Shadrach in the Furnace

4

The liver, the body’s largest gland, is a useful and complex organ weighing a kilogram and a half — about two percent of the total body weight — that performs hundreds of significant biochemical functions. The liver produces bile, a green liquid essential to digestion. Through the liver passes exhausted venous blood en route to the heart, blood which the liver filters to remove bacteria, poisons, drugs, and other noxious impurities. To the blood the liver adds the plasma proteins it manufactures, among them the clotting agent fibrinogen and the anticoagulant heparin. From the blood the liver takes sugar, which it converts to glycogen and stores until the body’s energy needs require it. The liver is responsible also for the conversion of fats and proteins into carbohydrates, the storage of fat-soluble vitamins, the manufacture of antibodies, the destruction of outworn red blood cells, and much else.

So many metabolic purposes does the liver serve that no vertebrate can survive more than a few hours without one. So central is it to life that it has extraordinary regenerative powers: if three quarters of the liver is removed, the remaining cells will multiply so rapidly that the gland will regain its original dimensions within two months. Even if ninety percent of the liver is destroyed, it continues to produce bile at the normal rate. Redundancy is our main avenue of survival. Nevertheless the liver is subject to many dysfunctions — the various jaundices, the various necroses, septicemia, dysenteric abscesses, cancer of the bile passages, and so forth. The liver’s totipotence enables it to withstand such dysfunctions for prolonged periods, but its powers of recuperation diminish, like most other things, with age.

Genghis Mao suffers from chronic liver trouble. To sustain his life and the life of the assorted artificial and transplanted organs within him, the Chairman must pour oceans of medication through his system each day, and even the most durable of livers would be hard pressed to handle the constant assault of high-powered chemicals it is asked to filter from Genghis Mao’s bloodstream. Then, too, the presence of so many alien organs sets up biochemical interaction phenomena within the body that the liver must counteract, and the strain is telling. The Chairman’s beleaguered liver is in a perpetually morbid state, aggravated by his great age and the unnatural intricacy of his composite internal structure, and periodically it must be replaced. That time has again come.

Two burly aides lift Genghis Mao’s short, slight figure onto a gurney and the familiar trip from the imperial bedchamber to the operating table commences. The Khan is cheerful, feverish and frail and beady-eyed though he looks; he nods and winks to the aides as they position him, telling them that he is comfortable; he chuckles, he even essays a quip or two. Mordecai is astounded, as always, by the Khan’s incredible calmness at such a moment, as evidenced by the telemetered data reaching his implanted sensors. Surely Genghis Mao knows that there is a significant chance of his dying during the operation, but his somatic output registers no apparent awareness of that — as though the Chairman’s spirit is so neatly balanced between love of life and hunger for death that it floats in perfect metabolic equilibrium. At any rate Shadrach is much less relaxed than his employer, perhaps because he regards the risks of a liver transplant operation as distinctly nontrivial and is far from ready to confront the personal uncertainties of a post-Genghis Mao world.

On silent pneumatic treads the gurney bearing the Chairman glides from the imperial bedchamber to the imperial office, thence via the private dining room into Shadrach Mordecai’s office, and — after an eternity of suspicious scanning — through Interface Five into the Surgery. This is a magnificent tetrahedral enclosure extending through the uppermost two stories of the Grand Tower of the Khan and subtending some thirty degrees of arc along the skin of the elongated conical building. A cruciform cluster of chromed fixtures at the room’s summit floods it with brilliant but not glaring light. A platform midway between floor and ceiling juts from the wall opposite the interface, dividing the great room almost in half on its far side, and atop this platform rests the dazzling aseptic transparent bubble within which the actual surgery is performed; beneath the platform that supports the bubble is the surgical stage’s environment-support apparatus: a huge sinister hooded cube of dull green metal, housing what Mordecai imagines to be pumps, filters, heating ducts, reservoirs of sterilizing chemicals, humidifiers, and other equipment. On the other side of the room is a ziggurat of supplementary machinery rising step by step on smooth blue-green benches for some thirty meters — a squat brick-colored power unit at the bottom, an array of metering devices, an autoclave, a laser bank, the anesthesia console, a camera boom and associated playback screens to enable consulting doctors to follow the events inside the bubble, and much other materiel, some of it wholly baffling to Mordecai.

