
THE 11th PLAGUE
By Jo-Ann Klainer & Albert S. Klainer, MD
[Originally published under the pseudonym L.T. Peters]
AUTHORS' NOTE
The 11th Plague was published in hardcover in 1973 by Simon and Schuster, Inc. under L. T. Peters (a pseudonym for the writing team of Jo-Ann Klainer and Albert S. Klainer, MD). The novel received an outstanding review by the New York Times at the time of publication and went on to be published in the UK by Secker and Warburg Ltd. It was subsequently published in paperback in the UK by Mayflower Books Ltd. and in the US by Pinnacle Books under the authors' given names.
The 11th Plague is being reissued by the authors because of its relevance in today's international terrorist environment. The question we must ask is: Can we stop the 11th plague from occurring today?
Copyright © 1973 by L.T. Peters
Cover illustration: Staphylococcus aureus, untreated cells. (scanning electronmicroscope image X 10,000 magnification) J Infect Dis 121:339-343 [1970]: KLAINER, AS, et al
The views and opinions expressed in this novel are those of the authors and do not necessarily reflect those of the medical profession, the military, or the government.
To Peter, Lori, and Traci
That their tomorrows shall be free from the diseases mankind creates today.
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seventeen
eighteen
nineteen
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epilogue
And the Lord said unto Moses,
Yet one plague more will I bring
upon Pharaoh, and upon Egypt;
... And there shall be a great cry
throughout all the land of Egypt,
such as there has never been,
nor ever shall be again.
Exodus 11:1, 6
He was dead.
No one was there to watch him die or to hear his final gasp for breath. No one paused to wipe away the foamy trickle of bluish blood that oozed form the corner of his mouth. No hands reached out to close the lids or cover the cold blue face.
Who he was or where he died made little difference. All that really mattered was that he had died. All his life he had wanted to be first---just once. And now he'd reached his goal---he was the first to die.
And with his death, the end began.
For Clark Brubaker, it began with a signal from the small pager in the breast pocket of his short white coat.
"Dr. Brubaker, call the Emergency Room, stat!"
Clark Brubaker was a second-year resident in Medicine, on rotation in the Emergency Room.
Sunday night at the University Hospital ER was always wild, but that rarely bothered Brubaker. He had little to do with the various traumas that characterized the patients who walked, limped or were carried through the mechanically operated swinging doors. The gunshot wounds, the stabbings, the broken bones and the lacerations all were referred to his surgical counterparts.
At 7 p.m. he had admitted a hippie with hepatitis to the Infectious Disease Service; at 10:30 p.m., an elderly woman to the Cardiology Service because of worsening congestive heart failure. The remainder of the evening had been spent dictating discharge summaries, reading the Annals of Internal Medicine, and drinking coffee in the cafeteria. At about 11:30, he had checked the patients in the Medical Intensive Care Unit.
He received the page as he was heading toward his on-call room.
The man was forty-two. He was unconscious. He was breathing rapidly and obviously working hard to do so. His skin was hot and dry and in keeping with the rectal temperature of 106˚ scrawled across the top of the ER sheet on the clipboard by his bedside. He was cyanotic, a bluish color imparted to the skin by the presence of blood without sufficient oxygen in the superficial blood vessels. His nail beds were blue, and the foamy trickle of blood that oozed from the corner of his mouth was bluer than it should have been.
Brubaker lifted the sheet and quickly surveyed the naked form. At first glance, he saw nothing. And then suddenly there they were. Tiny, flame-shaped hemorrhages were appearing over the man's upper chest. He watched as one crop and then another came into view.
Brubaker continued his examination, but he worked more rapidly now. He took his stethoscope out of his pocket and, as he had done hundreds of times before, placed the flat surface over the upper chest and listened. Nothing!
He tapped the head of the stethoscope with his finger. The static told him that the instrument was functioning properly, but no matter how he adjusted the black plastic ends in his ears, he could hear no air moving in and out of the man's chest. He moved the stethoscope from one area to the next. Nothing! Yet the man was still breathing.
He listened over the heart. The distant sounds resembled the ticking of a watch but occurred at the rate of 180 times per minute. Too fast---more than twice the normal rate.
To Brubaker, it seemed simple. The rapid rate did not allow the heart to fill sufficiently with blood between beats. The heart muscle itself, the myocardium, was not getting enough blood to provide it with the oxygen it needed to work.
"Get me an electrocardiogram and a chest film, stat!" He nodded impatiently to a middle-aged man standing in the doorway. The orderly turned slowly to leave.
"Get the lead out, this guy's dying. And get me a nurse."
The rest of the physical examination revealed no other obvious abnormalities. Now he had to put the pieces together. The fever and the abnormal chest findings were consistent with overwhelming pneumonia. The hemorrhages in the skin were indications of bacteria in the bloodstream; their rapid appearance usually meant overwhelming, often fatal, infection.
His thoughts were interrupted by a voice behind him.
"Need something, Clark?"
Clark Brubaker liked Mrs. McGinnis. She was old and somewhat bossy, but when you were in trouble in the Emergency Room, she could be worth her weight in gold. If only she'd learn not to call doctors by their first names! he thought, forcing a smile as he turned to answer her.
"Yes, Mother." It was his way of getting back at her. "Some digitalis."
"Think you should be wearing a mask and gown?"
"What do you think he's got? Bubonic plague? Listen, I'm too tired and you're too mean for the bugs to bite us. Besides, when I ask for medication to treat heart failure, I don't expect a lesson in isolation procedures." He scolded her with a smile.
"Whatever he's got, it looks like it's going to kill him."
"Were you able to get any sputum when he came in?"
"No, he was dry as a bone. No cough. Just that blood at the corner of his mouth. I sent it to the bacteriology lab. I'll check to see if his admission lab work has been done and if x-ray is on its way. And I'll bring you a million units of penicillin."
"Thanks." He gave her a boyish grin. "Don't get arrested for practicing without a license."
He stared at the view box on the wall beside the bed. There was no air, not one piece of lung with air in it. The man couldn't be getting any oxygen at all.
Brubaker glanced from the film to the colored laboratory slips in his hand.
White blood count, 42,000. It was markedly elevated above the normal range of 5,000 to 10,000. At least his white blood cells were responding to the infection.
The next slip had a note penciled across the top. "Blood hemolyzed. Suggest repeat sample." Hemolysis meant that something was destroying the man's red blood cells too rapidly and in an abnormal manner. He read on. Hemoglobin, 6.1 grams. Not only did the man lack oxygen, but he didn't have enough red blood cells to carry the little that he was getting.
Brubaker wondered if the lab technician had hemolyzed the blood and decided to draw a sample himself. Quickly he wrote out a list of tests he wanted and reached for a syringe.
He looked at the skin again. It was now almost entirely covered with the tiny, flame-shaped hemorrhages; some were coalescing to form irregular blood spots on the skin. More blood was oozing from the corner of the mouth. Still too blue.
Without a wasted motion, he moved behind the man's head, grasped his jaws, and deftly inserted a curved rubber endotracheal tube through the left nostril and into the trachea, the main windpipe. When the position of the tube had been secured, he threaded a soft rubber catheter into it. With the help of the built-in wall vacuum system, he was able to suck out a large amount of bluish, clotted blood mixed with thick, odorless yellow pus. He set aside a specimen to be sent to the bacteriology laboratory.
Within seconds, the endotracheal tube was attached to the mechanical respirator, the proper mixture of moist air and oxygen estimated, and the adjustments made.
This guy must have been sick for days before coming in, thought Brubaker. He reached for the clipboard to see if the admitting nurse had noted when his symptoms had started.
"42 y.o. male entirely well until one hr. ago...."
He had been working on the man for forty-five minutes. Now the respiration was mechanically controlled, and Brubaker himself was suctioning the windpipe every two to three minutes. But despite the administration of antibiotics, digitalis, and oxygen, the patient continued to die. Rapidly.
Brubaker sat on the metal stool beside the bed to think. Pneumonia was suffocating the man. Even the respirator could not provide him with enough air to supply his tissues adequately with oxygen. He needed blood, lasix and hydrocortisone. Brubaker started to call the nurse but was interrupted by the silence in the room, now disturbed only by the clicking and blowing sounds of the respirator.
He didn't have to turn off the respirator to know the man was dead. Instinctively he placed his fingers on the patient's wrist to verify the absence of a pulse. There was no blood pressure, no spontaneous movement. In one hour and forty-five minutes, forty-two years of life had been abruptly ended.
Brubaker was still. He didn't try external cardiac massage or any of the other heroics that could sometimes bring the dead back. Somehow he knew that there was no life to be salvaged.
Brubaker turned off the respirator and stood motionless, still clasping the man's wrist. Death did not usually affect him this way, but tonight he felt totally alone.
The footsteps startled him.
"Here put this on."
Mrs. McGinnis handed him a neatly folded surgical gown, a semi-rigid turquoise mask, and a light-green cap. She wore the same. Her hand had lost its sureness and trembled slightly. Her skin seemed paler than before. Above the mask, her eyes radiated fear.
Brubaker tried to regain his composure. "Where are you going---to a masked ball? Since when have we required formal dress to treat pneumonia?"
"Dr. Brubaker." It was the first time in two years she had called him that. "There are three more cases. I ordered x-rays on each. They're up on the view boxes beside each bed. They all look the same---like this." She nodded toward the still form. "And a four-year-old boy was just brought into Pediatrics; he was dead." Her voice shook. "Overwhelming pneumonia."
Brubaker stared at her. McGinnis had seen death before. The night of the plane crash she'd taken over like a general.
"Come on," he said. "Two or three cases of pneumonia coming into an Emergency Room at once isn't so unusual. I once admitted six cases of meningitis in an hour."
The fear in her eyes remained. Without further comment, he started to put on the mask and gown. He tried to think of something else to say to cut the gloom but couldn't find the words.
The nurse walked behind him and tied the gown, grasping it at the top and bottom to be sure it covered his back. She took a sponge moistened with disinfectant and carefully cleansed his stethoscope while he uneasily watched her every move.
The silence ended abruptly as an intern rushed into the room.
"They're dead. The three of them are dead. What the hell is going on?" The intern didn't look frightened. He seemed angry at the idea that three people should just have come in and died without his approval. "And to top it off, one more was just carried in; and the police ambulance is bringing in somebody with fever and a rash. Do we have a special sale on tonight?"
Brubaker brushed him aside and walked to the main desk. Who were all these people? Where did they come from? Had they all been exposed to the same thing?
By the time he had read the admission data on each and come to the conclusion that there was no connection between any of them---at least none he could see---six more persons with the same acute illness had been admitted. Same rash, same fever, same pneumonia. Four had died.
It was 2 a.m. There had been twelve admissions and nine deaths in two hours. The twelve patients had nothing in common except the disease. Something was very wrong.
Brubaker felt hot; his head ached; and he was suddenly overwhelmingly tired. He reached for the phone.
"Operator, get me Dr. Cullen. ... Yes, that's right, the Chief Medical Resident. And also, would you give me the number of Dr. Richards, the Infectious Disease Fellow, in case I need it."
As he waited for the ring, an orderly handed him a note from the bacteriology lab.
"Staphylococci. Should have known it." Brubaker frowned. "Probably one of the few bugs that could kill so quickly. But why so many? Where did all these people suddenly get staph pneumonia?"
Suddenly Brubaker swayed. When the phone rang, he didn't hear it. His eyes would not focus. He pulled at the surgical mask to try to get more air. He coughed painfully. With the second spasmodic cough, there was the sweet taste of blood in the back of his throat.
Clark Brubaker's fear was short-lived. The comfort of coma came quickly.
Mrs. McGinnis held his cold hand, covered now with tiny hemorrhages, to her breast. The tears rolled over the top of her mask. She watched Clark Brubaker struggle for breath. She saw the boyish face grow suddenly old and still.
Doomsday was three hours old.
"It is done."
Ahmed Machdi put the receiver down. He stared at the phone, watching it go in and out of focus as the tears swelled to the point of flowing and then receded. His hand still clutched the receiver.
"Funny," he thought. "The telephone rings, you pick it up, and a small voice far away tells you it's time to die. The phone clicks, the voice is gone, and you are left alone to take inventory of your life."
Ahmed Mahdi was sixty-four years old. For forty years he had been his country's most prominent figure in the world of microbiology. When he was elected to the Royal Society for Microbiology, his presentation concerning the metabolism of bacteria in oxygen-free environments was characterized as the "most significant contribution made by a scientist of the Arab world" and had been proposed for the Pasteur Medal, but that was the year Max Schwartz received the coveted award for his work on streptococci.
Machdi was a product of the London school. Bachelor's degree from Oxford at age twenty-one. Doctorate in Bacteriology from the London School of Tropical Medicine and Hygiene at twenty-four. At twenty-eight, he was Chief of Microbiology for his country's Ministry of Defense.
Quietly, without fanfare, with no more recognition than the one hundred fourteen publications which bore his name, he worked and watched lesser men pass him by. But he had remained content, because he knew little and cared little about the world outside his laboratory.
Although, literally speaking, it was the property of the Ministry of Defense, his laboratory was the only space on the vast face of the earth that Ahmed Machdi felt belonged to him. In the cool shadows of evening, when everyone else had left, he could close the doors, and, even if only for a short while, play the role of master.
His kingdom was neither large nor ostentatious. The paint was cracking on the walls and peeling from the ceilings. The broad, rusting blades of the fans that hung from the ceilings turned slowly, casting flickering shadows wherever there was light. The fans were merely a symbol of the past; when the laboratory had been air-conditioned, he had refused to allow them to be removed---they were his constant reminder of the days when his world was simple and uncomplicated.
In 1947, his country began preparation for war against its eternal enemy. Failures and disappointments in the war of 1948 caused many changes in the government and elsewhere. Machdi's research budget was cut by 30 per cent in 1949. By 1962 funds were available for only his salary, that of a part-time technician, and a few supplies. However, he managed to continue his research and still refused to be led or misled by the political upheaval around him---until 1964, when the prostitution of his soul began.
He remembered it well.
He sat and listened to the two men. The room was in the Ministry of Defense, but he had not been in it before. The office of the Minister of National Defense and Security was large and roomy, about twice as large as the entire microbiology laboratory three floors below. Machdi felt as if he were suspended in space---in the middle of a large glass cube. The conversation did not help to ease the illusion.
The president was smooth and condescending. "Dr. Machdi, how can we exist today without a program?"
The Minister was direct and impatient. "The Ministry of Defense, Dr. Machdi, does not employ a Microbiology Division to count the germs in our men's rooms. We must join the twentieth century---become a military power that commands respect. Guns and tanks and infantry are no longer sufficient. We need something more. A nuclear weapon is for the moment beyond our means. In comparison, a biological warfare program is a more realistic consideration.
Machdi tried to choose his words carefully. "Gentlemen, all my life I have been a scientist. My contribution has been small, but it has been an honest effort which has brought some good to mankind and some recognition to our country and the rest of the Arab world in the field of microbiology."
The minister interrupted him. "That is just the point. We know you have the talent. You are the man who can give us what we must have---a weapon we can use against our enemies as both a threat and a deterrent."
"I was not aware that you were a proponent of the use of science for destruction." Machdi fumbled for the words. "Much of science was founded here centuries ago. Must we destroy our heritage to destroy our enemies?"
"If our neighbors swallow us up, who will remember that we gave birth to science? Who will give a damn about our heritage? Whether our forefathers can sleep with their consciences and whether you can live with yours doesn't concern me. Do you think that the biological warfare programs in the United States, in England, or across the Canal are run by men of science who have less conscience than you? Of course not! But they know that the most important thing is winning." His voice became softer. "Believe it or not, it doesn't really matter how."
Though no great patriot, Ahmed Machdi loved his country. He was too old to fight. He could not judge whether the Minister's words were partial truths. He still knew very little about what was happening in the world outside his laboratory, but he knew they would have their way. With him---or with his replacement. He wanted to save himself, to salvage his work, to insure his security for the few years remaining. He knew he could not refuse. He would find a way to compromise---with the Minister, with himself, and with science.
Machdi looked at the President. "Do you agree, Mr. President?"
The President did not look at Machdi. He did not speak. He merely nodded.
"So be it, then." Machdi rose to leave. "If you want a biological warfare program, you shall have one. If we ever use it..."---he paused---"may the world forgive us---if it survives!"
At first it was easy.
He had more funds than he could use. He continued the research he was working on and merely added quarterly and annual reports to the Minister. The "biological warfare program" consisted of keeping duplicate records of certain experiments. After all, bacteria were bacteria---whatever their intended purpose. It all depended on how you looked at them. To Ahmed Machdi, an experiment in bacterial metabolism was just that, and no more; to the Minister and others like him, it might well be an exercise in weaponry. All it took was a change in a word, a phrase, or a sentence; the copy then could be marked "Top Secret" and sent to the Minister.
In truth, the papers sent to the Minister were no more secret than the published papers that reported their contents. Each part in itself deemed to be of scientific value was published in one of a variety of widely read journals. Only a jaundiced eye could recognize them for what they might be; only an adversary would think of putting the parts together.
As a year passed, and then two, Machdi became concerned. Rejuvenated by the renewed availability of money, his research flourished. But his fear grew that funds might be cut or even stopped if he did not produce something more for the Minister, and so he justified his work by manipulating the emphasis of the material contained in his reports. The Minister was interested in a weapon, not a Nobel Prize. Machdi wrote for him the words he wanted to read by learning the language and science of biological warfare. Without really trying, he gained expertise in what characterized a good biological weapon and about methods of delivery, camouflage and detection. He read about the effects of climate, population density, naturally acquired and artificially induced immunity, portals of entry, and contagion.
Some agents, he knew, were sublethal and meant to induce an illness that was self-limited or easily treatable; these could be used to incapacitate a foe for a period of time defined by the agent and by the host. Their use was difficult, because strict control was a prerequisite for success; a change in virulence could make a weapon lethal for the attacker as well as the victim.
Other agents were meant to kill---to kill small or large numbers of persons, animals or plants. These were somewhat simpler to use and control; being a little dead was just as good as being a lot dead. There were still limiting factors in their use. A good weapon killed only one's enemies, not one's friends. The duration of effect had to be flexible and finite---an island contaminated for a hundred years by the anthrax bacillus was of no value.
