Forta shrugged. She helped me sit on the bed, then left the room. In a moment Emerald returned. "You asked for it, sir, you got it," she said.
"Remember Mondy?" I asked.
"That's later."
"But the potential to understand, to nurture, had to exist before," I said. "He was a badly disturbed man, but you helped him. Will help him. Help me now."
"Listen, Worry, you've taken an injury. It's not fatal, and probably not permanent. A few days, and your kidneys will resume their function, and you'll be off the loop. So all you need to do is rest and plan ahead."
She made absolute sense, and I needed that. But I needed more. "Just hold me," I said.
She pushed me gently back to lie on the bed, and she lay beside me, and put her arms around me as well as was feasible, and drew my head in to the hollow of her neck, and there we lay. "You're a good woman," I said.
"You're a good man," she replied.
I drifted back to sleep, and when I woke she remained, sleeping beside me. I lifted my head, feeling better, and gazed at her face. I was tempted to remove the mask, but felt it would be somehow like abusing her. Instead I lowered my head and kissed her lips.
She woke, startled, and I laughed. "Fear not, damsel; I have not deprived you of your virtue," I said.
"You're feeling better," she stated.
"To sleep in the arms of a good woman—that's good medicine."
"So it seems," she agreed.
I felt better all day, but on the following day I began to degrade, as the wastes accumulated in my blood and tissues. I was due for another dialysis treatment, as my kidneys still had not recovered their function.
The doctor arrived with a dialysis nurse. He checked my loop. He shook his head. "Some clotting," he said.
"I see no clot," I said.
He smiled briefly. "You are thinking of external clots, which are hard knots of blood. Internal clots are long strings attaching to the irritation. When they break off and travel through the bloodstream, they can cause trouble elsewhere. That is not something we feel sanguine about." He smiled again, indicating humor. The term sanguine referred to blood; that was the pun.
"Where do they travel?" I inquired, morbidly interested.
"It can be anywhere. Sometimes they can exist for some time without causing harm. But if they snag in the lungs, or the brain—"
"Get rid of the clot," I said.
"We'll use heparin," he said. "That in effect thins down the blood so as to avoid clotting in the machine. It should eliminate the problem. After the treatment we'll neutralize the heparin. There should be no problem, as long as we remain on top of it."
"Stay on top of it," I agreed.
The nurse proceeded to the dialysis. This seemed to be a complicated process in detail, but she knew what she was doing. Soon my blood was coursing through the machine. I felt a little faint, but realized that this was probably psychological; the machine, the nurse assured me, used only a fraction of the amount of blood that the early models did. In any event, it would all be returned to me.
The principle of dialysis, I learned, was to run the blood through filters and osmotic solutions, so that the wastes passed out through the cellophane membrane while nutrients passed in. It was possible to feed a person through dialysis, or to medicate him, in addition to purifying his blood. The machine was not and could not be the equal of the natural kidney function, but the treatments would keep me alive and healthy until my own kidneys recovered.
This time I was conscious during the dialysis. I saw my blood flow through the tube in my arm into the machine, and the return flow to my vein. In the early days, the doctor explained, so much blood had to enter the machine for processing that the patient might lose consciousness or go into shock. But today only a relatively small amount of blood was used, only about a cup, and the treatment was so thorough that in only a few seconds that blood was back in the body, completely restored. The machines had originated as big as bureaus, but this one was only about thirty centimeters long. The blood went in one end and came out the other, refreshed. But the actual time of dialysis could not be cut, because the limitation was that of my body, not the machine. They could not pump the blood through faster than my blood vessels could handle it.
Now the doctor questioned me, trying to ascertain the source of my malady. "The kidneys don't simply shut down out of perversity," he said. "There had to have been poisoning or illness to cause this reaction. Until this point we have been concerned merely with pulling you through, but we don't want to finish without having a clear notion of cause."
I wanted to know the cause too! "I have always been healthy," I said. "The only problems I have ever had have been from injury or torture or poison."
"Those could do it," he said with a small, grim smile. "Injury in the past less likely perhaps, but—torture?"
I explained about my session as a prisoner of my political opponent, just before I became Tyrant. I had been made to feel pain by a nerve stimulator, and had been memory-washed.
The doctor shook his head. "I think not, in that case. But what of poison?"
"Food contamination, actually," I said. "Enemies in Saturn managed to feed me contaminated yeast. I suffered some liver and kidney damage—" I broke off, realizing what I had said.
The doctor nodded. He questioned me closely about the episode. "That would seem to account for it," he concluded. "I'm surprised they didn't require you to come in for regular examinations, to forestall this very occurrence."
"But that was over three years ago!" I said, not wanting to admit that they had required that, but that I had disobeyed. "I recovered, and have had no trouble since."
"I fear this is bad news," the doctor said. "I had assumed that this was a case of acute nephritis, but it may be chronic."
"Acute what?"
