23/99 5:00 PM Page 17
M Y
M O V I E
B U S I N E S S
1 7
tic convulsions, the frequency of eclamptic patients requiring treatment immediately fell to a quarter of its former rate.
The first cesarean section to be performed at the
Boston Lying-In Hospital was on July 13, 1894. The procedure required forty-six minutes. An incision was made in the abdominal wall, almost a foot long, and the uterus was lifted through it—“an enormous organ,” as my grandfather has described it, “the color of a ripe plum.” The uterus rested on the patient’s abdomen, where it was said (in my grandfather’s words) “to fill the eyes of the behold-ers with wonder and respect.”
Grandfather describes the exposed uterus, in such a
procedure, as follows: “A quick slash through its walls brought a gush of liquid and blood which shot halfway across the room.” He adds: “The operation as performed today [he meant the 1940s] is a comparatively dull affair; the incision is much smaller and the uterus is opened as it lies in the abdominal cavity. Much of the drama has gone.”
When I began my research for The Cider House Rules, I needed to see a bowel-cancer surgery in order to appreciate what a cesarean section in the old days must have looked like.
6190_Irving_04_js.qxd
8/23/99 5:12 PM Page 18
4
N O T Q U I T E A W A K E
As for abortion,Grandfather was wise to observe
that “as long as there are unwanted pregnancies,
women will attempt to rid themselves of them.”
I was fourteen when I read that, in 1956. I was forty-three when The Cider House Rules was published, in 1985. I like to think that my grandfather would have enjoyed the
novel. I doubt that the story of the good Dr. Larch becoming an abortionist would have shocked him. That part of the story, I believe, would have merited Dr. Irving’s approval.
There is another part of the novel, however, of which I’m certain Grandfather would have dis approved. That Dr.
Larch must find a young abortionist to replace him was a necessary reality of orphanage hospitals that I doubt Dr.
6190_Irving_04_js.qxd 8/23/99 5:12 PM Page 19
M Y
M O V I E
B U S I N E S S
1 9
Irving ever considered. It would probably have offended my grandfather’s sense of proper training even to imagine that Dr. Larch would need to create, among the best and the brightest of his unadoptable orphans, a fellow obstetrician and abortionist.
After all, Fritz Irving was a Harvard man. The concept of a single physician training a mere boy to be a doctor—
not to mention creating false cre
dentials for his young medical student, which Dr. Larch does—would not likely have gained my grandfather’s sympathy. More likely, as much a pioneer in his field as he was, Dr. Irving was old-school in the sense that he believed in schools. He believed in the tradition of medicine (despite its aforementioned
“relics of barbarism”); he believed in the idea of a curricu-lum of training for physicians. Medicine was a frontier for my grandfather, but a formal education and its boundaries were the gods he believed in.
Dr. Irving would not have wanted Dr. Larch to go to
jail, or to lose his license to practice medicine, simply because he performed abortions; however, I’m guessing that Grandfather would have wanted Homer Wells to go to jail for being less than a properly trained physician. Moreover, Dr. Frederick C. Irving was never a fan of midwives. Had he been alive to read my novel, I’ve little doubt that Grandfather would have deemed Homer no better than a glorified midwife.
6190_Irving_04_js.qxd 8/23/99 5:12 PM Page 20
2 0
J O H N I R V I N G
Yet I took great pains in The Cider House Rules to make Dr. Larch a good teacher and Homer Wells a dutiful student. Homer makes no mistakes of a medical nature in the novel—nor, to my knowledge, did I. A medical historian read the book in manuscript, as did several doctors, an obstetrician and gynecological surgeon among them. (I was told sarcastically by one of the doctors that I somehow managed to get my episiotomies in the right place.)
In the course of researching the novel, I saw a number of babies born, a number of abortions performed, and a number of other gynecological procedures of a surgical kind. I never fainted or threw up, but the bowel-cancer surgery made me sweat. At one point—when the patient, although fully anesthetized, opened her eyes and appeared to stare at her insides, which were piled on top of her abdomen (not inside her, where they belonged) . . . well, at that point I felt I couldn’t get sufficient air through my surgical mask.
“She’s awake!” I whispered to the anesthesiologist, who appeared to be asleep.
He calmly looked at the patient and said, “Close your eyes, dear,” which she did.
Later the anesthesiologist told me: “There are degrees of what you novelists call ‘awake.’”
6190_Irving_05_js.qxd 8/23/99 5:13 PM Page 21
5
T H E G R E A T G O D I R V I N G
Given the sophistication of modern medicine,we
forget how recent much of this is. Anesthesia,
antibiotics, an understanding of sepsis—all are
recent. Even more recent is a substantial increase in the general public’s comprehension of hygiene. People today have more medical common sense. But when my grandfather was a young intern in the South End of Boston, his principal patients were poor immigrants, many of them living in cold-water slums. “All the standard forms of vice were there,” Grandfather wrote, “such as prostitution, drug addiction, and alcoholism; and in addition palmists, fortune-tellers, Chinese herb doctors, abortionists, and sexual perverts were all about.”
As a young obstetrician, Fritz Irving made many home
6190_Irving_05_js.qxd 8/23/99 5:13 PM Page 22
2 2
J O H N I R V I N G
deliveries. He carried a bag with a small sterilizer contain-ing rubber gloves, two clamps, a pair of scissors for cutting the umbilical cord, and a bottle of ergot to make the uterus contract after delivery. He once delivered a
Lithuanian child near Haymarket Square. The baby was born normally, but the afterbirth refused to come away.