In general, conscience and peace of mind were not a problem to Machdi. The rationalization that mankind would never become sufficiently insane to unleash disease as a weapon of war satisfied him. He gained additional comfort form his knowledge that the Minister could, with the entire contents of his laboratory, only induce in the recipient a little nausea, vomiting and diarrhea.
Like most discoveries in science, Machdi's discovery of the weapon was unplanned---a mistake; unlike some mistakes, however, it was at once recognized.
Machdi's key to the study of bacterial metabolism lay in his ability to induce mutants---microorganisms that were different in some way from their parents. Mutations could be induced by a variety of methods, including radiation, antibiotics, or alteration of growth conditions to favor some characteristics and eliminate others. Machdi's talent was his ability to alter his test organisms to answer the question each of his experiments was designed to ask.
He was working on a series of experiments on rapid adaptation for survival, with specific interest in how bacteria reacted when exposed to antibacterial drugs. He knew, for example, that some bacteria exposed to penicillin produced a substance, penicillinase, which cleaved the penicillin molecule at a specific site, thus rendering it ineffective. In other words these organisms could survive by inactivating the drug. He hypothesized that there must be many other ways by which bacteria could adapt to adverse conditions. If he could discover how a single cell adapted to change, perhaps the information obtained could be extrapolated to multicellular organisms---even to man. If so, the key to evolution would be his.
He spent months developing the mutant for this purpose. The first several experiments were so successful that Machdi was skeptical and paused to reevaluate his data. It was natural that he should check the test organism first. As each of its characteristics was tabulated, Machdi's concern grew. When he looked at the sum total of his labors, he realized that in this very same mutant that might provide the key to evolution lay the potential to destroy with disease. He had unwittingly developed what he had so meticulously tried to avoid---a weapon. The mutant reproduced itself once every fifteen to twenty minutes under the proper experimental conditions. Its potential was terrifying.
In his fear, Machdi checked again. He had made no error. Had he spent forty years with no purpose other than to produce the perfect biological weapon, Machdi could not have surpassed what he had done in these few months.
Death in cotton-plugged test tubes lay in a rack before him. Only he could decide.
\*
For hours he sat in the same old wooden swivel chair with its worn straw cushion. What had been home and retreat for so many years was now the place he must test conscience. He failed his.
At this stage in his life, Ahmed Machdi feared oblivion more than death itself. As a philosophical friend had once said to him: "The dying man fears he will be forgotten more than he fears death. He reaches from the grave not to grasp at life but to try to scratch his name on the scrolls of time before the lid of his coffin closes and erases him forever."
Machdi's work was his legacy. The key to biologic adaptation---perhaps to evolution itself---could be his gift to mankind.
The mutant organism he had created was a necessary part of his plan. There might not be time to tailor another. To destroy it was to devaluate his existence and bankrupt his memory.
The Minister need not know. Time would solve this problem. Soon, Machdi felt, there would be no need for biological warfare programs. Several of the major powers were discussing termination of their programs. The Minister, he thought, would have no choice but to follow suit. Then he could return to his work. The mutant, preserved and hidden, would then be utilized for the purpose he had intended.
He carefully standardized his cultures and lyophilized them---they were frozen, dried, and sealed in sterile glass ampules. Bacteria in the numbers needed for each future experiment would be instantly available merely by reconstituting the contents of a vial with sterile nutrient broth. The ampules were stored at -70˚ C for preservation and safekeeping in a place he believed known only to himself. The records of the mutant's birth, the tabulation of its characteristics, and his personal notes were carefully hidden in his safe. Among the contents of the safe also were the data from his last experiment---before he realized the dangerous potential of his finding. In it, Machdi had tested the sensitivity of these bacteria to a wide variety of antibacterial compounds. That the organism was resistant to all individually and sensitive only to a single combination of antibiotics rarely used in man had convinced Machdi of its lethality.
Conversion of the biological warfare laboratories in the United States to centers for cancer research in 1971 endowed his mutant with even greater potential, as did England's renunciation of "all programs dealing with the production of weapons for biological or chemical warfare" in 1972. The status quo had been altered. Biological weapons had not been used because all the major powers had equal capability for this type of destruction, and each feared retaliation in kind. Now there was no longer a standoff. But as the psychoses of war were replaced by the neuroses of the conference table, Machdi felt more secure. He settled comfortably once more into the world he loved best---the world of science with its challenging goal of uncovering new knowledge.
Then, at last, came the honor that had eluded him for so long---the Pasteur Medal, awarded him for his "pioneer research into the development of artificially induced bacterial mutants." The medal was to be awarded at the annual meeting of the International Society for Microbiology, meeting this year at the Royal French Academy of Sciences in Paris.
Despite the magnitude of the honor, he at first refused to go to the meeting; he had not been away from his laboratory since he had returned from school in London as a young man. The recognition of winning was sufficient for him; to be present personally to receive the medal would not enhance the honor.
He informed the Minister of his decision.
The Minister laughed. "I do not understand you, Machdi. Here you are awarded one of the most prestigious medals in your field, and you want to stay home."
"I will accept in absentia. It's all the same."
"No, it's not the same, Machdi. Go and receive your honor---in person. I want you to go. I insist." He paused and sat back in his chair, seemingly examining his hands as he placed the fingertips of one against those of the other. "Besides, it will be good for the country. We can use some favorable publicity now." He sat up suddenly and pressed the first button of the intercom on the credenza behind him. "Raoul, come in, please."
He turned toward Machdi. "My secretary will make all of your travel arrangements."
Machdi started to protest, and then thought better of it. As always, the Minister would have his way. It was settled---he would go.
Ahmed Machdi was tired. The trip had been exciting and satisfying, but he was glad to be home. He removed the medal from its walnut stand on the corner of his desk and turned it slowly between his fingers. All those years for such a tiny piece of gold. But he read his name engraved on the back for the hundredth time with undiminished satisfaction.
Absorbed in his thoughts, he did not hear the door of the laboratory open nor the footsteps behind him. He replaced the medal and turned back toward his laboratory bench. The dark shadow of a man and the cold, black muzzle of a machine pistol barred his way.
"Dr. Machdi?"
Ahmed Machdi felt no sensation but fear. He grasped the sides of the seat and braced his feet as the jeep swayed from side to side through the soft sand. He turned to look back at the fading lights of the city. The scene grew smaller as the jeep sped from it. He watched until the dust obscured it from his view, and then he turned to look ahead at the setting sun.
At first, surprise and fear had precluded rational thought; but now he had time to think, and the stinging pain of the desert sand driving against his cheeks stimulated his mind. He knew his captors, and the knowledge terrified him. To a logical man like Machdi, the guerrillas were the antithesis of all he believed in. But until this moment they had belonged to another world. Suddenly all of this had changed.
The word "Terror" was written in bold red Arabic letters across a white sheet behind the desk. The flickering light from an oil lamp on a small wooden table in the corner of the room cast the shadow of the man across the makeshift banner.
Ahmed Machdi studied the man in the oppressive silence that now enveloped them. There was no uniform---he had always thought all terrorists wore olive drab fatigues and were laden with grenades and bullets. This man was clean-shaven and neatly groomed; he wore an impeccable white linen suit with a red orchid in the lapel and a red silk handkerchief in his breast pocket. His features were smooth and clean, and his dark skin enhanced the bright teeth now visible as he began to smile.
"Welcome, Dr. Machdi," he said. "I am Josef Kassim. My hearty congratulations upon your receipt of the Pasteur Medal. It is no small honor---one the Arab world can be proud of. It is a distinct privilege for me to meet such a distinguished scientist." He paused and clapped his hands. "We shall have food and wine as we talk. You must be hungry after your long journey."
Machdi refused both when they were set on a small table before him. His host talked as he ate.
"Relax, my friend. We will not harm you." He saw Machdi glance at the banner behind him and smiled. "That is for our enemies; you are a friend."
"I do not know you or your friends, nor do I wish to be classified as such." Machdi was surprised at his courage. "I simply wish to return to my home, my laboratory and my work."
"And you shall. You shall. As soon as we have finished our little talk. But do have something to eat." He paused and smiled. "Ah, I understand. Do not worry. This is not the last meal of the condemned man. Please eat."
Machdi started to shake his head. Suddenly he realized how parched his mouth was from the ride through the desert. "Perhaps a little wine."
"Good." Kassim continued to eat. Finally he pushed back his chair, wiped his mouth with the red handkerchief, and lit a cigarette.
"You are a peaceful man, Dr. Machdi. You have said as much yourself. The fact that your country seeks peace at the price of honor does not disturb you. But peace for us will come only when we have what we want. And we must take it now---now when the enemy least expects it. We have convinced several of our friends to join us. We shall be ready to move very soon." He paused, drew deeply on his cigarette, and exhaled the smoke slowly.
"That is why you are here. To come right to the point, the time has come to use the weapon you have hidden so jealously in your laboratory."
Machdi's courage deserted him, but Kassim continued as if he did not notice the scientist's sudden pallor.
"A biologic weapon such as you possess can bring us victory."
Machdi remained silent He was puzzled. How had Kassim learned about the weapon? From the Minister?
As if in answer to his unspoken questions, Kassim reached into the middle drawer of his desk, withdrew a folder and handed it to Machdi.
Machdi opened the folder.
"As you can see," said Kassim, "those are photostats of your laboratory notebook---the one you did not mention in your reports to the Minister of Defense. I do not wish to belabor the point, nor do I wish to waste your time and mine listening to your denials. This organism is, in your own words"---he pointed to the folder---"'the ideal weapon.' We have it, and we intend to use it!"
"You are mad," said Machdi. "Besides, why do you need this weapon if you are so ready?"
"The weapon will not be used against our enemy; it will be used against the United States."
"The United States?" It was almost a scream. Machdi fell backward into his chair.
Kassim saw his opportunity. "Now listen, Dr. Machdi, and listen well. The fate of all of us---of the world---may depend on how well you listen---and hear. First, to use such a weapon against an obvious enemy would be disastrous. Retaliation from the enemy or from one of his allies could destroy us."
"And the United States? They will just sit by when they find out? They have more nuclear weapons than we have bacteria. What you propose is suicide."
"What will the Americans do? Nothing, if they do not understand what is happening. We must be subtle. They must think that they are experiencing an epidemic of natural disease. By the time they realize it is not so, we will have won. And if we are clever enough, they will never be certain how they were attacked or by whom."
He paused, and Machdi finally said, "But if you have my papers, what more do you want of me?"
"It's very simple, my friend." Kassim spoke calmly now. "We will take care of the enemy. You will take care of the United States." He waited for the small figure opposite him to respond.
Machdi started to speak. He could not.
Josef Kassim continued. He was well prepared. "You will work out the details and inform me of them within the week. By the way, you cannot destroy the cultures; we have them. If you refuse, the weapon will still be used; but proper control may not be possible. That is why we need you. As I said, we are not out to destroy the United States; we just want to hurt her enough so that she cannot interfere in our business. Do you see now how important your role is? You not only shall have given us the weapon, but you can insure that its effect will not be entirely lethal. Does that satisfy your conscience a little?"
"You are wrong," said Machdi. "I have no idea what would happen if I infected an animal with the organism, let alone a man. What I know about this microorganism is limited to the test tube." Machdi was now calmer. Perhaps here was his out. "In all honesty, I cannot even hazard a guess as to whether it can be controlled. If you really want to know what will happen, give me some time to find out."
"There is no time," shouted Kassim. "Your present knowledge of this microbe will have to be sufficient for our current needs."
The terrorist stood up. His face suddenly became hard and his voice cold. "We have wasted enough time. To be blunt, you have no choice. You will agree to help us or..." He spread his hands. "I will leave you for a few minutes to decide."
Alone in the room, Machdi did not for a minute doubt Kassim would carry out his unspoken threat. To refuse meant the end of his life and with it, of his work. More important, his lethal discovery would be used without any controls at all.
A week later Machdi stood before Kassim. "It is very simple. I have outlined the procedure for you in detail. It's all in there." The scientist pointed to the folder he had just handed over. Then he turned and left, without another word.
Machdi handed the envelope to the courier and watched him put it into the briefcase handcuffed to his wrist.
"I thought you might deliver this to a friend of mine in America. He has repeatedly asked me for a reprint of my latest article, and I would like him to have it without the usual delay of Second Class Mail. As long as you are going to Boston, I thought you might drop it off."
He was surprised at his own cunning. A diplomatic courier would not be searched. In addition, a courier was trained not to examine the material he carried. Even if he did, he would not understand the significance of its contents.
Machdi prayed that Max Schwartz would.
"So it is done."
The brief phone call from Kassim meant the end.
Machdi put the capsule on his tongue and swallowed a small amount of water from the paper cup that trembled in his hand. He looked around; the familiar scenes in the office where he had spent so much of his life grew dim. Even the old wooden chair with the worn straw cushion seemed to fade beneath him. Darkness came quickly. His last thoughts were of God and forgiveness.
Alex Kahn looked around the empty office at University Hospital where for the past six years he had worked and planned his meteoric rise to success. The early morning sunlight filtering through the window blinds made the room seem more lonely. He had come back to pick up his last few personal belongings from his desk. Then he would drive to New York.
The six years at University Hospital had passed quickly; he had been happy and productive here, but visions of fame and power had persisted. The decision to leave this large, midwestern medical center really hadn't been a difficult one---he loved medicine and was obsessed with the idea of success in it, and the job of Chairman of the Department of Medicine at one of New York's leading hospitals would bring him one step closer to reaching his ultimate goal.
Alex Kahn was thirty-six. He had finished college, medical school, internship, and two years of residency in internal medicine in Boston. The next three years there had been spent in training with the legendary Max Schwartz. If you finished that training with body and soul intact, you were considered a specialist in infectious diseases; but more important, you were accepted as one of "Max's boys." Members of this elite club were among the most respected physicians in the country, perhaps in the world. Sixty-three of the one hundred forty-six departments of infectious diseases in the medical schools of the United States were headed by members of this club.
Alex Kahn was a member in good standing. Most felt that he was the heir apparent to Max Schwartz's throne that would be vacated in four years when the famous doctor reached sixty-five, the compulsory age for retirement in most university-associated medical schools. Everyone knew that Max would choose his own successor to the Max Schwartz Chair in Infectious Diseases. It was an endowed position; the salary of $50,000 and the Professorship were guaranteed by the friends of Max Schwartz who had been its architects. The doctor who acceded to the position would wield Max Schwartz's power; his word and his policies would guide the specialty of Infectious Diseases in the United States. This was Alex Kahn's ultimate goal. He knew Max would look for a successor outside of Boston; it was customary, and it was politically advantageous---no one was bypassed; no feelings were hurt; an outsider could come in and clean house as he saw fit in his own department. Thus, Alex had purposely left Boston for University Hospital as the first step to qualify for the position as Schwartz's successor. Now New York would bring him another step closer to the throne; success there would make him the most logical choice.
During his three years with Max Schwartz, Alex had worked hard---hard to learn, hard to please his mentor, but hardest to discover the key to the great physician. Toward the end of his training, the answer became apparent. Max Schwartz was an intuitively brilliant diagnostician. He could walk into a patient's room and ask the question everyone else had forgotten, or see what others had missed, and then put all the facts together to arrive at the correct diagnosis. In addition, he had the talent to hold an audience spellbound and to excite them to applause when he finished speaking. It was a rare mixture of vast knowledge and instantaneous recall stimulated by a keen sense of observation and a flair for showmanship.
"Alex," Schwartz had once said, "when you have been giving Grand Rounds as long as I have, you learn to play the game. They don't give me simple, everyday cases. So first I eliminate the common---being careful, however, to calculate the odds that they would sneak in a simple case just to fool me. But I know the common well enough to recognize it---and so do you. Once I've decided it is probably an uncommon case, I look for clues to help me make the diagnosis. Once I've made it, or think I have, I give the best goddamned discussion I can. I make it dramatic, exciting, forceful. I fill in the gaps with showmanship. A professor of Medicine must be a good showman. Then, on the outside chance I'm wrong, the audience is so overwhelmed by my presentation that they forgive me. I just make sure I'm right more often than I'm wrong."
He was right most of the time. When you got to be a Max Schwartz, they gave you every rare and difficult case they could dig up. It also became part of the game---don't let Max get the diagnosis. But he always did.
When Alex Kahn came to University Hospital, he carried as much of Max Schwartz with him as he could take---his teaching, his lectures, his approach to infectious diseases, his philosophy, even some of his mannerisms and jokes. He came to start a Division of Infectious Diseases where there had been none. In six years he had trained sixteen Fellows; he had started an Infectious Disease course for medical students, interns and residents that drew an audience from an area within a hundred mile radius; Infectious Disease Rounds excelled Medical Grand Rounds---and were better attended. Within two years, his division had added two full-time faculty members; it had become the strongest division in a strong department of medicine. At the end of three years, Alex was promoted from Assistant Professor to Associate Professor. He had published seventeen papers that bore his name as senior author, and there were fourteen more that listed him among their authors. If there was a difficult case, everyone came to him for help; and like his mentor, he slowly developed the knack for arriving at the correct diagnosis and choosing the proper therapy. As a teacher, he was superb. The medical students worshipped him and tried to emulate him. His success was rapid, complete, rewarding. The position in New York would have satisfied most men; to Alex, it was merely a stepping-stone into the shoes Max Schwartz soon would vacate.
As Alex glanced around the empty office for one last time to see if anything had been overlooked, he was interrupted by the telephone. It continued to ring, annoying him, and he remembered how he used to welcome the ringing. That same ring six years ago had meant his first consultations, his first private patients, his first invitations to speak. As he became busier, the ringing meant interruptions, more demands on his time, less time to do what he wanted to do. But he accepted it as part of the price of success. This call was to change his life.
"Damn it," he mumbled. "It never stops." He leaned forward in his chair to look through the door to see if his secretary was sitting at her desk. Realizing that it was too early for her to be there, he lifted the receiver.
"Dr. Kahn speaking. Can I help you?"
"Dr. Kahn, this is Roger Cullen. Sorry to bother you. I know you're getting ready to leave, but this is important."