"Each of your kidneys has on the order of one million tiny units, called nephrons, that process the blood in parallel. There is more than one type of nephron, but for our purpose we may assume they are all identical. Each does a complete job of cleaning the blood it handles; this is no assembly line. Essentially, the nephron filters out the solids and processes the fluids of the blood, where the wastes are. It recovers from that fluid all the useful ingredients, and allows the rest to pass on out of the system: the urine. What affects one nephron is likely to affect them all, and when the nephron shuts down, your body has no way to eliminate its waste products. So blood urea nitrogen builds up—we call it BUN—and—"
"I understand," I said, not caring to get that technical. "So when there is trouble with the nephron, that's nephritis."
"Correct," he said. "And I am a nephrologist, a doctor specializing in these matters."
"But why is an acute case to be preferred over a chronic case? Is it milder?"
"No, the opposite is apt to be the case. Acute nephritis can take you out in days, if untreated, while you can go for years without even being aware of chronic nephritis. The acute condition can occur as the result of some temporary insult to the tissue, such as poisoning; once the poison clears, the nephrons recover, and you have no further trouble. This may have happened when you suffered the food poisoning. But sometimes the damage is limited, and the shutdown is only partial, or only a percentage of the nephrons are affected. Since the body has an enormous overcapacity, you can lose as much as ninety percent of your nephrons, and suffer no ill effects; the remaining ten percent do the whole job. But beyond that, it can get awkward. At five percent capacity, you do feel it, and below that—"
"You mean, an acute case could have knocked out ninety-five percent for a week, but a chronic case may have been working up to it for three years, and I only felt it when the critical level of damage was reached?"
"Exactly. Now, this is not a diagnosis. We shall have to do a biopsy for that. But I believe we should not delay on that."
"A biopsy?"
"We take a sample of the kidney tissue and analyze it in the laboratory. Then we can tell the state of
the nephrons."
"Better do it," I agreed. "But if this is chronic instead of acute, does it mean there's no cure?"
"It means we'll have to schedule you for transplant," he said. "Your kidneys are marvels of accommodation, but once they're gone, they're gone. Fortunately, modern immunosuppressive techniques make kidney transplant feasible in the vast majority of cases. Thanks to your support, Tyrant, we have a fully competent transplant facility here on Triton. We shall have you functioning normally again, never fear."
I glanced across at Spirit, who had remained mute throughout. It was possible that we knew something the doctor didn't.
The nurse concluded the dialysis. Thanks to my discussion with the doctor, the hours had passed without notice. They cleaned up the equipment and put it away, and restored my loop to its normal loop configuration, and gave me the neutralizer to the heparin employed to prevent clotting during treatment. Smilo came up, and I stroked his massive head. "Don't chew on that loop," I cautioned him. I had been afraid at one point that the odor of blood would unhinge his equilibrium, but he was a well-fed tiger, and he knew the smell of my blood and would not attack me. Henceforth he would not be sedated during my treatments.
But some hours later I got up to get something to eat—my diet was temporarily severely restricted, to prevent avoidable accumulation of wastes or fluid—and passed out without warning. The next thing I knew, the doctor was back. Evidently he had done something to restore me. "What happened?" I asked.
"Heparin rebound," he said curtly.
"Say in layman's terms?"
"We give you heparin to prevent clotting," he explained. "But the blood's ability to clot is an important survival feature; without it you would be hemophiliac, and could suffer internal bleeding. So after the treatment we neutralize the heparin. Unfortunately, sometimes the neutralizer wears off before the heparin is out of the system, so the heparin rebounds when it isn't wanted. Evidently my error; every human body is unique to itself, and I misjudged your tolerances. I shall see that it doesn't happen again."
He was a competent and honest man, and very good with explanations. I had confidence in him. Evidently I had rated the best.
In due course they did the biopsy and confirmed the diagnosis: chronic nephritis. "Actually, glomerulonephritis," the doctor said. "The glomerulus is the filter at the beginning of the nephron. Your own immune system did you in."
"How's that?" I asked, alarmed.
"Your food poisoning evidently had an infective component," he said. "That is, it came across like a disease, and your immune system fought it. You seem to have an extraordinarily effective immune system. I researched the Saturn records on your prior episode, and discovered that this particular strain was unusually harmful, and you received a double dose. You could have died; some did, from the single dose. But you recovered remarkably. Unfortunately, in some cases the body's immune system mistakes some of its own tissue for that of the harmful intrusion, and the glomerulus is especially subject to such error. So your system made antibodies against your own glomeruli, and systematically took them out. Now that process is virtually complete. Had your immune system been less vigilant—"
"I have a good immune system," I agreed glumly. "It can throw off any drug."
"Well, that is not precisely the way it operates—"
"It's the way mine works," I said. "I cannot be addicted. It helped me throw off the mem-wash rapidly enough to save my political career, too."
He did not debate the issue, but I could see he did not believe this. He departed.
"This is going to interfere with a transplant, too," Spirit said. "No way your system will tolerate a foreign kidney."
I nodded glumly. "Maybe the doctor will have an answer."
The doctor did. "Immunosuppressive therapy," he said. "Standard procedure for transplantation. We go for the closest possible tissue match, then damp down the immune response."
"Better test it first," I warned.
"Naturally."