The new mother’s mother, who was attending the birth, gave her daughter a beer bottle to blow into. This sometimes worked—by increasing the intra-abdominal pres-
sure. But the beer-bottle method failed this time. As the young woman was bleeding freely, my grandfather knew that unless he delivered the afterbirth promptly, he would be faced with a serious hemorrhage.
Grandfather grasped the top of the new mother’s uterus through her abdominal wall and squeezed firmly. His patient screamed and clawed at his hands. The patient’s mother seized him around the waist (in an attempt to bite him in the back). The patient’s husband, also in attendance, tried to strangle my grandfather. But the placenta separated and soon appeared, just as Grandfather felt he was near to fainting. “The family,” Dr. Irving wrote, “balked of their opportunity to do me bodily injury, lapsed into sulky silence.”
Perhaps it was experiences like these that gave my
grandfather a condescending view of the poor and the un-educated, and of the many ethnic minorities in the South
6190_Irving_05_js.qxd 8/23/99 5:13 PM Page 23
M Y
M O V I E
B U S I N E S S
2 3
End of Boston in his time. I remember him (maybe falsely) as an imperious and scornful figure, usually in a three-piece suit; a gold pocket watch made his vest pocket bulge.
He wore suspenders and cufflinks. The smell of ether sur-rounded him like a shroud. (Probably I have imagined the ether—the smell of which, from my tonsillectomy, is as permanent as certain childhood nightmares.)
At Harvard Medical School in Dr. Irving’s day, all the Boston hospitals—possibly because there were so many of them—were known by their nicknames or abbreviations.
The Peter Bent Brigham Hospital was called the Peter Bent; the Boston Lying-In was the B.L.I. My grandfather, even for years after he retired from the medical-school faculty, was known as The Great God Irving of the B.L.I.
But, in his own family, no one dared follow Fritz Irving into medicine. Had he cut too daunting a path? Our failure to follow in his footsteps could conceivably have disappointed him. I don’t really know—I never knew him well.
Grandfather died of a heart attack on Christmas Eve, 1957, when I was fifteen.
Now many (if not most) of his former medical-school
students are also dead. I hear more frequently from some of the grown children that my grandfather delivered; most of them are older than I am. Since they were only newborn babies when they first and last laid eyes on my grandfather, they have no idea that he was once known as The Great
6190_Irving_05_js.qxd 8/23/99 5:13 PM Page 24
2 4
J O H N I R V I N G
God Irving of the B.L.I. All they know about him is that he wrote that highly objectionable poem, which their parents have handed down to them; since the publication of The Cider House Rules, some of them have sent me handwritten or typewritten copies. (Now, instead of my father, I am sent copies of the scandalous poem.)
Once a retired obstetrician called me and recited all seventeen stanzas of “The Ballad of Chambers Street”
from memory over the telephone. He was calling from a restaurant in Florida. He was drunk, but lucidly drunk. It was his grandson’s wedding, he said; everyone was giving speeches. When it was the retired doctor’s turn to speak,
“The Ballad of Chambers Street” came back to him in its entirety. After he’d recited the poem to the astonished wedding party, his wife banished him from the table. Then he called me.
“But my phone number is unlisted,” I said to him. (I was living in New York City at the time.) “How’d you get my phone number?”
He replied that, as a doctor, he’d had “fair success” at getting calls put through to people with unlisted phone numbers. “It works about half the time,” he assured me.
“What works?” I asked him.
“I say I’m calling to report a death in the family,” the old doctor told me. “The key is overwhelming the operator with a lot of medical language.”
6190_Irving_05_js.qxd 8/23/99 5:13 PM Page 25
M Y
M O V I E
B U S I N E S S
2 5
I suppose that a retired obstetrician who could remember “The Ballad of Chambers Street” from his days in medical school could be reasonably “overwhelming.”
I thanked the elderly g
entleman for his phone call. “Dr.
Irving would have been proud of you,” I added.
I know a man (I’m sure you do, too) who has the irritating habit of saying, repeatedly, “That sounds like something that could happen only in a novel.” Well, here is yet another entry in that ever-expanding category: one of America’s pioneers in obstetrics and gynecological surgery is best remembered for a dirty poem. As my dad said to me once: “What your grandfather wrote in one weekend has already outlived him, and his reputation, by almost forty years.”
6190_Irving_06_js.qxd 8/23/99 5:13 PM Page 26
6
T O B E O F U S E
n 1980, when I first wrote some notes to myself about The Cider House Rules, I began with the imagined rela-Itionship between an orphanage physician and an un-
adoptable orphan—a child he brings into the world who cannot find a place in the world. Each time the orphan is adopted, it doesn’t work; he ends up back at the orphanage. The physician, a childless man, becomes like a father to this boy. But if they know the love of a father-son relationship, they also know the conflict. When I began my notes on the novel, I didn’t know what the conflict would be—only that there had to be one.
I went to the medical-history library at Yale. The more I read about orphanages and orphanage hospitals, the more I realized that, in that period of time when abortion was illegal in the United States (between 1846 and 1973), a
6190_Irving_06_js.qxd 8/23/99 5:13 PM Page 27
M Y
M O V I E
B U S I N E S S
2 7
woman with an unwanted pregnancy would be more likely to find a physician willing to give her a safe abortion in an orphanage hospital than in any other kind. A doctor in an orphanage would know what happened, and what too
often didn’t happen, to those children who were left behind. In Dr. Larch’s day, there were many orphans—most notably, the sickly and the unattractive—languishing in orphanages, unadopted. In their teenage years, they would become wards of the state.
And so I made Dr. Larch an abortionist. As for the
young orphan he trains to be a doctor, I made Homer Wells unwilling to perform abortions. After all, he’s an orphan—the only thing his mother gave him was life itself.