Alex Kahn was not particularly fond of Roger Cullen, the Chief Medical Resident. He thought Cullen was no more than a messenger boy and hatchet man for the Chief of Medicine. Alex thought that a Chief Resident should be a physician who had seasoned medical knowledge, maturity of judgment, and the ability to represent the wishes and policies of his boss without being offensive. Cullen had none of these attributes. In addition, he was a fourth-generation alumnus of Johns Hopkins; he was not particularly fond of Jews and occasionally did not try hard enough to hide it.
"Dr. Cullen, I have left. I just stopped by to pick up a few things. If there's an immediate problem, call Dr. Richards, the Infectious Disease Fellow. If it can wait for half an hour or so, call Dr. Perkins. He's my successor. He should be in soon."
"I'm sorry, Dr. Kahn. I really don't know how to say this, but I don't think you should leave for New York. We have a problem that's growing by the minute and I don't think anyone but you is capable of evaluating it."
"Now look, Roger..." He paused. Alex was surprised that he didn't just scream a few four-letter words and slam the phone down. But he was puzzled. Cullen was so damned polite; he was almost begging. Besides, as much as he disliked the resident, he knew Cullen knew his place. He wouldn't be telling a division chief what he should or should not do unless there was a damned good reason.
"OK, Roger. Thirty seconds. What's the problem?"
"Thanks, Dr. Kahn. Since midnight, we've been seeing a rather unusual type of pneumonia. Rapid onset. Sick for only about one or two hours, high fever, shortness of breath, dry cough, chest pain, cyanosis, and a hemorrhagic rash. On admission to the ER, sick as hell, comatose, no air moving in the chest. The chest x-ray shows pneumonia involving almost all of the lungs. There's a high white count and severe hemolysis. Low oxygen in the blood and no response to 100 percent oxygen even by respirator. Sputum smears show what looks like staph. We've had no luck with large doses of any of the antibiotics we've tried."
Alex Kahn leaned back in his chair. So far the problem sounded simple. He lit a cigarette and settled down to give Cullen a short step-by-step explanation of the problem in the true Max Schwartz fashion.
"The whole course seems entirely consistent with acute staphylococcal pneumonia, Roger. I'm a little surprised at the onset. Staph pneumonia is almost never primary; it's always secondary to something else, usually a preceding viral infection of the upper respiratory tract or even viral pneumonia. These patients probably had a very mild viral infection beforehand. Because of the coma, you couldn't get a history of it; or whoever gave you the history probably just didn't know the patient had had an infection. Were you able to get any material from the rash for examination?"
"No."
"Too bad. A smear of that might have shown you the bug. Good way to prove bacteria in the bloodstream. The cyanosis and the lack of oxygen are typical of overwhelming pneumonia."
He paused to listen to the effect of his words on Roger Cullen. "Just like Max would have done," he thought. "Make it sound so simple the listener feels like two bits."
Alex was pleased with himself. He continued.
"Have you tried steroids? They usually help reduce the inflammation in the lungs and allow better oxygenation. Steroids also may reduce the hemolysis. It's probably due to a staphylococcal toxin, you know."
"We haven't had time. They all died too quickly."
"What do you mean 'they all died'? How many cases have you seen since midnight?"
"Sixty-four. So far only the last three---the ones that came in about an hour ago---are still alive."
"Sixty-four! What the hell are you doing down there? Why didn't you call for help? Why didn't you call Dr. Richards and have him call one of us? Where the hell is he?"
"Dr. Richards did come in, Dr. Kahn. He came in at 4 a.m. when I called him. He died two hours ago. He didn't have a chance to call you. Dr. Brubaker also died---about 3 a.m."
"Dr. Cullen, are you telling me that since midnight sixty-one people have died of overwhelming pneumonia? Staphylococcal pneumonia that probably isn't even transmitted from man to man? And that every one of them became sick so quickly that it was too late for therapy? Doctor, we have had no such problem with staphylococcal pneumonia in this hospital since I came here; and that was six years ago."
Alex Kahn realized he was screaming into the receiver. Anger had replaced reason; fear had replaced logic. He looked at his watch. It was 8 a.m.
"I'll be right down. I want the x-rays lined up with the charts. I want to look at every damned sputum smear myself. Call Bacteriology and tell them I want to see every culture they have from every one of those patients---including Brubaker and Richards."
"Thanks, Dr. Kahn. I really am afraid this is some wild type of epidemic. So far, I can't figure it out. I hope you can---or we're going to be burying a lot of people who were healthy yesterday. By the way, I've called the hospital administrator and informed him that we have a problem; I didn't want to go into detail with him and start a panic. I asked him to keep all unauthorized persons out of the ER and to have everyone entering put on a mask and gown. I told him I would be discussing this with you."
"Good judgment, Roger." His dislike for the man decreased as his own concern mounted. "I'll be right down."
"An epidemic?" Alex said the word slowly to himself. "But an epidemic of this severity and virulence would be damned unusual in the United States in the 1970's."
Something else kept bothering him. He'd seen a lot of overwhelming staphylococcal infections, and none had ever acted like this. He'd have to look at those cultures carefully himself. Even a lab technician couldn't mistake something else for staph sixty-four times in a row!
Alex Kahn knew he was good. Damned good. He could diagnose and treat almost anything he encountered in his daily practice---common or uncommon. He also knew where he was weak. In all the years of training and practice, one of the few entities he had never encountered was a true epidemic. He had been through influenza seasons and meningitis outbreaks; he had been involved in a cluster of cases of streptococcal infection on the delivery floor---so-called puerperal sepsis. Thirty or forty cases of he same disease had been the most he had seen at one time. What he had just heard sounded like only the beginning. He began to calculate: sixty cases in about eight hours; a hundred eighty cases in one day. The statistics staggered him, and the picture his mind was developing for him was terrifying.
He had often laughed at friends who went abroad to study infection in underdeveloped countries. "You'll be our country's biggest expert on Jungle Fever, but you'll wait a long time for your first case," he used to tell them. He truly believed that to practice in the United Sates you had to approach infectious diseases as they occurred here. Sure, a rare case or two came by, especially since the availability of air travel and the outbreak of limited wars here and there; but such cases could be looked up in textbooks. That took a trip to the library, not a trip to Timbuktu. But he had missed the point. What one learned in Timbuktu was not only how to treat Jungle Fever but how to treat a virulent communicable disease occurring in many persons at the same time with very little help available and with fewer beds and less medicine than there were patients.
For some reason, he suddenly remembered something Max Schwartz used to say. "Doc, the buck-passing stops at the Professor. When you're it, there's no 'old man' to run to for help. The final decisions become yours. It's kind of lonely at first, but you learn. First thing you learn is to stop your own panic and to start thinking clearly---to call on every bit of knowledge and experience you've hoarded to make the decisions that have to be made. And finally you learn that some of your decisions will be wrong, and you'll have to live with them. When you've learned all that, Doc, you're ready to be the Professor."
Now Alex knew he'd have to make all those decisions Max Schwartz used to talk about. Cullen was waiting for him to "pull this one out."
He stood up, put his bulging briefcase on the floor, and scribbled a note to his secretary. New York would wait for him.
He put on his white coat, and, dressed in this armor, walked toward the elevator.
\*
Alex was tired. His office was dark. He looked at his watch. Almost midnight. He didn't know it, but he had lived through the first twenty-four hours of doomsday.
He lay down on the couch. At first the cold vinyl felt uncomfortable through his shirt; then it was soothing. He lit a cigarette and lay back to watch the smoke curling up into the darkness. His jaws ached; they always did when he wore a surgical mask for any length of time. His mouth was dry. He felt dirty. He couldn't remember when he had felt so frustrated. The day had brought his self-esteem crashing down around him. Many questions had been asked, but he had not been able to answer them. He didn't know if there were any answers. At this moment, he wasn't sure what he knew. It was a rude awakening.
The situation around him was deteriorating rapidly. In little more than fifteen hours he had seen seventy-nine cases of whatever it was they were seeing. A total of one hundred forty-three patients with fever, coma, cyanosis, hemorrhagic rash, hemolysis and pneumonia on chest x-ray had passed through the swinging doors of the Emergency Room at University Hospital. One hundred thirty-four had died. Nine were still fighting the losing battle. None had survived for longer than three hours from the time their names were entered in the ER log. As if this were not bad enough, calls to other hospitals in the city revealed more of the same. Memorial Hospital had had seventy-one cases; all had died. Methodist, sixteen cases and the same number of deaths. Mt. Sinai, thirty cases; two were still alive---but hardly. He had not bothered to call the other three hospitals located within the city limits.
When he had reached the Emergency Room, Cullen had met him at the door and handed him a mask and gown. As they walked to the small laboratory located behind the nurses' station, the resident went over the cases. Then for thirty-five minutes Alex Kahn sat silently at the microscope. Only his hands moved---to focus, to move the mechanical stage, to change slides as he systematically and rapidly examined specimen after specimen. He looked at the smears of sputum---actually they were smears of the bloody froth that trickled from the mouth rather than true secretions from the lower respiratory tract. He looked at the smears made from material randomly chosen from the multitude of test tubes, flasks and agar plates that served as media for the growth, isolation and identification of bacteria. He looked at slides until his eyes tired of staring at the round, brightly lit, highly magnified field. Then he carefully examined the few cultures that manifested some growth; these came from the first few patients who had died. Despite the rapid rate that seemed to characterize the growth of the microbe in the human body, it appeared as if it was following a slow and leisurely growth curve in the test tube. At eight hours, there was little to see; but Alex Kahn's experienced eye extracted whatever visual information was to be had. He smelled each growing culture; he had learned long ago that some organisms could be identified by their odor or that of their metabolic by-products. When he had finished, he knew little except that this overwhelming disease seemed to be caused by bacteria which looked like staphylococci under the microscope and appeared as odorless, creamy yellow colonies on artificial culture media.
He stood up and looked around to be certain all the slides and cultures had been safely put away.
"Now let's look at the x-rays."
They walked to the rows of view boxes. Alex Kahn stood in front of the first, legs apart, hands on his hips, staring at the celluloid negative of the first patient's chest. His eyes scanned the film carefully and systematically. The bony structures---collarbones, breastbone and ribs---looked normal. There were no soft tissue abnormalities; the size and shape of the heart were not remarkable, although he wondered about a certain fullness that could represent early heart failure. Then the lungs. Normally these appeared black or gray in x-rays because the air in them allowed the x-rays easy penetration to blacken the film; usually, the black was arborized by the white markings of larger arteries and veins near the heart. But the lungs of this first patient appeared almost entirely white. Alex shook his head and walked to the next film. He repeated the procedure until each of the films had been examined.
"Christ!" There wasn't much else that could be said about the x-ray evidence for this overwhelming pneumonia that appeared on film after film. "Let's see the patients."
Cullen followed him to the first bed. The patient was dead. They moved on.
He observed. He palpated. He percussed. He listened. Over and over again. As patient after patient came in and died, he forgot his role as the Professor. He drew blood, he passed endotracheal tubes, he suctioned, he started intravenous therapy---things he had not done since training.
As the day wore on, he realized that no matter what they did, the patient died. He started therapy, he changed therapy---and death made therapy superfluous.
His vigor changed to frustration; his frustration to uncertainty, to fatigue, to fear. Finally, when he could see, hear and feel no more that would do any patient any good, he stopped. He felt he needed to get away and try to put everything into perspective. Maybe the answer would come. He removed his scrub suit, showered carefully with disinfectant soap, dressed, and left the Emergency Room. As he walked toward the elevator that would take him to his office, the bustling silence was interrupted by the screams of more ambulance sirens.
He felt better. Not much better, but better. He suddenly realized he was hungry and thirsty. The cafeteria would be closed, but there was probably some instant coffee in his lab across the hall. He sat up and rubbed the back of his neck. He stood up, stretched, and walked to the window to look out. Opening the blinds, he saw through the blackness that it was starting to rain. He wondered what the rain would do to this damned epidemic. His thoughts were interrupted by the ringing of the phone. He walked to his desk quickly and reached for the receiver.
"Dr. Kahn speaking."
"Alex?"
Alex Kahn knew that voice well. How many times had he listened to it in the middle of the night?"
"Alex---are you there?"
"Yes, Dr. Schwartz. Sorry. Your voice startled me. Gosh, it's good to hear from you!" He paused, momentarily embarrassed at the boyish eagerness of his own voice.
"Alex, how are things there? How much pneumonia have you seen in the past twenty-four hours?"
The question didn't surprise him. Maybe it was because Alex always expected Max Schwartz to know everything.
"About one hundred fifty cases here, probably another hundred or more in the rest of the city."
"How many have died?" asked Dr. Schwartz.
"All but a couple," he answered, unconsciously dropping his eyes as if the phone before him were the face of the man to whom he was speaking.
"Well, you're doing better than we are; but the you had a good teacher."
Alex Kahn suddenly stiffened. "What do you mean?"
"We've seen three hundred six cases between here, the Boston City Hospital, and Mass. General. We haven't been able to save one. Sudden onset, fever, coma, hemorrhagic rash..."
Alex listened as the clear, concise voice described in detail what they both had seen during the previous terrible day.
"That's just how I put it together." Alex's voice had regained some of its usual confidence. "But I just can't conceive of acute, overwhelming staphylococcal pneumonia occurring so quickly in so many persons."
"That's just the point, Alex; it can't be staphylococcal pneumonia as we're used to seeing it. And it's occurring in at least forty cities in the same plague-like fashion, the rapidity of which is unlike any infectious disease I know. I've spoken to everyone I could reach, and it's the same everywhere---New York, Los Angeles, Chicago. No one knows exactly what it is, and no one has had a case that's survived for more than a few hours. Have you had anybody who's survived for more than two or three hours?"
"No."
"Have you got a smear or culture that looks like anything but common, everyday staphylococci?"
"No." The worry in Max Schwartz's voice reawakened his own fear. The Max Schwartz he knew wasn't afraid of any microorganism.
"Alex, I've made some rough calculations. There have been about forty-five hundred cases and almost the same number of deaths already. There's no reason to believe that his won't continue in geometric progression. We could lose a million people!" Max Schwartz's voice was the same, but the tone suddenly became softer---almost a whisper. "If we can't stop this, we could be wiped out!"
Alex Kahn listened, but he could not believe what he heard. Max Schwartz would not talk about epidemics that could wipe out a country unless he really believed what he was saying.
The voice on the other end of the line continued. "I've got to leave in a minute, Alex, so listen to me carefully. Something is very wrong. Natural disease just does not act like this. There could have been an accident somewhere; some major lab working with a very virulent organism might have had a spill. Any reputable lab would have reported it if an accident had occurred. There have been no such reports. So if it was an accident, it's been missed---unless some goddamned fool is trying to cover it up. Or," he paused, "someone has decided to start an epidemic. My intuition tells me that we have been attacked."
Alex sank into his chair. He knew this must be some sort of nightmare. But Max was still talking.
"Alex, I want you to get out of there. Get samples of all the cultures you've got cooking on those patients and meet me. Got a pencil? I'll give you directions."
"What the hell are you talking about, Dr. Schwartz?" He was surprised at his own words. No one spoke to the "boss" that way. "I can't just up and leave in the middle of all this."
He was interrupted before he could protest further---before he could but into words the terrible burden of responsibility he felt.
"Alex, listen." The voice was not harsh as he had expected it to be. "You can't do anything there. You and I and many other people have done all we know how to do and have gotten nowhere. We've got to concentrate our efforts and find out what's causing this disease. If we do, then maybe we can come up with something to beat it. We've got to do this as quickly as possible. I don't know how much time we have, but we can't see forty-five hundred cases a day and survive long---besides, it may pyramid like any other communicable disease. Doesn't take much arithmetic to figure out what the end result will be. I need your help, Alex."
In all the time Alex had known Max Schwartz, he'd never known him to need anyone's help. Alex couldn't refuse. Besides, Max Schwartz was probably right. What good was Alex doing where he was?
"Go ahead, Dr. Schwartz. Tell me what you want me to do." Alex snapped on the light over his desk and found a pad and pencil.
"OK, Alex. My secretary has arranged a seat for you on TWA flight 243 leaving at 6:05 a.m. for Washington, D.C. Just pick up the ticket at the airport a half hour before boarding. The reservation is in your name."
Alex thought as he wrote, "Damn it, there was never any doubt in his mind that I'd come. He hasn't changed a bit."
"I've already called Donald McBride, the head of your Bacteriology Lab. He's an old friend. And he doesn't ask questions. He's packing the cultures you want right now---himself. Each flask and plate is sealed with parafilm. He's cushioning them with popcorn and latex particles. This will all be packed in a heavy glass container that fits into a larger one. The space between the two will be filled with nitric acid. It shouldn't hurt the glass; but if it's dropped and broken, the acid should kill anything that spills. He's putting the whole thing in one of those small flight suitcases that will fit under your seat on the plane. When you get to the airport, see a Mr. Tanner; he'll be the head security guard on duty at that time. I've arranged with him to allow you to take the bag onto the plane without having it searched at the gate."
Alex felt a little better. Max hadn't changed. The son of a bitch thought of everything. For the first time in hours, Alex began to have faith that the world was not really coming to an end.
"When you get to Dulles in Washington, a Major Small will take you from there. Got it?"
"I've got it, Dr. Schwartz. Where can I be reached? I'd like to leave a number. I'd like to know how things are going here."
"You can't leave a number, Alex. You're just going to have to disappear for a while. We've got to keep this thing hushed up until we know what's going on. You'll understand why soon." Max Schwartz paused. "Where are Lori and the children?"
Max Schwartz's sudden interest in his family startled Alex. In all the years he had known the great physician, Max Schwartz had never once expressed even the slightest interest in anyone not connected with his profession.
"They're staying with her parents in New Hampshire until I can get things settled in New York. The apartment we bought won't be ready for about three weeks."
"Let them stay there. Couldn't be much safer. Can I count on you, Alex?"
"You know you can. I just feel damned uncomfortable not knowing what's going on or where I'm going."
"I know. I'll answer all your questions in a few hours when I see you. Good-bye."
Alex put down the receiver. The mention of Lori and the children made him feel even more alone. He sat back in his chair and for a few minutes allowed himself the luxury of retreating into the past.
He was an intern with Saturday afternoon off. Harvard had just beaten Yale. It was starting to snow, and suddenly it was a wonderful world.