He tested it—and my body threw off the immune suppressive drug. This didn't occur immediately, but the doctor was monitoring my response closely, and very soon realized what was happening. In addition, my body had built up an immunity to the heparin, and clotting was a problem again. They had to change to a different anticoagulant, and establish a loop on a new site. "I have never encountered this before," the doctor admitted, intrigued.
It was evident that the transplant the doctor had planned on would not be feasible; my immune response could not be permanently suppressed, other than by heroic measures that we agreed were not warranted. "But we can use a synthetic kidney. That's one grown from neutral tissue in the laboratory, that does not excite the immune response. Unfortunately, it is relatively bulky and clumsy, being three times the size of a normal one. But it will do the job."
"All the same, better test me for reaction to it," I said.
He did—and my body rejected it. "This is unique in the annals of medicine!" the doctor exclaimed, almost with admiration. "Your body really can reject inanimate substances!"
I was not as thrilled with this confirmation as he seemed to be. "No synthetic kidney, then."
He sobered. "I'm afraid not. However, dialysis is not merely a short-term expedient. We can set you up for CAPD—"
"For what?"
"CAPD. Continuous ambulatory peritoneal dialysis. That employs your own peritoneal membrane, so there is no problem of rejection. The fluid is put into your abdomen, and the blood filters through—"
"And my membrane would heal to cut off what it took to be leakage," I said grimly. "Can you test for that?"
He ran his tests, and confirmed my suspicion. "This is truly amazing," he said, evidently thinking of the case history he would write on this that would make him famous. "Your body renders itself impervious to modification by such means."
"This has been quite useful in the past," I said. "But it is losing its appeal."
"Still," he said with a certain artificial cheer, "regular dialysis can be rendered almost as convenient. We can set up an AV shunt—"
"A what?"
"An arteriovenous shunt. That is, a direct connection between an artery and a vein, using no plastic loop, so there is no clotting problem. This can be tapped into for each dialysis."
"May not work," I warned him.
He tried it, and it did work—for a couple of dialyses. Then the clotting got bad, and when the surgeon checked into it, he discovered that my blood vessels were healing, and the shunt was in the process of being cut out and the normal separate artery and vein bloodflow restored. My body would not tolerate the foreign meddling.
Thus we were reduced to the loop, which even with the anticoagulants was only good for as few as three dialysis sessions before the clotting became too awkward. The clotting was because my body was laboring to heal itself, but it was dangerous, just as my immune system's attack on my own kidneys had been dangerous to my long-term health. My system was too independent for its own good.
"How long can this continue?" I asked the doctor.
"We are much more efficient at developing sites for dialysis," he said with assumed cheer. "It is unfortunate that we can not reuse a site once we have finished with it; the scar tissue and the threat of clotting prevent that. But we do far less damage than was done when this technique was new. I'd say you can continue for a decade or more, by which time there could be a breakthrough that would extend it further."
"But my illness must not be known," I said. "How long can it continue without showing?"
"You mean, on your arms? You want them free of scar tissue? And your neck? That cuts it in half, approximately."
Half. Five years. I was sixty-four years old now; that set my limit at sixty-nine. Somehow I had thought I would live forever; now it was clear that this had been overly optimistic.
"I'll need to travel," I said. "Can I be dialyzed elsewhere in the System?"
"Why, certainly," he agreed heartily. "There are dialysis
clinics on every planet."
"Without outsiders knowing?"
"That I can't say. Each planet has its own regulations."
"Can I hire your nurse to go with me, so it can be done privately?"
He smiled. "Tyrant, you don't need to go to such an extreme. We can train you for home dialysis. Designate someone on your staff, and—"
"I'll do it," Forta said immediately. "I have had some experience with field medicine; I'm sure I can handle this."
"It is not hard to learn," the doctor said. "The process has been greatly simplified since the early days. But it requires serious commitment, because one mistake can be like forgetting to seal your suit before stepping outside the dome."
"She can handle it," I said. I knew Spirit would be willing to do it, but Spirit was busy running the show; it was better to leave her free for that.
So Forta trained for dialysis, and in due course she handled the job, three times a week. She learned rapidly and well; her only bad moment in training was when the nurse slipped some dye into the works, and it looked as if the dialysis machine were leaking blood. This might seem like a cruel prank. It was cruel, but a necessary part of the training. Forta took one appalled look at the leak and launched me into the bypass mode so that my blood no longer coursed through the machine. Then, saying nothing to me, she opened the machine to check the tubing. All was in order. Unwilling to accept that, she inspected every aspect of the process closely, and finally located the source of the "leak": the vial of dye. She made a kind of growl in her throat that set Smilo's ears perking, and fished out the vial. She resumed the dialysis, and when the nurse made a "routine" check Forta acted as if nothing had happened. This might have been a mistake, because if a genuine leak went unnoticed, disaster could follow. But when the nurse discovered that the vial was gone, she knew, and Forta passed. I had been tuning in to a program on a holo, and hadn't even realized that anything had happened; I picked this up later. We learned that this was a regular part of such training. Suppose a real leak developed when there was no professional nurse available to set it right? The home dialyzer had to be competent, and to keep her head in the crisis.