He does not need to understand what functions all this equipment serves. He will perform no actual surgery. His role in the operation is as part of the auxiliary equipment — for, with his capability to monitor, evaluate, and report on the moment-by-moment physiological changes within Genghis Mao’s body, he is a kind of supercomputer, far more supple and perceptive than any medical machine could be. The Chairman’s condition will, of course, be monitored by the usual machinery as well (redundancy is our main avenue . . .) but Shadrach, standing at Warhaftig’s elbow and receiving direct bulletins from the Khan’s interior, will be able to interpret and recommend with an intuitive and deductive wisdom that no machine could attempt. He is neither flattered nor insulted by his function as a supercomputer: it is merely what he is here to do. The gurney waddles onto the operating stage and positions itself next to the table. The table’s own octopuslike, power-driven, glittering steel arms, extending telescopically, embrace Genghis Mao, lift him, and make the transfer; the gurney marches away. Mordecai, Warhaftig, and Warhaftig’s two assistants, all properly scrubbed and gowned, enter the aseptic bubble; it is sealed behind them and will not open again until the operation is over. Now a soft hissing: the atmosphere of the bubble is being withdrawn and replaced by a surgically clean environment.

Genghis Mao, supine but still conscious and in high spirits, darts bright, keen glances everywhere, alertly observing each phase of the preparations. The assistants lay bare the Chairman’s small hard torso — Genghis Mao is light-framed but muscular, with little subcutaneous fat and sparse body hair; the fine scars of innumerable operations crisscross his yellow-bronze skin — and begin the laborious process of connecting the terminals of the monitoring devices. Warhaftig thoughtfully palpates the Khan’s abdomen and adjusts the cutting angle of the surgical laser. The anesthesiologist, whose post is outside the bubble, runs off preliminary acupuncture combinations on his keyboard. “Hook up the perfusion,” Warhaftig mutters absently to Shadrach Mordecai, who is pleased to have something to do.

Since Genghis Mao will be liverless for four to six hours, an artificial liver must be used to sustain him during the operation. But no wholly artificial liver has ever been perfected, not even now, after more than fifty years of organ-transplant technology. The squat cubical device Warhaftig employs is a mechano-organic composite: pipes, tubes, pumps, and electrodialytic filters keep the patient’s blood properly pure, but the basic biochemical functions of the liver, having thus far proven impossible to duplicate mechanically, are performed by the naked liver of a dog, resting in a bath of warm fluid at the core of the apparatus. Mordecai deftly slides two needles into Genghis Mao’s upper arm, one tapping a vein, the other entering an artery. The arterial line seems to encounter some resistance and Shadrach hesitates. The Chairman winks. This is old stuff to him. “Go ahead,” he murmurs. “I’m all right.” Mordecai completes the hookup and nods to an assistant. Shortly the Chairman’s blood is traveling toward the dialyzing coils, perfusing thereafter through the moist red lobes of the canine liver, and returning to the Chairman’s body. Shadrach keeps careful check on Genghis Mao’s telemeter reports: fine, fine, everything fine. “Immunosuppressives,” Warhaftig orders. For several weeks, in anticipation of the operation, Mordecai has been dosing the Khan with antimetabolitic drugs, gradually raising the level in order to damp out Genghis Mao’s normal graft-rejecting immune response. By now the Khan’s antigenic structure has been so weakened that the chance of a graft rejection is slight, but no risks will be run: Genghis Mao receives a last jolt of antimetabolites now, as well as a dose of corticosteroids, and an aide outside the bubble activates a node that will irradiate the blood passing through the liver-surrogate, thus destroying the rejection-inducing lymphocyte corpuscles. Redundancy, redundancy, ever redundancy! The Khan’s heart beats strongly. Everything is at normal throb, Mordecai perceives: blood pressure, pulse, body temperature, peristaltic rhythm, muscle tonus, pupil dilation, muscular reflexes. “Anesthesia,” Warhaftig says.