The cold wind blew in icy gusts through the concrete tunnels of Harvard Stadium as the triumphant crowd surged home. Enjoying every minute away from the overwhelming pressures of a university hospital internship in Boston, Alex allowed himself to be carried along, not paying too much attention to the direction.
"Hi, Alex." Her face was bright and alive. The cold had painted her cheeks and the tip of her nose a lively pink, highlighting her warm brown eyes. A lock of dark hair fell over her forehead from beneath a white knit stocking cap, and she stopped to brush it away with her mittened hand.
He paused to admire the face and then gave her a puzzled look, somewhat embarrassed because he had a feeling he should know who she was.
"I'm Lori Stack. We went to high school together." She smiled understandingly. "I'm sure you don't remember me."
He didn't; but suddenly the crowd pushed at both of them, and he took her hand to keep from getting separated from her.
He invited her to dinner that night, and they talked about everything and anything until the restaurant was empty and a disgruntled waiter told them it was time to go.
From then on he saw her at least once a week and found he looked forward more and more to the time they spent together. When he was with her, he could escape from the world of medicine; he could relax in her warmth and understanding. He found himself falling hopelessly in love with her but could not in any way justify this frightening relationship to himself. He was an intern earning $2,460 a year, he had at least two years of residency ahead of him, and he had already decided to apply for a fellowship with the famous Dr. Max Schwartz. There would be no place for a wife in his immediate future. A remark his father used to make further strengthened his decision: "If you want to travel fast and far, Alex, travel light."
He began to see her less and less but could not bring himself not to see her at all. When February came, it seemed his problem would be solved---he became the intern on the Infectious Diseases Service for two months. This was Max Schwartz's service, and it meant being available in the hospital twenty-four hours a day every day---there was no time for anything else. Occasionally, at one or two in the morning, as he sat bleary-eyed going over patients' charts, he would stop for a moment and think of her with longing. Once or twice he reached for the phone to call her, but he never did. The long hours of total involvement in medicine convinced him that he had made the correct decision.
Then suddenly at 9 p.m., on March 12, everything changed. He was just finishing a progress note on a patient with a urinary tract infection whom he had admitted earlier that afternoon when the phone rang at the nurses' station. An aide answered it and then covered the mouthpiece with her hand. "Dr. Kahn, it's for you. Dr. Schwartz."
Max Schwartz called at night for many reasons: to check on a sick patient, to advise the staff that he was sending in a new one, to give someone hell for something that had gone wrong during the day, or just because he had one of his frequent premonitions that he ought to call to be certain "everything was going smoothly." Alex Kahn could never tell in advance which reason it was going to be, and he always answered Dr. Schwartz's phone calls with the fear that this was one of those times he would catch hell.
"Dr. Kahn? Schwartz." It was always just "Schwartz"---not "Dr. Schwartz" or "Max Schwartz," just "Schwartz."
"Yes, Dr. Schwartz," he tried to keep his voice firm and confident.
"I'm sending in the daughter of an old college classmate. She's got a fever of 106 degrees, a stiff neck, and she's comatose. Probably meningitis. She'll be in by ambulance in about ten minutes. You take care of her. I'm on my way to an American Board of Internal Medicine Meeting in Philadelphia. When you've got her worked up, call Dr. Hardy, my associate, and discuss the therapy with him; he'll come in to see her tonight if you need him, or else he'll see her first thing in the morning."
Alex Kahn was elated. The fact that Max Schwartz trusted him sufficiently to take care of one of his patients was an unexpected compliment, one that came to few interns.
"I've already called and arranged for her admission. They'll send her directly up to the fifth floor. She's pretty sick, so don't waste any time. Do a lumbar puncture the minute she arrives. I want her on therapy within an hour." He paused. "No screw-ups, Dr. Kahn." He paused again. "Any questions?"
"Just her name, Dr. Schwartz."
"Lori Stack. She's twenty-three. The rest of the information will be on the face sheet of her chart. Call Hardy if you need any help. Good-bye."
Alex Kahn was numb. He clutched at the silent phone until his knuckles were white; and then he put it down with an uncertain shaking hand. He was still sitting there in thoughtless silence when the nurse's aide announced Lori's arrival.
"Your patient is in, Dr. Kahn. She's in 512. The nurse is taking her temperature and blood pressure now. The lumbar puncture set is by her bedside. Looks pretty sick. I'll get some blood culture bottles for you."
He made himself get up and put on the mask and gown used for protection against communicable diseases. Until he knew definitely what she had, he'd have to assume it was contagious. He went down the corridor to her room.
"Temp's 106 degrees, blood pressure ninety over forty." The nurse rolled up the cloth blood pressure cuff, put it in the wire basket behind the head of the bed, and began to open the green sterile wraps of the lumbar puncture set on the bedside table.
He walked to the bedside and looked down. For the fist time he learned, as every doctor must, that it is hard to be rational when treating someone loved. This wasn't the Lori that he knew. The vibrant skin was hot and pale, the soft lips parched and dry, the dark hair without sheen. And in that terrible moment, as he stood watching her, he realized for the first time that something besides medicine could be so very important to him.
"Dr. Kahn?" The nurse's voice startled him. "I'll help you do the lumbar puncture. Here are your gloves."
Somehow, Alex Kahn rose to the occasion. He had little choice. Max Schwartz had left for Philadelphia. It would take Dr. Hardy an hour to get in, and there was no one covering the Infectious Disease Service now but him. Besides, what excuse did he have? That his love was so great that he couldn't help her? Right now she didn't need his love---she needed medical skill and knowledge. It was this realization that saved him.
He worked quickly. A short physical examination substantiated what Max Schwartz had told him earlier. He did a lumbar puncture. The spinal fluid was crystal clear, like water---normal. He sent samples to the laboratory to be certain of his finding. Being busy stimulated his mind, and he began to think more clearly. He remembered what Max Schwartz always preached: "When you've got a comatose patient with a stiff neck and the spinal fluid is normal, look for that upper lobe pneumonia." As usual, Dr. Schwartz was right. The chest x-ray showed an occult lobar pneumonia of the upper lobe of the right lung. After informing Dr. Hardy of the situation, he started Lori on intravenous penicillin and sat down by her bedside to write up her chart. He stayed by her all night.
At 7 a.m. her fever was down to 100˚, and she was breathing peacefully; he knew she would be all right. He left to shave and change his clothes. When he returned to see her with Dr. Hardy during teaching rounds at 10:00 a.m., she was beginning to stir; her temperature was normal.
He had given her life. Now he would give her his love.
Lori lay quietly in bed watching the IV fluid run into her vein. Tomorrow the IV would come out; the following day she would be discharged to finish convalescing at home. At first, she had dreaded each day that brought her closer to leaving the hospital. At least here she could see Alex. But as she began to recover fully, she realized that this illness had been simply an artificial hold on him. She loved him, she respected his love for medicine, and she was willing to accept the fact that his profession would be a jealous mistress. But she had made up her mind. She would have him only if he were ready to make her a part of his world---even a small part.
"IV ready to come out?"
"Oh, I don't know. I may miss it." She smiled.
"Tell you what. I'll trade you."
"It'll have to be something special."
"It is." He withdrew the ring from the pocket of his white jacket.
They were married three months later.
It was a good marriage. Good because she loved him enough to make it work. She created a world for him outside of medicine, one filled with love and understanding to which he could escape when the burden of administering to the sick and the dying became overwhelming. She knew her role in his life and played it well. He wanted her to stay aloof from his career. She was there when he needed her and tried with great success to remain in the background except during the social occasions inevitable in any university setting. She kept silent when he didn't want to talk and listened avidly when he chose to share even a small problem with her. She loved him unceasingly, and he knew it; and in his own way, he returned her love. Their marriage flourished because she could give and did not expect him to give equally in return.
They had been married two and a half years when their first child, a son, Peter, was born. Alex Kahn was then in the first year of his fellowship with Max Schwartz and for the first time in their marriage, she began to hate the terrible loneliness and to suffer the effect of Max Schwartz's total influence over her husband.
Before Peter was born, she had been able to compensate for Alex's absence by busying herself with her job as a teacher, with visits to friends, or even by window shopping with dreams of the day when they would be able to afford some of the things brightly displayed behind the large plate glass windows of the many department stores that lined Washington and Tremont streets in downtown Boston. Once or twice a week she had been able to meet Alex for a hurried supper in the hospital cafeteria or for a late evening snack in the residents' lounge.
Now she found herself imprisoned in their three-room apartment by this tiny infant who was the product of their love but who now demanded her constant attention. Her loneliness was accentuated by her feeling of guilt that she could not accept motherhood without this ambivalence. It might have been different had Alex been there, if only for moral support and to share in the wonder of their first child; but his long hours at the hospital allowed them little time to be a family. Even on the rare occasions when she could afford a baby sitter, she found that she was too tired to enjoy going out. She minded Alex's absence most in the evening when she had put Peter to bed and was left alone in the dark emptiness of the apartment with little to do but finish folding the day's laundry. Predictably she converted her loneliness into resentment of the man she felt was keeping her husband from her.
Like most of the wives of "Max's boys," she knew of his greatness but resented what she thought he was doing to her marriage. They all felt the same way. It was more than the canceled dinner parties, the missed concerts, the movies they never saw. It was the feeling that he came first. When Max called, his "boys" jumped. Where he went, they went. Those years meant a family without a father and a husband. Max Schwartz demanded a loyalty and devotion that left no time for anything else. His Fellows were tired, insecure men, who occasionally came home to eat and sleep.
None of the wives had ever met him. Each had her own mental picture of what he must be like---this legendary man whom their husbands feared and loved and hated all at the same time.
But despite her loneliness and her resentment, Lori tried---sometimes more successfully than others---to keep conflict between herself and Alex to a minimum. She kept telling herself that she could tolerate today because she hoped for a better tomorrow---and she knew that tomorrow would come when Alex finished his training with Max Schwartz.
Alex was at University Hospital as an Assistant Professor when their two daughters were born, and it was better. Despite the fact that he was no less devoted to medicine, he could be his own man. He was able to take Saturday and Sunday afternoons off to be with Lori and the children; and she began to feel for the first time that they were, indeed, a family. She became more content and settled comfortably into the life of a doctor's wife. As long as she knew that they had a very special place in Alex's heart---there had been times during his training with Max Schwartz when she had questioned it---she was happy. Now that he was successful and becoming more so, she felt that the sacrifices had been worth it; and when she lay in his arms in the quiet darkness of night and felt his warmth and his love, she knew it was so.
Over the years, Alex Kahn had loved her more than he had thought it possible to love anyone. All of his fears had been needless---she had not been a hindrance to his career at all. Her love had sustained him through times when he felt he might not otherwise have been able to withstand the overwhelming pressures thrust upon him. He knew they had had their difficulties, especially when Peter was first born; but somehow it had been convenient for him to interpret her complaints of loneliness as postpartum depression. Selfishly, he had allowed her unhappiness to pass; and it did. He could not have wanted more in a wife, and though he was sure he rarely showed it, he was totally devoted to her.
Now suddenly faced with the monstrous plague, Alex realized how much Lori and the children truly meant to him. He felt alone and helpless. There was nothing he could do to protect them or to insure their safety. The realization that a disease threatened their very existence that at present was beyond the scope of all of his skill and knowledge frustrated him. He was beginning to understand the terrible significance of Max Schwartz's statement that they could all be "wiped out." It was possible that he might never see Lori and the children again.
"I love you, Lori." He said the words aloud to himself and listened to their echo in the empty office.
He glanced at his watch. It was 4:30 a.m. Time to start for the airport.
He looked around the empty office---again. So much had happened since the last time he had done this.
He picked up the suitcase Donald McBride had delivered. It was heavy and uncomfortable to carry. It suddenly occurred to him that in this dark-brown, leatherette flight bag, protected from the world by glass and acid, popcorn and latex, parafilm and cotton plugs, was death---death which could hurl mankind to a premature end unless someone, somewhere, could find a key to turn it off.
Alex looked down through the glass nose of the helicopter and watched the hills of western Maryland fly by several hundred feet beneath him. He figured it was Maryland from the direction and distance they had flown since Dulles. Neither Major Small nor the pilot had been willing to tell him their destination, and he couldn't even guess which army installation it would be because there were so many that surrounded the nation's capital. He just sat beside the silent pilot, listening to the motor above and watching the peaceful landscape below.
As his eyes caught the sun reflecting off the aluminum-painted surface of a water tower above the hills several miles ahead, he felt the helicopter start to descend. He knew where he was.
"Of course," he thought. "The logical place---Fort Detrick. It's ideal. Secluded, yet accessible, with an excellent communication system and the best infectious diseases laboratories in the world for the isolation and identification of a 'hot' bug."
He spread his feet for balance and braced himself as the helicopter accelerated its descent.
Fort Detrick. Once the home of the army's biological warfare program, it lay peacefully hidden at the edge of Frederick in the rolling hills of western Maryland about fifty miles northwest of Washington.
Detrick had started as a single building at the beginning of World War II. As time went on, it became the country's largest and most sophisticated facility for research in microbiology. At its peak, it consisted of some 460 buildings situated on 1,230 acres of farmland surrounded by security wire fencing. What took place behind the fence was known only to the army personnel who worked there for a year or two---rarely more---and to the members of a distinguished civilian advisory board who sat as consultants and overseers to the programs.
Actually Detrick had two fences. Behind the outer one were the administrative facilities and tenant units, an army unit from the medical research center at Walter Reed and a navy liaison unit.
The medical unit was the antithesis of the biological warfare program. Staffed by hand-picked physicians from many medical specialties, it concentrated on research into the early detection, diagnosis and treatment of infectious diseases, especially those which might be used as weapons of war against the United States. From the work of this small group evolved many advances for the good of mankind. Their research had led to the development of vaccines against tularemia and plague and against several of the viruses known to cause encephalitis. There were few secrets, and the results of most of its studies were readily available to prestigious scientific journals.
Within the inner fence were a group of brick buildings that, for lack of a better name, were termed the Biological Warfare Laboratories. They were surrounded by this second fence not only for secrecy, but also to prevent persons from trespassing where they had no business and thus inadvertently being exposed to agents that could do them harm. The discoveries made in these buildings were indeed lethal, but the possibility of their actual use had never seriously arisen. As the cold war eased in the late sixties and the beginning of the seventies, political pressure mounted against the whole program. Finally, in 1971, public opinion forced the conversion of Fort Detrick to a center for cancer research.
Alex Kahn had been there once before. As members of a panel established by the President's Science Advisory Committee and the National Academy of Sciences, he and six others had visited Fort Detrick to decide the disposition of those laboratories that had been designed specifically for work with highly virulent and communicable infectious agents. Their decision had resulted in the setting aside of a small area for this purpose under the supervision of the National Institute of Health at Bethesda, Maryland, and of the Communicable Disease Center in Atlanta, Georgia. Perhaps because of their previous identity, these few laboratories had remained empty and unused. Until now.
Max Schwartz was sitting at the far end of a long and empty conference table. Chair tilted back against the wall, knees up, his stubby fingers folded over his sport coat, he looked up and smiled as Alex opened the door, giving the younger man a silent nod of recognition.
"Same old Max," Alex thought as he walked the length of the table to shake hands with the respected physician, teacher and scholar. Dr. Schwartz wore a light-blue oxford-cloth shirt with button-down collar, a maroon wool tie, a tweed sport coat that wouldn't button over his ample mid-section, and flannel slacks that hardly reached the top of his penny loafers. In Boston they all used to kid about it as Max's uniform of the day.
Beneath the slicked-back gray hair Max's face appeared somewhat more wrinkled and his eyes more tired since Alex had seen him last at the Atlantic City meetings two years before.
They shook hands warmly. For a moment the traditional barrier between teacher and student was gone.
"Good to see you, Alex. Wish it were under better circumstances. The others will be here in a moment."
"The others?"
"You don't think they'd let you and me play war without any soldiers, do you? But they're all pretty good people. By the way, did Major Small take the cultures off your hands?"
Alex nodded. He started to speak but was interrupted by the opening of the door and a shuffling of feet.
Five men entered. Three wore the traditional green uniform of the army; their insignia identified them as generals. The other two wore bland civilian suits.
Alex watched them carefully as they took their places around the table. He couldn't tell if their serious faces meant they were irritated at being there or concerned because they knew the reason for the meeting. He was surprised not to see any of Max's other "boys," until the alarming thought occurred to him that he might be the sole survivor of the "club" rather than the only member chosen for attendance.
His thoughts were interrupted by the heavyset, balding general next to Max Schwartz, who rose as he spoke.
"Gentlemen, I think you all know Dr. Max Schwartz, the distinguished specialist in infectious diseases. Dr. Schwartz has raised some very serious questions related to national security. I am afraid that I must agree with him now that I have had time to look at the statistics. In a moment, I will ask him to brief you on a situation that only he seems to have been astute enough to recognize. Before doing so, however, I see at least one face I don't recognize"---he looked at Alex apologetically---"so perhaps we can take a moment to introduce ourselves.
"For those of you who don't know me"---he looked at Alex again---"I am General Mark McKitridge, advisor to the Chief of Staff of the Army in all matters related to unconventional weapons. I was commanding officer of the Chemical Corps until two years ago when---and I'm sure I don't have to remind you of this---the army's formal program in this field ended. I am a soldier and an organic chemist by profession, with a doctorate in organic chemistry from M.I.T." He turned to the office next to him and motioned for him to continue.
Lieutenant General Marion Slade, a graduate of West Point, was the army's "jack-of-all-trades." If something had to be done, he saw that it was done; if something was needed that didn't exist, he saw to it that it was invented; he was a military genius in the specialties of improvisation and elimination of red tape. His authority stemmed from the three silver stars on each shoulder as well as from his position as Chief of the Quartermaster Corps and adviser to the Joint Chiefs of Staff in all matters related to military supply.
Brigadier General James J. Rahway was Commanding Officer of the Walter Reed Army Medical Center in Washington. He had a unique qualification that not even Max Schwartz possessed---significant personal experience in widespread epidemics. He had been the chief medical officer assigned to represent the United States in medical assistance programs during epidemics of smallpox in Pakistan, typhoid fever in Mexico, and typhus in Southeast Asia. He had been intimately involved in the World Health Organization's successful efforts to stem the influenza pandemic of 1971. His performance in each of these situations was outstanding.
Warren C. Tracey had retired from the Army Medical Corps in 1968 to become civilian director of the army's medical research program. By training an endocrinologist, he had in 1964 been assigned by mistake---the army was famous for mistakes in assignment---to an infectious disease research unit. Rather than waste his efforts complaining about the "system," he had applied his knowledge of human glands to study their reaction to infection. He was the driving force behind the creation of a new subspecialty in the area of infectious diseases---the metabolism of infection. He was, perhaps, the most knowledgeable individual in the country about the metabolic response of the host to infectious illnesses. Just prior to leaving the laboratory to become an administrator, he had initiated a program to investigate methods of detecting infection before a person became overtly sick.
Roger Bergen was unknown to almost all of them. He was a direct representative of the President; he would keep the Commander-in-Chief informed of everything that happened in this room and its surroundings.
As each person around the table introduced himself, it was obvious why each was there.
Alex Kahn was about to rise to introduce himself, but Max Schwartz saved him the effort.
"Alex, excuse me. I would like to introduce you. Gentlemen, this is Dr. Alex Kahn, one of my 'boys.' Dr. Kahn is here because I need him. He's an excellent physician and very knowledgeable in infectious diseases. When I tell you the reason for our meeting, you'll understand why he's here."
Alex was sure he was having auditory hallucinations. Max Schwartz paid compliments about once every five years, and then always out of earshot of the subject of the compliment.
Max Schwartz continued. "Get comfortable, gentlemen. These may be your last moments of leisure for quite a while." He lit a cigarette, loosened his tie, and sat down.
Several of the others---to Alex's surprise, even the generals---removed their jackets. Roger Bergen poured coffee from an urn in the corner and passed the cups around the table. The break in the formalities gave the group more the appearance of men who had come together to work. This was the atmosphere Max Schwartz wanted. He took a final puff on his cigarette, crushed it out in the metal ashtray before him, exhaled slowly, and began.
"It is my opinion that we have been attacked with some sort of biological weapon, probably of bacterial origin. I fear that, whatever the agent is, it is sufficiently lethal to kill a million or more persons in he United States within the next two to three weeks if it is not stopped or if we cannot find a method of treating the illness it causes."
He could not have been more direct or more concise.
Alex Kahn and General McKitridge had had at least some knowledge of what Max Schwartz would say. They watched the effect of his words as their meaning hit the others.
General Slade reacted with disbelief and anger. Standing up deliberately, he placed both fists on the table, knuckles down, and glared at the man who had just spoken. "Dr. Schwartz, when a man of your reputation makes an unfounded statement like that, he is either specifically interested in starting a national panic, or he has some ulterior motive in mind. I do not care to listen to any more of this nonsense. I have just come from Fort Meade; I stopped at the Pentagon on the way here. I did not see any evidence of plague in the streets. I don't know what the hell you're talking about!" He turned to reach for his jacket, and his eyes suddenly caught those of McKitridge. "Mark, you said you knew what this was all about. Did you call me all the way out here to listen to one more person whose nose was out of joint because Detrick was closed and he wasn't asked? You don't really believe all this, do you?"
"Marion, sit down!" The voice carried all the weight of an extra star. Slade looked at his superior and sat down quietly.
"Marion---and all of you. I did not expect you to receive this news calmly. I did expect you to receive it with courtesy and to listen and think before you open your damned mouths to insult the only person among us who was astute enough to see what was in front of his nose. I apologize, Dr. Schwartz. Please go on."
"I apologize also, Dr. Schwartz," Slade interrupted. "I had no right to speak to you like that. Perhaps you should have been a little less direct. But with all due respect, I think you owe it to all of us to defend your remarks and back them up with good, solid facts. No one---not you, sir, not General McKitridge, not the President himself---has the privilege of making such a statement as you just did without substantiating it with fact!"
"You are absolutely right, General Slade; but let me make it very clear to all of you that we cannot afford the luxury of good manners right now. We've got to doubt, to question, to make each other prove what is said. We aren't going to have the chance---or the time---to be anything but outspoken and direct. That's why Alex and I are the only clinical infectious disease people here. If we need outside help at any time, we'll get it fast. Right now, the fewer people involved the better. General McKitridge has spoken to the President about this. He's asked me to take charge, and I agreed. For the present, I prefer to do it this way. If there are any objections, let's get them over with now so we can go to work."
No one knew enough about what was going on to object.
Max Schwartz reached into his trouser pocket and pulled out a piece of paper. As he unfolded it, the linear and longitudinal numbers and letters identified it as computer readout. He spread it on the table before him and ran the edge of his hand over it to smooth out the wrinkles.
"These figures were received from the Communicable Disease Center thirty-five minutes ago. In the past thirty hours 4,316 cases of pneumonia have been reported. Most of these have been classified as 'staphylococcal pneumonia' or 'pneumonia, type unknown.' All the patients have died; only fatal cases are reported so quickly, anyway. If we say as a conservative estimate that only one out of every ten cases is reported---that's about average for most reportable diseases---we come up with the startling figure of about 45,000 cases of fatal pneumonia that have occurred in the United States in less than two days. Over the past two years, gentlemen, there were a total---a total, mind you---of 300,000 to 500,000 cases of fatal pneumonia per year.
"Even being conservative, I estimate that we are seeing more than fifteen times the usual number of cases of pneumonia. This means we could see over eight million cases in the coming year. But," he paused, "this figure is based on an assumption that approximately the same number of cases will occur tomorrow as today; in other words, that the rate will be constant. The figures for the last thirty hours show that the rate is not constant. It is increasing. Now what can this mean? To me several things. First, the disease, whatever it is, may be communicable. A infects B; B infects C and D; and so forth. On the other hand, it could mean that the source of infection is continuing to increase in size; in other words, as the bug multiplies, more are around to infect more people. Although I hate computers, I didn't have enough time or paper to figure out the projected figures based on an increasing, rather than a constant, number of cases per day; so General McKitridge fed some of the crude data into the computer at the Pentagon so we could have some figures to give you.
"At this projected rate, gentlemen, there will be approximately 250,000 cases in a week, about three million in a month, and"---he stared hard at the group---"at this time next year there will be nobody alive in the United States! We shall have been wiped out."
The silence in the room was absolute. At first, each of the six listeners merely stared ahead. Then one by one they turned and looked at each other. Each had heard the figures. Their validity had to be substantiated, but each asked himself, "What difference would it make if Schwartz were only half right? A fourth?"
The professor continued. "Now let's get down to some basic questions. What could be going on? First, no natural disease I know attacks on such a scale. Would you agree, Dr. Rahway? Dr. Tracey?"
Both nodded their agreement.
"If it's not a natural disease, what is it? Perhaps a laboratory accident. I checked briefly; none has occurred. Have your surveillance teams uncovered any accidents, Mark?"
"Not even a hint of one, Dr. Schwartz. We haven't had too much time to check, but we've contacted all the major labs known to be working with 'hot' agents. No accidents. The safety checks at these kinds of places are pretty damned good, so it's unlikely that even a very minor 'spill' would have gone unnoticed. It is possible that some 'mongrel joint' is playing with something, but there are very few even of these that aren't monitored by government safety agencies nowadays. We're in the process of checking into them and should have some word in a couple of hours."
"Another possibility is that our store of biologic warfare agents is the source. Would you give us a report, Mark, to get the puzzled look off everyone's face." Max Schwartz again surrendered the floor to General McKitridge.
"Gentlemen, when Fort Detrick was closed in 1971, we were faced with the problem of what to do with our so-called 'stockpile' of weapons. Should we destroy all the 'bugs' as Dr. Schwartz likes to call them? In addition to the practical and logistical problems involved in doing so, there were two other aspects we had to consider. First, if we did destroy everything, we would essentially be stripping ourselves of all power in this area and would have to start over from scratch if the need for such a program arose at any time in the future. Second, the value of these microorganisms, not in dollars and cents, but with regard to potential usefulness in microbiologic research, was immeasurable. It was, therefore, decided by the President, by the Joint Chiefs of Staff, and by the National Security Council that these organisms should be stored in a safe place, the identity of which would be known to only a handful of persons who needed to know to insure safety. The way the system is set up, no leak could occur without being detected. There has been none. Please continue, Dr. Schwartz."
"I think, for the moment then, we must assume that my original premise is correct."
"Excuse me, Dr. Schwartz." General Slade looked around the table. "This is just not what I envisioned a biological warfare attack would be like. How about you, Jim? You've had experience with natural epidemics---could Dr. Schwartz be wrong? Could this be just some weird natural disease?"
Rahway just shrugged his shoulders. The look on his face suggested that at least he did not disagree with Dr. Schwartz.
"What did you expect it to be like?" asked Max Schwartz. "Purple gas being sprayed from silver rockets marked with skull and crossbones? Jet bombers dropping glass bombs filled with bubbling green fluid? Don't be naive, General; if it were that way, even some dumb 'shavetail' fresh out of West Point would get the hint. How long do you think it would take your boss to push the button and release all those atomic missiles I've been paying for with my tax money? No enemy would take a chance on our ability to retaliate. The only way it could work would be if the enemy could mislead or confuse us. Their hope must be to kill or incapacitate us all before we recognize this as a biological warfare attack and before we identify our attacker and push the button. Our enemies know we won't push that button if there's one spark of doubt in our minds---too expensive for us.
"But who is the miserable son of a bitch who started this? Russia? Red China? Our other 'good friends' in Asia? Somehow I don't think any of them is that dumb---or brave enough to play this kind of game. I think it has to be somebody we wouldn't suspect, somebody who hasn't got as much to lose. What do you think, Mark?"
"I think you missed your calling, Dr. Schwartz. You should have been a general---or a politician."
The break in the tension was welcome.
A little over two hours later, a messenger brought the next report from the Communicable Disease Center to Max Schwartz and handed a sealed envelope to General McKitridge.
Both men silently scanned the computer printouts and frowned.
Dr. Schwartz spoke first. "Latest total reported, 6,813 cases. That's a hell of a lot of fatal pneumonia in less than two days. The slope of that curve is increasing faster than we had anticipated." He looked over at the paper McKitridge held. "Anything we should know about?"
"Well, Max, I'm afraid you're right. After you called me this morning, I got hold of CDC's latest statistics and gave them to Jerry Busch, our computer analyst. He went over them with one of the epidemiology boys and then programmed a set of equations. To make a long story short, the behavior of whatever we're seeing is unlike that of any natural disease in its memory bank." He paused. "That's not all. Busch got the clue, so he crisscrossed the tapes, or whatever he does with that mechanical brain, and fed it some data gathered at Detrick during its heyday. The present data compared well with project DADA-68-X542TS. That 'TS' stands for 'Top Secret,' so we had to get clearance to break the code. That project was a series of mock-up field tests to evaluate a bacterial warfare agent. Got to hand it to you, Max. You're better and faster than a computer."
McKitridge looked around the room. "Well, gentlemen, anybody got any doubts left?" There were none. What the professor had suspected was horribly true.
"We can indulge in self-pity later. Let's check our assignments again and get to work fast." Max Schwartz scanned his list.
"Marion, you're going to get things going. Right?"
"Right! In a couple of hours we'll have communications to all the major cities involved, CDC, the National Institute of Allergy and Infectious Disease, and the White House. We'll have a line to feed data to the computer here at Detrick and one to Reed in case we need theirs. We'll have fast helicopter service to Andrews and supersonic jets from there to transport anything needed. I'll have sleeping quarters set up in the old bachelor officers' quarters for all of us and any extra personnel we may need. We can use the dining facilities here on post. All the lab equipment you need and more is right here; no problem. Anything else?"
"No, that's fine. General Rahway, are you set? With your knowledge of epidemics, you should be a great help."
Rahway looked at his notes. "I've got all my stuff at Reed, so I'll start in Washington to try to protect some top level and critical government people. I plan to get twenty teams out in the next few hours with a physician and an epidemiologist on each; I'll try to send a bacteriologist to join them later. We'll start with the largest cities, but we'll try to get a team to every trouble spot as soon as we can. One problem is that we may be crippled by the loss of essential personnel. We'll have to keep in touch."
"Warren, what about you? Can you set up your screening tests and evaluate from here?"
"I'll stay; it'll be like old times for me." Tracey spoke with a slow, soft drawl that reflected his Midwest birthplace. "Marion can have blood samples flown in, and we'll run them here. All the equipment is probably stored in my old lab anyway.
"Marion, can you send me about six lab technicians?"
Tracey turned to the general. "And a good top sergeant as a supervisor?"
"This afternoon, Warren. By the way, Dr. Schwartz, I'll send you whomever the Chief of Bacteriology from Reed can spare to help you out. Is that all right with you, Jim?"
General Rahway nodded. "But I'd like to save some hospital personnel to work on the cultures that come into Reed and for the epidemiology teams." He paused. "Say, why don't you get Sam Ross? He's the best diagnostic bacteriologist we ever had. He retired last year, but he's living over in Rockville."
"Good idea. I'll have him out to you soon as possible." Slade made another note on his clipboard.
"And you, Roger, will brief the President. Be very frank with him. We may need his help at a moment's notice. Tell him General McKitridge will personally keep him informed. Dr. Kahn and I will remain here and take a careful look at what cultures we have so far. I've arranged to have random specimens sent here from at least a dozen major hospitals. The only chance we have is to isolate and identify this damned bug. If we can, we should have enough drugs in our armamentarium of antimicrobial agents to find one or a combination that should work. If not, we can get some of the super-chemists at one of the drug companies to invent one for us."
"I'll be commuting between here and the Pentagon, Max." McKitridge gathered his papers and stood up. "I'll arrange to have every bit of epidemiologic data teletyped directly to you. I'll be back in a few hours, after I've gone over the situation with the Joint Chiefs. Maybe they can figure out why all this is happening and pinpoint the enemy; they're much more up to date on the minute-to-minute changes in the international situation than I am."
"Max, I have a question," General Slade interjected. "Is there anything we can take---penicillin or something---to prevent our getting sick? Should we wear protective clothing?"
"Just use common sense, Marion. Wash your hands frequently and thoroughly. Be careful what and where you eat. Avoid sick people; wear a mask if you do come into contact with anyone ill. How can we prescribe prophylactic antibiotics when we don't know what the bug is?
"For the time being, let's approach this problem logically. Panic can only lead to disaster. If there are no other questions, I think we're about through."
The men rose, put on their jackets, nodded farewell to one another and started to leave.
"Gentlemen." It was Max Schwartz who spoke. "A moment more of your time." He paused. "I am a Jew by birth. I have not practiced much religion since. One can always find excuses. There comes a time, however, when science and skill and knowledge are not enough. A time when we must believe that there is a God, some Being who watches over us. This is such a time. Will you join me in prayer?"
The doctor's voice was soft, but his eyes reflected his fear. At the acme of a success attained by few, Max Schwartz was humble.
The room fell silent as all returned to the table and stood, heads bowed.
"God, before you stand seven men," the professor intoned. "Good, wise, dedicated men. But imperfect. Never before in the history of mankind has so great a burden of responsibility rested so heavily on so few shoulders. We stand on the brink of disaster. Help us, Lord, to be wiser, to think clearly. Help us to overcome this enemy whose sword is disease, whose weapon is suffering. We beg You, Lord. Amen."
As one they turned and left the room.
No one could have predicted what it would be like. A virulent epidemic of a fatal disease was entirely foreign to the United States in the 1970's. In the first half of this century, advances in American medicine had essentially conquered commonplace illnesses, and through antibiotics, most bacterial infections were now controlled. Excellence in preventive medicine had paradoxically made the United States especially susceptible to this new plague. Freedom from epidemic disease had produced a community totally unprepared, and it now began to bend beneath the overwhelming burden of the sick and the dying.
It was a matter of priorities---when thousands were dying, what was the value of a single life? Soon that terrible choice would have to be made between who might survive and who could not. Until then, the need to fight for every life began to saturate the medical facilities available.
It was a matter of medical economics---the number of physicians, nurses, paramedical personnel, hospital beds, and medication versus the number who needed these vital commodities. The first terrible lesson to be learned was that the demand far exceeded the supply. Soon there would be beds in the corridors, in the lobbies, and wherever space allowed, until there would be no empty beds at all; soon the sick would lie on benches, on mats, on the cold concrete floors or wherever there was a space to die. Doctors and nurses became a luxury for the few who came first---the rest died while waiting. It all became a matter of waiting---once illness struck, life waited for death to consume it.
All the normal statistics suddenly became meaningless; the only statistic that mattered was the number of deaths. There was no treatment, no cure, no prophylaxis, to combat this unknown illness that telescoped life into a few short hours of agony before death.
Martin Beck had been sitting for hours in a corner of the lobby of the Baltimore City Hospital. He watched the rain on the large windows blur the headlights of the approaching ambulance. The suspicion and the hatred were returning to rekindle the spark that would soon grow into uncontrolled vengeance.
The night, the rain, the sounds and smells of the hospital were all the same, but that had been years ago...
He had finished his chores at the experimental animal farm at Fort Detrick and was walking back to the guardhouse to turn in his security badge before leaving for the night.
Dark clouds hid the hilltops, and the entire fort and the surrounding countryside were enveloped in a heavy mist. The rain was refreshing, and he could feel it blowing in his face and trickling down his neck. The road wound in a black ribbon from the duck pond, beside the fields used for growing experimental corn, and then down to the laboratories near the main gate. Head down, hands thrust deep into the pockets of his raincoat, he walked slowly, breaking his stride only to kick the pebbles by the roadside. He needed time to think through the inner conflicts that grew each day he worked at Detrick.
His older brother, Jerry, a maintenance man at the Fort, had gotten the job for him. At first it had only been little things that disturbed him. He'd forgotten to turn in his security badge one evening and had been given a severe reprimand. Then he had left the door to one of the "hot" labs open and had been given a long lecture by some second lieutenant fresh out of college. Now all the regulations, the secrets and everything else were gnawing at him. The protestors recently outside the gate with their handout pamphlets had given focus to his dissatisfaction. It wasn't the place that was wrong---it was the program. That was a threat to mankind. Biological warfare was the immoral utilization of science as a weapon for destruction. But he was not certain he could find another job, and he would have to resolve this conflict between his need for employment and his recently acquired scruples.