The anesthesiologist, perched high on the far wall at the keyboard of an instrument more complicated than a concert synthesizer, begins his virtuoso performance. A touch of his sensitive fingertips and the shining retractable claws of the operating table unfold and hover over the Chairman’s body. The anesthesiologist seeks the acupuncture points, maneuvering the claws into place by remote control, probing with little sonic blurts until he finds the precise conduits of neural energy; when he has arranged his metal fingers to his satisfaction, he activates the ultrasonic generators and beams of sonic force rush from the hovering fingers into the Khan’s relaxed, motionless body. No acupuncture needles penetrate Genghis Mao, merely a laminar flow of high-frequency sound entering the acupuncture meridians. Warhaftig, using epidermal electrodes, tests the Khan’s reactions, confers with the anesthesiologist, tests again, asks Mordecai for a reading, runs a deeper test, gets no wince of pain from Genghis Mao. The steel digits of the sonipuncture equipment sparkle in the bright light of the operating chamber; they surround Genghis Mao like the bristly organs of insects, palps or stings or ovipositors. Genghis Mao never permits a general anesthetic to be administered to him — loss of consciousness is too much like death — and Warhaftig dislikes all chemical anesthetics, general or local, so sonipuncture is the method of choice both for doctor and for patient. Fully conscious still, terrifyingly alert, Genghis Mao offers reports on his deepening loss of sensation. At last Warhaftig and the anesthesiologist deem the process complete.

“We begin now,” the surgeon declares.

There is a momentary dip in the illumination as all surgical devices and support systems are activated at once. Mordecai imagines a throb passing through the entire building under the sudden power demand. To the left of the operating table is the perfusion machine, quietly pumping blood from Genghis Mao and forcing it through the dialysis coils. To the right waits the new liver, which has been stored in an iced saline solution since its removal from the donor and now is being bathed by warm fluids bringing it to body temperature. Warhaftig checks his laser bank one last time and, with a quick jab of a long bony finger against the control stud, causes a flash of dazzling purple light to leap forth and cut a thin red incision in Genghis Mao’s abdomen. The Khan remains entirely motionless. The surgeon glances at Shadrach, who says, “All systems placid. Keep going.”

Deftly, Warhaftig slices deeper. As he makes each cut, scanners record the epidermal stratifications down to the cellular level, so that all joins will be perfect when the abdominal cavity is resealed. Bright steel retractors move automatically into place to hold the widening incision. The Khan watches the early phases with deep fascination, but, as his internal organs are laid bare, he turns his head away and stares toward the domed ceiling. Perhaps he finds the sight of his viscera frightening or repellent, Mordecai thinks, but more likely the Chairman is merely bored with them, having been cut open so many times.

Now the dark diseased liver is visible, heavy, spongy, sullen in color. Warhaftig, fingers moving like unerring spindles, clamps the arteries and veins connected to it. With quick daredevil flicks of his laser scalpel he severs the portal vein, the hepatic artery, the inferior vena cava, the ligamentum teres, and the bile duct. “Done,” he murmurs, and Genghis Mao’s third liver is lifted from his abdomen. Away for biopsy; the fourth waits close by, large and plump and healthy, resting within a crystalline jewel-case.

The surgeon and his team commence the most taxing part of the operation. Any pigsticker can make an incision, but only an artist can execute perfect sutures. Warhaftig seals flesh to flesh with a different laser, one that welds rather than cuts. Slowly, showing no sign of fatigue, he connects the closed-off arteries, veins, and bile duct to the new liver. Genghis Mao is limp, almost comatose now, eyes glazed, lips slack: Shadrach Mordecai has seen this response before and understands it well. It is a sign neither of exhaustion nor of shock. It is no more than a kind of yogic exercise by which the Chairman disassociates himself from the boredom of his long ordeal. His vital signs are still high, with a preponderance of alpha rhythms in the cerebral output. Warhaftig toils on. The liver has been installed. The Khan’s pulse rate rises and corrective measures must be taken, but this is to be expected; no cause for alarm. Meticulously Warhaftig rejoins peritoneum and muscular layers and dermis and epidermis, collaborating in this process with the computer that feeds him the stratification data. Every join is flawless. Scar formation will be minimal. Now the abdominal wall is closed. Warhaftig steps back, cool, self-satisfied, and lesser beings take over. The transplant has been accomplished in exactly five hours. Mordecai leans forward to study Genghis Mao’s face. The Chairman sleeps, so it would seem, facial muscles relaxed, eyes quiescent, chest rising and falling evenly; but no, but no, the mere shadow of Shadrach seems to register on the Khan’s consciousness, for his thin lips pull back in a frosty smile; his left eye opens and performs an unmistakable wink. “Well, that’s another one over with,” Genghis Mao says, his voice firm and clear.