He looked up and blinked as the rain struck his eyes. As he brushed away the drops, he watched the distant headlights grow larger and brighter as they approached.
"That son of a bitch must think the speed limit is for everyone but him," he thought as he moved off the road onto the gravel shoulder to avoid being splashed as the vehicle sped by.
He glanced backward as he heard the squeal of the brakes. The driver stood up and looked back at him. He hadn't bothered to put the canvas top on the jeep, and the rain ran in rivulets from the rim of his helmet and down the front of his raincoat.
"Martin Beck?"
"Almost the late Martin Beck if you'd skidded on that wet asphalt." He started to walk back toward the jeep, but the driver was backing up toward him almost as fast as he had passed.
"Something's wrong with your brother. They want you at the base hospital. Get in; I'll drive you there."
As he climbed in, Martin Beck felt a sudden surge of panic. Jerry worked in one of the "hot" areas. It was a dangerous job, but Jerry needed the additional hundred dollars a month hazardous pay---his oldest son had muscular dystrophy, and doctor and hospital bills were high. Jerry had known the risks of working in these buildings, but he also knew that an intricate system of safeguards protected him against all but the most overwhelming exposure to some virulent agent. Martin Beck was certain that was what must have happened, and his rage at Detrick grew as fear for his brother gripped him.
As the driver made a wide turn to head back toward the base hospital, the jeep skidded, swayed, and then sped down the wet, black road. Martin Beck pulled his collar up around his face to protect it from the enveloping spray as they raced through the cold mist of the falling night.
Martin Beck didn't hear the doctor's words as he stared at his brother who lay in the isolation room beyond the glass partition. A nurse in a white protective gown, cap and mask was adjusting the intravenous tubing. Jerry Beck was dying, and his brother knew it.
"He was working in the crawl space above one of the 'hot' labs and fell through the ceiling, rupturing one of the supply lines. He must have gotten an overwhelming dose of the bug. We've done everything possible." The doctor's words seemed miles away. "He won't make it, Mr. Beck. I'm sorry."
"Sorry?" Martin Beck said the word silently to himself. He pressed his face closer against the glass---as he and Jerry used to do as children when they'd stand at the large living room window and watch the snow paint the Cumberland hills white.
"Jerry." He formed the word with his lips but no sound came
He stayed until the end.
The siren of another ambulance interrupted his reverie and brought him back to the present. It was the seventh ambulance in the last ten minutes. Something was very wrong.
He looked up as two doctors, both unshaven, both appearing tired, sat down on the couch across from him. They talked in soft staccato sentences between sips of coffee from paper cups.
"Something's wrong, Jack. Ten deaths from pneumonia in the past hour, and three more dying in the ER. What's going on here?"
"Keep your voice down." The man looked up and seemed to see Martin Beck for the first time. He leaned closer to his colleague.
Beck suddenly became alert. Without moving or changing his expression, he listened harder.
"Paul Kendall called me from Pittsburgh ten minutes ago. Wanted to know if we could spare some penicillin."
"Pittsburgh? How the hell could Pittsburgh run out of penicillin?"
The voice became lower, but Martin Beck heard every word. "They've had eighty-six deaths from pneumonia at his hospital alone. It's the same at University, Montefiore, and Children's. They're all running out of penicillin"---he paused and looked around again---"and everything else. They're declaring a state of medical emergency."
"Why didn't you tell him to call Frank Andrews at D.C. General? He's an infectious disease man. He should have loads of penicillin available."
"He's already done that. Same thing in D.C. Philadelphia, too."
"New York?"
"Uh-huh."
Beck had heard enough. He got up quietly and left.
He drove slowly, trying hard to watch the double yellow line in the middle of the road outlined only by the dull headlights. The rain made the road slick and caused the light pickup truck to sway and skid around the curves. The silence, broken only by the rain beating on the roof, gave him ample time to think.
Since leaving Fort Detrick almost ten years before, he had been working part time at the Baltimore City Hospital. This gave him enough to live on and ample time to act as leader of a group of political dissidents.
In all the years he had worked at the hospital, he had never seen so many ambulances---not even during his shifts in the ER---and the conversation he had overheard increased his feeling that something was terribly wrong.
The rain was beating against his windshield making it difficult to see, and he tried to concentrate on a sharp curve ahead. Out of the corner of his eye he was watching the water leak through the metal frame of the window in front of him when it suddenly hit him---a leak---Detrick!
From the first day they said Fort Detrick was to be converted to a cancer research center, Martin Beck had refused to believe it. Perhaps it was his cynical nature; perhaps it was rage over his brother's death. But he had an unalterable belief that it was a lie. Martin Beck could only see things in terms of black and white---gray was to him an inconceivable abstraction. He had learned much from his association with the Army---the main thing was to doubt the statements for public consumption, the plans for phasing out and for de-escalation. Detrick was a billion-dollar installation endowed with immeasurable war-making potential. He could not conceive that the generals would just call a halt to it all; he could not imagine that they had suddenly acquired such altruistic goals as the health and welfare of mankind.
About two years before, he had persuaded a friend, a deliveryman for the post cleaners, to take him through the main gate in his truck. In disbelief he had walked around the huge complex unnoticed. There was little security, and to the unbiased eye Fort Detrick was, indeed, no longer functioning in its previous capacity. But as fate always predetermines all things, Martin Beck could not help but see the large vans and tank trucks parked at one corner of what appeared to be a closed laboratory. Then it was simply an innocent question here and there and equally innocent answers. All the talk about the destruction of biological warfare agents was, he was sure just that---talk. He was right. No one in his right mind would just throw away this valuable stockpile of death. He had the single half-truth that he needed to perpetuate his cause.
And now, two years later, driving through the wind and rain, he began to put the pieces together. In his fanaticism he had no difficulty devising an equation that he solved with equal facility.
He drove faster. The time had come to act.
Alex Kahn was worried. His fear increased as the hours passed. Time was rushing forward---as if the end of its journey were in sight. Max Schwartz's prayer had disturbed him. He had prayed not as a showman but because this time he was not certain he could handle the "buck."
For three hours now, Alex had watched the famous Dr. Schwartz work in the laboratory. Wearing the rubber apron that was his trademark, he examined the cultures. With flawless technique, he prepared subcultures to propagate and preserve the organism. He inoculated special media that would reveal specific characteristics of the microorganism that might lead to its identity. Utilizing carefully standardized pipettes, he prepared dilutions for bacterial counts and serologic tests. The next progress meeting was scheduled for 6:00 p.m., and he wanted these preliminary studies underway before then.
As Dr. Schwartz became busier, he motioned Alex to join him at the bench. For a time they worked in silence except for an occasional word to call the other's attention to some seemingly important observation.
They took special care in preparing the anaerobic cultures. Max Schwartz had preached for years that when cultures did not agree with the clinical disease, one must always suspect an anaerobe, a microorganism that grows optimally in the absence of oxygen. Anaerobes were difficult to work with. Most grew slowly---some required three to four weeks to produce detectable growth. In addition, it was difficult to remove all oxygen from an incubator jar.
As they finished replacing the air in the anaerobic jars with nitrogen, the professor became more talkative.
"I'm betting on an anaerobe, Alex. Probably a mixed infection with the staph we're seeing plus an anaerobe. A synergistic infection could explain the whole thing." Max Schwartz's paper in the Journal of Infectious Diseases in 1946 was one of the first clinical reviews of synergistic infections, where two microorganisms resulted in an infection that neither could produce alone. He had pointed out what had come to be called "Schwartz's Paradox"---one saw two microorganisms under the microscope but recovered only one by the usual cultural techniques. He explained that the positive culture usually reflected the presence of the aerobic member of the pair; the anaerobic organism, requiring more time for growth, might not appear in cultures until two to three weeks---sometimes longer---after the first.
"I don't know, Dr. Schwartz. We've seen only one organism."
"We see what looks like one, Alex, but there could be two that look alike. This whole thing is so damned strange, nothing would surprise me." He looked at his watch.
"Everything cleaned up? All the cultures in the incubator? The next batch of epidemiology reports ought to be in from CDC by now. I want to look at those before the meeting starts. Let's go."
"There have been 10,318 cases! We're in trouble, Alex." Max Schwartz made a few mental calculations and frowned. "This thing is spreading faster than we anticipated. If we don't come up with some answers soon, there may be nobody left to treat---if we can find what to treat and how. If we could only get our hands on the bug and identify it! At the rate this thing is spreading, we've got only a limited amount of time to find the answer. I don't like to rush; you make mistakes. And we can't afford mistakes this time."
"Maybe something's turned up. It's been six hours."
"Wishful thinking, I'm afraid, but let's see at the meeting."
They walked into the conference room. Two new faces had been added. Alex recognized both of them as Max Schwartz greeted the newcomers.
He had met Sam Ross several times at the annual meetings of the American Society for Microbiology. Ross was a classical bacteriologist who had just retired as Chief of Clinical Bacteriology at Walter Reed; he was highly respected for his diagnostic work in isolating and identifying bacteria from clinical material.
James Calvin was a man of his own age, and he was the person who had made epidemiology a computer science. He could take data other people gave him about outbreaks of disease, convert them into symbols on magnetic tape, and pull the answer out of the other end of a computer. Alex was anxious to see what he could do with their data.
As Alex took his seat, Max Schwartz was starting to speak:
"Before going any further, I want to take a few minutes to tell you what we're up against. We haven't had much time, of course, but I'd like to give you what we do have. Perhaps someone will have some suggestions. Especially you, Sam. I'm sure you and Jim have been filled in on the details." He smiled at the bacteriologist.
"You're all familiar now with the problem. Basically, the disease is an overwhelming pneumonia. The bug is probably contracted by inhalation. That narrows it down some. This would mean that the bug has to be transmitted either in the air or by dust, droplet or some other inanimate object on which it can live.
"I'm not sure whether it's transmitted from man to man. I think the clue may be in that resident and the Infectious Disease Fellow at Alex's place who both died within hours after their first exposure to a patient. I don't know of any disease that could be passed form one person to another and be fatal so quickly. The inoculum, or number of bacteria that would have to be passed, would be phenomenal. Why, the recipient would almost have had to breathe in pure pus. These patients don't even bring up sputum. No, I don't think it's passed from person to person. The people who seem to 'catch' it from one another must coincidentally have been exposed to the same source. It just appears that one has given it to the other. Damned clever. We could waste a lot of time on precautions and isolation rather than looking for the source. What do you think, Alex?"
Alex Kahn knew he had been "had." Of course, that was it. Why hadn't he thought of it? Max Schwartz was absolutely right. He'd spent all his time trying to figure out how the hell Brubaker and Richards had contracted the disease from their patients so quickly, when in fact they might have been carrying it for days---even weeks---and become sick only when the number of organisms in their bodies had become great enough to cause the disease. If a large number of people had been exposed at the same time, they'd all get sick at about the same time.
"I think you've hit the nail on the head, Dr. Schwartz. I never thought of that possibility. It completely threw me off the track."
"Exactly what it was supposed to do, Alex."
"I have a question," Warren Tracey interrupted. "Why are the cases increasing so rapidly if it's not transmitted from man to man?"
"Because more and more persons are being exposed to the source, and the size of the source increases as the bacteria multiply."
"That makes sense. Go on."
"Let's take a look at what we have," Dr. Schwartz continued. "Very little. The staph we've recovered in Boston are the same as those Alex has recovered; from what I gather it's the same all over. It's a phage type 80/81. That's a way of classifying staphylococci---to make it simple, by the viruses, or phages, they keep company with. It's somewhat resistant to penicillin, but it's fairly sensitive to other antibiotics, though only in the test tube. None of these drugs seem to work in patients. Why?
"If the staph we're seeing is the bug but doesn't respond to therapy, that could be for a number of reasons:
"The sensitivity testing could have been performed improperly in the laboratory. Very unlikely. I checked all the tests myself.
"There's always the possibility that, due to some freak accident in preparation, a large batch of antibiotics came through with decreased or absent antibacterial activity. Also very unlikely. My lab and two others checked random samples of fifteen different drugs we had used from four different companies. We also had the quality control divisions of these companies check them for biologic activity as well as chemical identity. The drugs are all OK---at least in the test tube. Once again, I can't emphasize enough that what we see in the test tube, in vitro, may be quite different from what we find in patients, in vivo. This is something we must keep in mind.
"It's possible that after the drug is given, something in the patient or something produced by the organism itself inactivates it. As far as we can tell, there seems to be nothing to interfere with drug effect except for the penicillinase that the bug produces. For the nonbacteriologists among you, penicillinase is a substance produced by some microorganisms that inactivates penicillin.
"What are the chances that the staph we're recovering is only one of several organisms that could be causing the disease? This is a real possibility. Staph is fairly easy to grow; it could be overgrowing everything else. I'm leaning toward a mixed infection caused by the staph and an anaerobe. This type of synergistic infection is very virulent and difficult to treat. We could have a problem here because it may take a long time to grow the anaerobe. Another possibility is that we could be dealing with a very unusual organism that requires special culture media. It could be a matter of trial and error to find the right cultural conditions. Sam, I'm hoping you can help us here."
Alex Kahn never stopped being amazed at how Max Schwartz could simplify the information to put the entire problem into perspective. But he thought Schwartz's theory about mixed infection failed to fulfill one of the usual requirements---they had not seen two organisms. But why was the staph acting this way? Why was it different from the hundreds of other infections he had seen with the 80/81 strain? Since the advent of the newer antistaphylococcal drugs in the early sixties, 80/81 had been much less of a problem. Maybe it had changed.
The course of the next few days might have been quite different had Alex Kahn's thoughts not been interrupted by Calvin, who started to speak as he taped some charts to the blackboard. At this point the epidemiology of the infection was as concrete as any other data they had.
Calvin added little that shed light on the problem, but he presented the data well, carefully defining the attack and case fatality rates. The available statistics were listed, charted, and converted into multicolored lines on graphs and diagrams. He showed maps of population, industry and the availability of medical facilities in affected areas of the country. Each important variable appeared as a colored or characteristically shaped symbol on the map.
Alex watched and listened. The audience was attentive and impressed. He looked at Max Schwartz. His pose was the same as before---chair tilted back, knees up, hands folded on his belly, face outlined in the smoke that curled upward from the dangling cigarette. The "boss" was impressed, too.
Alex looked for his opening. He needed that weak spot in Calvin's presentation to mar his flawless job, to put the two contemporaries on equal footing again. Max Schwartz had taught him well. Don't let the competition gather too much momentum.
It was a weak blow, but it might work. The epidemiologist had shown another map of the country. On it were black dots that illustrated the clusters of deaths around forty major cities, with an occasional dot on the periphery. He flipped to a map of the Northeast to demonstrate the number of cases in Boston, New York, Philadelphia, Washington and Baltimore.
Alex interrupted him in a carefully chosen tone. "Jim, I know you probably haven't had time, but I wonder if you've coned down on each of the cities separately? Do the cases occur in any specific section? Is there a pattern---for example, restaurants, colleges, beaches, swimming pools? Maybe even hospitals? You know, some suggestion of where the infection started?"
Calvin was ready for him. "I haven't had time to chart all the information, Alex; but the majority of cases seem to be clustered around the centers of forty of our major cities. We made a list of all the buildings and what's in each one and of the population densities by block and street in each of these cities. We fed this information to the computer to have it pick out trends and recurrent characteristics. The only common denominator is the main post office in the middle of each city." He laughed. "That's not really significant, though, Alex, as I'm sure you know." His tone reflected that he could play the game, too.
"Maybe they mailed the bug to us," Alex retorted sarcastically, but with a slight smile.
Max Schwartz suddenly sat bolt upright and stared at him.
"What did you say, Alex?"
For a fleeting second Alex wished he hadn't said anything. He should have let Calvin gain the "points." Max Schwartz enjoyed a good joke, but only at the appropriate time, and never at formal meetings.
Alex repeated his statement reluctantly. "I said, 'Maybe they mailed the bug to us.'" He smiled meekly.
Max Schwartz slammed his fist on the table. "That's it! How goddamned clever! I'd like to meet the smart son of a bitch who worked this one out."
The others stared at him blankly.
"Don't you see?" he went on, his voice and gestures reflecting his excitement. "They did just that. They mailed it to us. Like you said, Jim, every city has a post office in the center. What better way to disseminate an organism? If they worked it right---and I'm sure they did---that damned bug has been contaminating every letter, every package, every stamp that comes out of the post offices in those forty cities." He pointed to the map Calvin had just shown. "Simple, effective and deadly! I'll bet you every person who walked into one of them walked out carrying the bug. Probably in the nose and throat. Then all you'd have to do was wait around for it to multiply and travel down into your lungs. They had the U.S. Mail delivering the bug to your doorstep. Open your mailbox, and you've got it. No wonder there are more cases around the center of town. The number of organisms is inversely proportional to the distance from the source. The greater the distance, the greater chance for the number to decrease on an inanimate object which won't support growth for an indefinite period of time---such as an envelope or a package.
"Marion, can you get enough men familiar with decontamination procedures to look into every one of those post offices? Tell them to be careful. If the organism is there, the number could be fantastic by now. Start with mail that most likely wouldn't be sent out. You know, damaged mail, anything that would cause a postal clerk to toss it into a dead bin. If I'm right, the packages, or whatever this thing came in, would still have to be in the post offices for it to work this way."
Marion Slade grabbed the phone and dialed a four-digit number while the others listened. For the fist time, it looked as if hope might be just around the corner.
"Paul, Marion Slade here. Listen carefully. I want you to do something for me.
"What do you mean you can't do it? I'm telling you that you have to do it. This is a national emergency. Your own miserable life may depend on it." He paused to listen.
"By what authority?" Slade repeated the question, his voice rising. "By mine. And if that's not enough, here." He pushed the phone toward Roger Bergen.
Alex was amazed. Roger Bergen merely said two sentences in a soft, leisurely tone before he put down the receiver. "He'll start within the hour. Every inch of the main post office in each of those forty cities will be carefully examined. Absolutely anything that appears suspicious will be flown here in airtight plastic bags. It may take some time, but it will be done."
Obviously, the Postmaster General knew Mr. Bergen.
They waited. Like expectant fathers, they paced the floor, made small talk, drank coffee and smoked.
The hours passed, and they waited---for the word that would prove or disprove the ray of hope Max Schwartz's astute mind had given them.
"If we get the organism, we probably will know where it came from and why, too." Dr. Schwartz was thinking out loud. Like the others, he kept looking at the phone.
"I'm sorry, I don't understand you." General McKitridge was glad to have something to talk about.
"A man is identified by his work. Most bacteriologists are known by the microorganisms they study---physicians by the diseases they know best. For example, take me. If you mention streptococci or meningitis, you think of me---and a few others, of course." He laughed good-naturedly; he wasn't sure, in fact, that there were others. "When we identify the organism, we'll have a pretty good idea of the people who are good enough to pull a trick like this."
Alex Kahn took comfort in the fact that Max Schwartz had changed his "ifs" to "whens."
The call finally came at midnight.
No one moved. All eyes turned to Marion Slade, everyone expecting him to take it. He lifted the receiver.
"General Slade here."
These were his only words.
When he put down the receiver, he walked over to Alex Kahn and Max Schwartz and shook the hand of each. His face broke into a broad smile.
"They've got it!"
The forty cities had been chosen for death because together they were inhabited by 35 percent of the population of the country. Many were centers of government, industry and culture. What better targets?
A city is many things. A star, a red dot, a small grid of squares on a map to symbolize its size. An area of land limited by arbitrary borders. A place where people come to live, to work, to dream, to marry, to bear children---and to die. A cold, impersonal mass of steel and stone and concrete and glass. But most of all, a city is people. People to walk on the streets and boulevards, to live and work in the houses and buildings that make up the blocks, to think and agree and disagree. People---all the rest is merely a shell for them to inhabit, a skeleton to give them support. Without them, a city has no soul, no life. And this weapon was aimed at the people.
They lived, they became ill, they fought for life with their fight for breath, and they died---all without knowing. For Max Schwartz was right. There were no clouds of deadly vapor, no broadcasts to announce a war, no signs which warned of plague.
At first size was the cities' protector. For in the great and endless mazes, the fear diffused. A hundred died, then two hundred, then three hundred and more. Yet who knew? The impersonal hand that wrote their names in hospital records and statistical tables knew. The doctors and the nurses---the ones who helped them fight and watched them lose---knew. And the figures dressed in black who laid them in the ground---they knew, too.
Fear is, in part, translated into a series of predictable, stereotyped, physiologic phenomena common to man and animals alike. The pupils dilate, the mouth becomes dry, the pulse quickens. This happens to all; yet each person reacts differently, his reaction predetermined by memory, experience and environment. This is what makes the individual response to fear unpredictable.
At one time or another, disease had been a part of all of their lives and death an abstraction of the future that belonged to others. Max Schwartz alone had seen what they could not. This new evil spreading now unchecked up and down the streets, into the homes and houses of the forty cities---and soon beyond---was not the evolution of a disease natural to them all, but a man-made curse. This was no "flu" epidemic from Hong Kong or England, no measles outbreak in Boston; this was no disease they had felt before.
And with each new death, the vicious cycle of fear and death began. No one was spared.
Lori Kahn was frightened. She stood on the sundeck of her parents' home in New Hampshire and listened to the wind moving through the pine trees that lined the shores of Lake Winnipesauke. The cool evening breeze rippled the orange reflection of the setting sun on the lake in a peaceful, never-ending rhythm. Crickets chirped, and now and then heat lightning lit up the distant horizon. Another time it might have been an ultimate evening, but what she had just heard would have spoiled even the most beautiful sunset.
Their next-door neighbor was visiting with them. He had just returned from New York, from the funeral of an uncle who had died suddenly from "overwhelming pneumonia." He had planned to stay on for a few more days, but what he had seen and heard had convinced him to return home immediately.
Some sort of fatal epidemic was occurring in New York. People were becoming frightened, and their fear was contagious.
There were also rumors that it wasn't just New York; it was also Boston, Philadelphia, Washington, and several other large cities.
Lori had excused herself and come out onto the sundeck to be alone with her thoughts and fears. Alex was in New York, and she hadn't heard from him.
She hated it when they were separated, but she knew his career demanded that he attend scientific meetings, accept speaking invitations, and serve on various committees that often required travel. She had even grown accustomed to not hearing from him for a day or two. Until now she had not been worried. He had told her on Sunday when he had put her and the children on the plane to New Hampshire that he would call as soon as he was settled in New York.
Suddenly the sun's last rays were gone, dark clouds hid the moon, and the wind turned cold. She pulled her cardigan tightly about her. It was beginning to rain as she went into the house to find the name of the hotel in New York where Alex would be staying until she and the children joined him.
Gamal Machdi sat in his room and mourned alone in the silent darkness. His father was dead. The separation had been too long, the rift too great, the differences too many for him to weep. There were only memories mixed with guilt and anger and a terrible gnawing ignorance of why and how death had come to the man who had been his father.
Gamal Machdi was very unlike his father. He had attended the university only at his father's insistence. Gamal's interests lay not in books and laboratories, but in people. As his ability to observe became keener, he began to see his life and those of others dominated by petty bureaucrats lusting for power under the guise of democracy and nationalism. To Gamal Machdi, that his father merely continued working in his narrow, private world no matter which government paid his wages or supported his research was inexplicable and unacceptable.
At first, father and son talked about it; they listened to each other and discussed. As time went on, they still talked; but now each knew he could never understand the other. Finally they realized there was no further need to speak; their views, their attitudes, their loyalties would never be the same.
They grew apart, seeing each other less and less and finally not at all. Gamal had glimpsed his father for the last time while he stood waiting outside the Government Center for a friend who was obtaining an illegal passport for him. Ahmed Machdi had been on his way to a meeting; he had not seen his son. Gamal had stood there silently and watched his father pass by. That he did not speak to him or embrace him would haunt him with guilt for the rest of his days.
Gamal Machdi had not been too old to fight. With courage and zeal he had joined a group whose goals were to restore dignity and freedom to their people and a place of respect among the nations of the world to their country. They were few in number and poorly organized; they had little money; their discovery was inevitable.
Gamal's choice was difficult: to stay in his country meant execution for treason; to leave meant to bid farewell to his home to start over in a strange land.
Gamal Machdi had come to the United States in 1956. He had at once realized that here was a place where he could still work for his homeland. He went back to school and excelled. With time came success. As Professor of Political Science at the City College of New York and as an expert on Middle Eastern affairs, he found adequate outlets for his nationalistic pride. He made peace with himself and with his new world. He wanted to make peace with his father, too---if only to rid himself of his plaguing guilt.
Finally, at the time of the cease-fire in the Middle East in 1970, Gamal had written to his father. There had been no answer. But now, only four days ago, he had returned home to find a notice that a registered letter was waiting for him at the main post office.
When he saw the postmark on the letter, he tore it open with great anticipation. The only message it contained was an official notification of his father's death. It was too late.
And so now for three days Gamal sat in loneliness and mourned and said to himself the words he should have said to his father long before.
It was warm in his room. But should he be so hot? He rose and turned on the light; the effort was overwhelming. There did not seem to be enough air. He reached to open the window. His hand and arm moved, but he could not feel where they hung in space. The lack of air was suffocating him. He sat back in his chair and tried to think, to take inventory of all he felt and of all his parts.
His left thumb was numb, and the numbness was spreading. Now the index finger; then the middle finger and part of his palm. As the lack of feeling overcame the ring finger and then the little finger, the whole of his left arm became dead. His brain told the right arm to move and lift the left---the volition was there, the parts were there, but the integration was lost. He looked across the room at the phone. But even as he looked, his vision blurred. The heavy pain in his chest, the feeling of suffocation, the will to move, the need to call for help, were all clearly imprinted in his mind. He could not move. He fought for breath. He thought it was too dark---perhaps the light bulb was failing. Darkness was enveloping him, separating him from reality, devouring him.
He experienced two final sensations---he tasted the blood welling up in his throat; he saw the red spots blossom on his feelingless hands. Before Death called, he had had one last fleeting chance to see his father---not the man, but his handiwork. But he never knew.
And so death came. To one. To many. Wherever it visited, it cast the shadow of fear on every life.
At first, it was fear with reason; but with time, fear would overcome reason---then there would be panic.
There is no greater catalyst for an epidemic than panic. For in the sudden, unreasoned and hysterical fear when caution and judgment are lost, disease spreads like wildfire.
In Washington, Chicago, Los Angeles, and all the other cities, people watched and waited. They watched persons known and unknown fall ill; a few lived to reach the hospital, but none returned. They waited in fear to see who would be next. They waited for an official word---from city and state health departments, from the federal government. None came. With this silence their fear grew; and then they began to see. They came step by step closer to panic.
None were spared. Men of wealth died beside the poor; strong men beside the weak; white men beside the black and yellow; Catholic beside Jew and Protestant. All fell before this enemy they could not see---an enemy they did not know and, therefore, could not fight. They could just lose. All of them.
The material recovered from the post offices arrived at a special holding area at Andrews Air Force Base. From there, it was transported to Detrick by helicopter and then by van to an area reserved for highly virulent and communicable agents. The packages were taken from the vans by automatic conveyor belts that delivered them directly to laboratories built for working with only the most hazardous materials.
Fort Detrick was famous---or infamous---for the best facilities in the world for working with highly virulent and contagious microorganisms. Many of its laboratories were designed with mazes of barriers to allow men, animals, air, water, equipment and waste materials to move in and out without contaminating the immediate environment or the surrounding countryside. The buildings and the laboratories within them were subdivided into areas of different degrees of contamination. The atmosphere in these areas was carefully controlled; a predetermined number of air changes occurred per minute, and a system of graded negative pressure controlled the movement of air---always from less to more contaminated areas. Passage of personnel from one area to another was interrupted by ultraviolet air locks, change rooms and disinfectant showers. Everything that entered or left an area or a laboratory was carefully monitored, and all waste material was sterilized before it was allowed to mix with the general sewage system. Even the air exhaust vents led through a carefully planned incineration system that could kill any living cell. Then the sterilized air was finally blown into the atmosphere through a series of filters in tall smokestacks that rose hundreds of feet above the buildings that housed the laboratories.
The basic feature of each laboratory was safety---safety for the personnel who worked in the laboratories and for everyone outside. Most of the laboratories employed glove boxes---airtight enclosures fitted with rubber gloves and a system of pass boxes and sterilizations devices. These completely separated man from microbe, yet allowed the former to work with and manipulate the latter.
The packages recovered from the post offices would be opened in one of these laboratories.
Although Max Schwartz had great respect for his own laboratory technique and equal disdain for the dangers of working with virulent organisms, he had raised no objections to the precautions engineered for this particular microbe.
A cursory examination revealed plain paper wrappings, cardboard cartons, and open flasks.
"Well, Alex, at least we know how it's being done." Dr. Schwartz frowned and rubbed his chin. "Each carton contained a flask with the culture reconstituted in liquid broth. The flasks were sealed with a special type of polystyrene which obviously dissolved in the time it took the packages to reach their destinations. That whitish material around the mouths of the flasks is all that is left of the seals. When the seals were gone, the cultures spilled. Once free, the number of organisms in the air and on any contaminated object increased to the level necessary for spread, making every piece of mail and every person entering and leaving those forty post offices a vector. Fiendishly clever!"
Samples of material were immediately sent to special units being set up by Army Intelligence and the FBI in another part of the building. These would be carefully examined for clues that might lead to the origin of the fatal pieces of mail.
Max Schwartz, Alex Kahn and Sam Ross went to work immediately with the help of six bacteriologists imported from Fort Meade and the Walter Reed Army Institute for Research. Although each had had some experience with glove boxes, they all found themselves clumsy because of the loss of the delicate sense of touch in their fingertips; but the gloves meant safety.
They made smears of everything. Fixed smears, where the organism was killed by the fixative, were examined with a variety of dyes to help define the size and shape of the bacteria and the presence or absence of characteristic intracellular structures; any or all of these factors might help them identify the microbe. They examined living organisms with special dyes that colored the cells without killing them. Many types of media were inoculated, especially specific inhibitory media that contained substances to prevent the growth of certain groups of bacteria and enhance the growth of others. Tests for biochemical, nutritional, metabolic and serologic characteristics were instituted. A variety of experimental animals were inoculated from the flasks themselves, as well as from the material that had been prepared by Max Schwartz.
"Goddamn it, Alex, what do you want to use monkeys for?" the professor barked. "They're hard to handle, expensive, and sensitive as hell. If you look at them sideways, their temperature goes up to 106˚. We need an animal that's small and can be used with ease in these damned glove boxes."
"Simply because the monkey is the experimental animal closest to man, Dr. Schwartz. Why waste a lot of time and effort doing studies in the guinea pig, for example, only to find its disease isn't related to the disease in man? We don't have to use monkeys, but we should use a similar primate."
"Listen, Doc, people were doing experiments with the guinea pig, rat, mouse, and rabbit and making damned significant contributions before you were even a glint in your father's eye. Trouble with you young hotshots is that if it isn't fancy-pancy or full of statistics, it isn't worth anything. Well, let me tell you something---a lot of us old-timers did pretty good work before you were around with your high and mighty ideas. Do you think we can work with anaerobes as easily in a monkey as we can in a guinea pig?"
Alex knew the time had come---as it did sooner or later to each of "Max's boys"---when he had to stand up and be counted for what he himself had done and said, not just another roll of memory tape programmed by the "boss." The time when the mouth tired of saying, "Yes, Dr. Schwartz, you're absolutely right." The time when the mind started functioning independently, free of constant worry about "What would the 'boss' do?" or "What will the 'chief' say?" Well, screw Max's job and the Chair and Boston! Alex Kahn had come of age.
"Look, Dr. Schwartz"---Alex was trying to be firm, yet polite---"your own studies in guinea pigs and rabbits were the foundation of what we know about septic shock, but they were only a foundation. Shock in these animals is far different from what it is in man. The target organs are different, and the reactions are different. Our present concepts of septic shock come from studies of experimental shock in monkeys and clinical shock in man. That doesn't mean your earlier studies were any less valuable." He tried to make his point with a minimum of damage to the older man's ego. "There's no doubt in my mind that the monkey is the best experimental animal in which to study human infection. As long as we're here at Detrick, which has the best monkey facilities in the country, I think we should use them---even if they're hard to work with."
"I think he's right, Max." Alex was grateful for Sam Ross's interruption. "If any place is set up to work with monkeys, this is it. If we use another animal and the disease turns out to be different in it than it is in man, we're going to waste an awful lot of time."
"Use whatever damned animals you like, but don't come crying to me when you can't get good anaerobic conditions in those little bastards." His angry glare at Alex was tempered with puzzlement about his protégé's sudden independent stand.
"I don't think it's an anaerobe, Dr. Schwartz," Alex continued. "There's no evidence for the presence of any bacteria other than the staph we've recovered. I think we're dealing with an unusual species of 80/81."
"Oh, you do, do you?" Few persons Alex knew were Max Schwartz's equal in sarcasm. "And what crystal ball tells you that? I say we're dealing with a mixed infection. When you've seen as much infection as I have---and I doubt you ever will---then you can come out with a dogmatic statement like that. I may be dogmatic, but at least I've got some thirty-odd years of experience to back me up. What have you got, five or six? You're still wet behind the ears, sonny."
His voice became softer. "Come on, Alex, you know better than to spar with the old man. You know there's no substitute for experience. Tell you what, we'll use monkeys; but let's use guinea pigs to set up the anaerobic studies. OK?"
Alex looked at Sam Ross out of the corner of his eye. The imperceptible nod told him he'd made his point and to quit while he was ahead.
"That sounds reasonable." Max Schwartz's smile assured him that Ross had given him good advice. But as he continued working, he wondered if he had blown his chance to be Max's heir.
They had worked for several hours without stopping.
The incubator was filled with cotton-plugged flasks and rack after rack of stoppered test tubes. The anaerobic jars were sealed and in a separate incubator. Samples had been incubated at room temperature and at 42˚ C as well as in the standard 37˚ C walk-in chests that characterized most large bacteriology laboratories. Monkeys and guinea pigs had been inoculated, and specimens had been prepared for examination with the electron microscope. Special samples were being flown to the Communicable Disease Center outside of Atlanta for gas chromatography studies; certain bacteria could be identified simply by the patterns of curves obtained with this instrument. Other specimens were being rushed to Ohio State University in Columbus for examination with the scanning electron microscope, a newer invention that allowed rapid visualization of populations of intact bacterial cells with three-dimensional perspective. Any piece of information that would help characterize the organism would be helpful.
Max Schwartz lit a cigarette and pushed his chair back. "Well, that's it. We'll just have to wait for the bastards to grow. What do we have up to this point? Sam, how about you?"
"No more than you had yesterday, Max. It looks like staph. It's so typical, I'm even willing to stick my neck out and agree with Alex that there's only one organism here. I'm afraid we're just going to have to wait for the cultures."
"Well, Alex, any new visions?" This time Max Schwartz's tone and smile were good-natured.
"Same here. This bug looks more like staph than staph does. If it isn't, it sure as hell is its twin brother."
Their conversation was interrupted by Marion Slade's urgent words over the intercom. "Excuse me, Max; General McKitridge would like to see all of you at once. It's important."
"Go ahead, you two," Sam Ross said. "I'll be along as soon as I've finished up here. Keeping up with you both is too much for a retired bacteriologist."
As Alex dressed after discarding his scrub suit and showering, he noticed the general whispering to Max Schwartz in a corner of the room. His stern look and sudden return to strict military posture puzzled and worried Alex.
The President was waiting at the head of the table where Max Schwartz had sat. Mark McKitridge and Warren Tracey were on his left, Roger Bergen and Marion Slade on his right.
It was as if they were seeing the picture on the covers of Time, Newsweek and a hundred other magazines and on the front pages of a hundred newspapers suddenly pasted onto a human body and sitting there, waiting for them.
The President rose as the two physicians entered. "Dr. Schwartz, good to see you again. And this must be Dr. Kahn; I've heard a lot of good things about you." He nodded pleasantly to Sam Ross as he arrived somewhat out of breath.
"It's good to see you again, too, Mr. President." Max Schwartz reached for the outstretched hand. "I guess you've already met the others, and this is Dr. Ross. We dragged him out of retirement. In his younger days he was a pretty good diagnostic bacteriologist."
General McKitridge looked puzzled. "I didn't realize you had met Dr. Schwartz before, Mr. President."
"Oh, yes, Mark. Dr. Schwartz was quite the adversary when we were discussing the termination of the biological warfare program a couple of years ago." The President sat down and motioned to the others to do the same.
"Well, Mr. President, what has happened now is just what I tried to convince you then might happen." Dr. Schwartz spoke gravely. "You will recall that I was against terminating the program, but I was outvoted. I felt that you made a mistake when you let political pressures force you to do something because it was expedient. It got the dissenters off your back and made you look good politically at a time when your image wasn't particularly attractive. I like to think that you would not have made the same decision if there had been no outside pressure. I believe you made a very big mistake, Mr. President. In fact, I would venture to say that if you had told everybody to go to hell then, you might be a little less popular now, but a few thousand people might still be breathing."
"To set the record straight, Dr. Schwartz, I signed the bill ending the program because I felt it was the correct thing to do. I'll admit that public opinion was a factor, but its major role was to bring the matter to my attention. The threat that disease might be used someday as a weapon existed as long as all the major powers had biological warfare programs. And there was always the possibility of some tragic error. I honestly felt the program should be stopped before any of these possibilities became a reality."
"But why did you have to advertise your decision, Mr. President?" Dr. Schwartz asked.
"Because in some respects, Dr. Schwartz, the strategic importance of terminating our program would have been meaningless without the publicity it received. All the other powers would have continued their programs. At least this way several major powers have joined us in abolishing biological warfare as a potential future weapon. And by being first, we also gained favorable world opinion."
"What you say may be true, Mr. President, but we also removed a powerful deterrent to our enemies. We had a great psychological weapon that could have been used at any time without harming anything more than a few ids and egos. And by giving it up---openly and unilaterally---we shifted the balance of power and invited someone to belt us in the mouth. Well, someone did. You made us first all right, Mr. President---the first major power to be the target of such a weapon."
"You know, Max, the thing I just can't figure out is how a physician whose vocation is to save lives and fight disease can be so set on a program that is its very antithesis." Mark McKitridge shook his head to emphasize his inability to understand the paradox.
"Don't give me that bullshit, Mark," Max Schwartz countered. "I've spent more hours sitting up with sick patients than you've spent sleeping." The general had hit a very sensitive chord. "Whether one is for or against a biological warfare program has nothing to do with the Hippocratic oath. And I've never been afraid to admit that I was in favor of a biological warfare program as a deterrent."
"Nobody doubts your sincerity, Dr. Schwartz." The President's voice reflected his respect for the physician. "Unfortunately, there was no way to accurately predict the future, and at this point our argument is academic. Having been briefed on the current situation, I assume that the discovery of the material in the post offices leaves no doubt in your mind that this is indeed a deliberate attack on us."
"No, Mr. President," Schwartz responded. "There's no doubt about it. Any ideas as to who our adversaries are?"
Mark McKitridge opened a folder and quickly glanced at the top sheet. "We've looked at all possibilities. Any of a dozen or so nations could be the one, but we can't pinpoint which with the presently available information. We've also looked at the overall international situation. The only change over the past several weeks seems to be a possible blowup in the Middle East, but I doubt that concerns us." He closed the folder.
"Dr. Schwartz." The President's mood had obviously changed. He spoke firmly, but with a certain strain in his voice. "What I am about to say is not to leave this room. I have chosen to confide in you because I wish you to understand clearly the urgency of your work. I know the difficulties you are facing, and I realize that giving you a deadline to come up with an answer will not make it any easier. Under the present circumstances, however, I have no choice. I can give you only five more days. By that time you must be able to tell the government that you are satisfied that you are well on your way to identifying the microorganism responsible and can make a judgment as to whether or not it is treatable. If you cannot do this at the end of the five days, you will, of course, continue your work; but then I will be forced to take certain actions to insure the safety of the country.
"I think it is only fair and proper to inform you what will be done if this epidemic cannot be brought under control. The Joint Chiefs, the National Security Council and the Cabinet support me in this decision. We all feel that any prolonged delay will do us irreparable harm. The nation may panic. If it does, we may not be able to administer a cure even if you can come up with one. We all feel that five days is a reasonable time for you to evaluate the medical situation; beyond that time, we might not be able to keep things under control.
"Mark, will you please continue?" The President motioned to General McKitridge, indicating that he had the floor. The general opened a red folder that had the words "Top Secret" stamped clearly across the cover.
"Gentlemen, the following is an outline only. I need not take up your time with the details. It applies to the eighteen nations listed." He pointed to a typewritten sheet before him. His voice was not that of the Mark McKitridge they had known for the past twenty-four hours. This was the general, the professional soldier, who had returned to the world he knew best. The time had run out for niceties, the polite interplay between gentlemen.
General McKitridge continued: "In three days, seventy-two hours from midnight tonight, the President will send an official note to the heads of state of these eighteen nations. He will inform them that we are presently being attacked with a biological weapon by an unknown adversary who has chosen to disregard the Geneva Convention. He will also inform them that we are ready to arbitrate the differences which may have led to this attack if the responsible party will inform us within forty-eight hours of receipt of his message of the identity of this agent and the treatment for the disease which it causes. If at the end of the forty-eight hours we have received no reply, an automatic state of war shall exist; and without further consultation we will utilize nuclear weapons to destroy them. All of them! The complete list of the eighteen nations will be provided to each of the heads of state so that they may mutually consult. In addition, should any further attack be made on this country during the waiting period, a state of war shall exist immediately with all of these nations. In other words, we will not waste the time to find out which one attacked us.
"Gentlemen, we have armed our entire nuclear attack force. We are not bluffing. We are prepared to institute full mobilization for a national emergency in forty-eight hours." Mark McKitridge looked at each of his listeners to be certain they grasped the meaning of his words. Then he closed the folder and sat down.
The silence was oppressive.
"Madness. Sheer madness." Max Schwartz spoke with little overt emotion. "We have become a race of madmen who are bent on destroying ourselves. Perhaps it is better that we do not survive."
Alex Kahn looked at him. It took him some time to realize that this man who always asked the questions that needed to be asked, who always had the answers when no one else did, had no more to say. What else could be said? He was frightened as he never had been before.
Finally, to break the silence, he asked, "How did you come up with that list of eighteen countries?"
"We always have a target preference list ready in case of a surprise attack," the general replied. "This is prepared by computer from analyzed information. In simple terms, it's a list of potential enemies. We can't take a chance this time. If we don't know our enemy, they all must go."
"And if it happens to be a friend," asked Alex, "who no longer wishes to be friendly? Or do we keep a few friends on the list, too?"
"Cold as it may sound, Alex, if our enemy is not on the list, we'll know it and we'll get him next time."
"If there is a next time." Alex was shocked at the cold, impersonal attitude toward wiping out millions of people. They were talking about a nuclear blow that could destroy mankind, not the odds in a bingo game.
The President interrupted him before he could speak further.
"I know this has come as a shock to you. I would like to add a comment or two before leaving.
"I'm playing your game, Dr. Schwartz. I'm praying that a show of brute strength will get us the answer if you can't come up with one first. I'm not bluffing, though. I am willing to wait the five days---no longer; then we will go to war. I know it sounds like madness; but I, too, cherish our way of life. Even if it means wiping out half the world to preserve it. I pray you find the answer first. I pray we never need to push the button. If we do, only history will be our judge. Good luck."
The President stood up, turned and left. General McKitridge and Roger Bergen followed him. After a minute, all the others except Alex Kahn and Max Schwartz left, too.
The two physicians sat in silence for almost an hour. The long shadows of sunset filled the room with an eerie glow. Alex watched the face of the older man sitting across from him. For a fleeting moment he had the premonition that the sun was setting on Max Schwartz, that the President's words had heralded the end of his career. Alex felt a sudden warmth and closeness to this man who now no longer seemed the distant symbol of the ultimate success in medicine. Now he seemed to be just a man---a man with the same feelings, the same fears, the same disappointments as Alex himself. How tragic it must be for him to have devoted his life to saving the lives of others, when to fail now would result in loss of life incomparable in magnitude to what he had worked to preserve.
Perhaps Max Schwartz was right. It was madness---a madness so great that the human mind could not comprehend its scope or its purpose.
Max Schwartz was alone in the small, dimly lit room that served as his sleeping quarters. It was sparsely furnished with a cot, an old wooden desk, a chair, and a metal gooseneck lamp that provided the only source of light.
He sat at the desk, browsing through the pile of mail that Betty, his secretary, had forwarded. Always on his frequent trips to lecture or attend meetings she sent his mail to the places on his itinerary where it was sure to reach him. This time, to keep his whereabouts unknown, he had arranged for her to deliver it to the Boston Army Base; it was forwarded from there courtesy of the U.S. Army after undergoing thorough decontamination. Isolated by the secrecy surrounding his present work, he found the letters a comforting reminder that everyday life still went on in the real world beyond the wire fences.
As usual, Betty had divided the mail into two neat packages, one containing personal letters and those requiring his immediate attention, the other, the many reprints of scientific articles he had requested from all over the world---reprints which over the years had filled rows of metal filing cabinets in a small room behind his office at the hospital.
None of the personal mail was of particular interest, so he began to read the titles of each of the reprints, separating them into two piles. The larger pile contained articles merely to be filed under a designated subject heading that he penned in red in the upper right-hand corner of the paper. The smaller pile consisted of papers of particular interest that he would read before they were filed. He set aside articles on streptococcal exotoxins, septic shock, a review of bacterial meningitis, and several papers concerning the first clinical trials of new antibiotics.
An article entitled "The Induction and Characteristics of Staphylococcal Mutants" caught his eye because he could not recall either reading or requesting it. The author was Ahmed Machdi. Like many reprints he received, it was personally signed. He read the handwritten words beneath the author's name: "To my good friend, Max Schwartz. Please accept this gift with my sincerest admiration and compliments. My best wishes for a long and healthy life." He was puzzled. It was an unusual note for a scientist. Besides, he was no "good friend" of Ahmed Machdi. He was familiar with the man's work in the field of bacterial metabolism; they had even met once as students in London many years before. But this greeting was hardly that of a casual acquaintance. He shrugged and started to put it down when his eye caught the date. The article had not yet been published. This was a preprint, a Xeroxed copy of an article yet to be published; authors occasionally sent these to colleagues who might be interested in the subject. He looked at the title again, especially at the words "Staphylococcal Mutants." He suddenly remembered Alex Kahn's words: "I think we're dealing with an unusual species of 80/81," and he wondered. He underlined the title several times in red and looked down at the bottom of the page to see where the work had been done. He could still hear the words of General McKitridge: "The only change over the past several weeks seems to be a possible blowup in the Middle East..."
"This could be it!" Max Schwartz said aloud. He grabbed the article. He had to see Alex.
The pain in his chest hit him as he stood up. It was a crushing, heavy pain, as if a ton of weight had been dropped on his breastbone. It radiated up into his neck and to his left shoulder and down the inner aspect of his left arm. He knew what it was.
He felt nauseated, faint, and short of breath, and he could feel cold sweat erupting on his forehead. The room began to spin. He lost consciousness before he hit the floor. The article was still clutched in his hand.
Alex Kahn had gone to the Fort's library. He was convinced that he had to investigate further his own theory that they were dealing with an unusual strain of staph 80/81.
He was familiar with clinical staphylococcal infections and had done some research on one of the staphylococcal toxins, but he had a working knowledge of only the common strains of this microorganism. He had spent two hours going through textbooks of microbiology and the recent literature and had been able to find almost nothing except a reference to the use of staphylococcal mutants in studies of bacterial respiration; the author was A. Machdi, a name he did not recognize. He made a mental note to read the paper later. As he was gathering up his belongings, a military policeman burst into the library's main reading room and shouted his name.
Alex turned to him and said quietly, as if to remind him that he was in a library, "I'm Dr. Kahn."
"Dr. Kahn," the man was still shouting and obviously out of breath, "we were making our usual night check, and we found Dr. Schwartz---on the floor of his room---unconscious! We've taken him to the base hospital. I think you'd better come right away. I've got a jeep outside, sir."
Alex Kahn just stood there silently and stared at the soldier. Mechanically, he put down his papers and followed him to the waiting jeep.
They sped past the parade ground, the Post Exchange, the Administration Building, the theater, and turned right toward the base hospital. The cool night air blowing in Alex's face cleared away some of the numbness. His first thought was that Max Schwartz had caught the disease, and his numbness changed to fear. "It can't be!" Alex wasn't sure if he had spoken aloud. He looked at the driver who showed no sign that he had heard; he repeated the words to himself. He would always remember his first thought. "Now the buck-passing will stop with me. There's no one else."
With a screech of brakes and a jolt, the jeep came to a halt. Alex looked up. The small white sign was clearly visible under the bare light bulb above it: HOSPITAL.
Alex sat on the edge of the bed and looked at the sweating ashen face partially covered by the plastic oxygen mask.
It was not pneumonia. There was no fever, no hemorrhagic rash, no trickle of blood from the mouth. The coils of electrocardiogram paper strewn on the floor told the story. Max Schwartz had had a massive myocardial infarction---severe damage or death of heart muscle due to inadequate blood supply---a massive heart attack. The prognosis was poor. Despite the administration of morphine, oxygen, digitalis, and drugs to reduce the irritability of the heart muscle and thereby the irregular cardiac rhythm, Max Schwartz was dying, and Alex Kahn knew it. He had placed him on a cardiac monitor to observe the beat-to-beat rhythm of the heart. He had a pacemaker nearby in case the heart should stop and a defibrillator to electrically stop fatal cardiac arrhythmia if they should develop. The Chief of Cardiology was on his way from Walter Reed by helicopter.
Alex sat and watched the man who had helped him gain all the knowledge he was now using.
He remembered Max Schwartz's words the night he had lost his first patient, a three-year-old girl, from overwhelming bacterial meningitis. He had been sitting on the edge of the bed then, too, unwilling to leave her side. Max Schwartz had sat down beside him and had put his arm around the young intern. Alex never forgot Max's soft voice or the words.
"Alex, let's go. There are other patients, son. The hardest lesson to learn is to accept death. You have to relearn it every time you lose a patient. I still do. Each death is just a reminder that medicine has come only so far. You can try hard, but you can't save them all. Some will just die---as if they're meant to die. Our job is to take care of the living."
Alex remembered how Max Schwartz had led him out of the room. To Alex, those few minutes were Max Schwartz's greatest.
The breathing became more labored. Alex felt the weak pulse; it was grossly irregular and thready. Max Schwartz continued to die. It was as he had said, "Some will just die---as if they're meant to die." Perhaps it was an instinct, perhaps it was because he had come to know the great man so well, but Alex knew Max Schwartz was meant to die---to die in this small fort buried in the hills of western Maryland. He would die as he had lived---battling for the lives of others. But how ironic that in the midst of this great epidemic he should die of a common heart attack.
Alex looked at the gray face, motionless except for an occasional jerk caused by agonal gasps for breath; even these were becoming less frequent. He listened to the quiet around him; only the hissing of the oxygen as it flowed from the outlet in the wall through the plastic tubing and into the plastic mask disturbed the silence. The room was cold and bare and lonely.
In these few moments when Max Schwartz was about to cross the threshold of death, Alex Kahn fought with the age-old question that plagued a doctor each time one of his patients began to die. It was a simple question, but one each physician had to accept the awesome burden of answering for his patient. When does life end and death begin?
When he was an intern, Alex Kahn believed that it was a doctor's job---no, his sacred responsibility---to preserve life for every precious second. Only God could take away what He had given. As long as there was breath and heartbeat, there was life. And even if spontaneous breathing stopped and the heart ceased to beat autonomously, progress and science had provided the electrical and mechanical means to maintain these life processes. With artificial aids, a doctor could keep his patient's body free from decay as long as he had the knowledge and experience to turn the right dials.
At first the justification for it all lay in the rationalization that where there was life, there was hope. But when time and time again hope proved false, and as he matured as a physician, Alex began to see that life was living, not just existing; he began to learn that the definition of living belonged to the patient alone---not to the doctor. He saw families forget what had been good and real about loved ones---all they remembered were the endless days of watching and waiting in a hospital room. When death finally came, they left with only the image of a body operating mechanically with tubes and pipes and wires---the good memories lost in the heartbreaking agony of slow death.
He could find no absolute answer to the problem of distinguishing between preserving life and prolonging death. Each case had to be balanced with understanding and pity and mercy for the dying and for those who had to go on living. Some answers satisfied him; others remained to haunt him and plague his soul and conscience.
Max Schwartz died ten minutes later. He never regained consciousness. Alex Kahn let him die as he would have wished---with dignity. The young doctor had known all along that he would not use the pacemaker or the defibrillator or the respirator or anything else. It had been a losing battle from the start; and at the end he had done what Max wanted. "Alex, when I die, I hope my doctor isn't some overzealous son of a bitch who'll stick a tube in every orifice and an electrode on every square inch of my body. I hope my doctor is a simple man who can recognize death when it comes to me, and will let me die in peace and with dignity." Alex allowed him this right.
He reached up and turned off the oxygen. Sitting on the edge of the bed holding the cold hand, he looked at the now silent face. And he remembered the man and his work and his devotion to medicine. He remembered all he had learned, and he knew then what Max Schwartz's legacy was to the world.
Alex wept. He wept for Max Schwartz. He wept for himself. He wept for mankind. All had lost with his death.
Alex lay on his bed and stared at the dark ceiling. For the first time in the past two days, he was on his own. In a few hours, the cultures would be ready for examination. Although he was grateful that Sam Ross would be there to help him, he knew that the final decision as to the identity and treatment of the organism would be his---he was now the physician-in-charge. The buck had passed to him.
His thoughts were interrupted by a knock on the door.
Marion Slade smiled. "I just stopped by for a minute, Alex, to tell you how sorry we are about Dr. Schwartz's death; we know how close you were to him. I also wanted to say that we know you can do the job. We're all behind you.
"Dr. Schwartz told me you could do it, too. He must have had a premonition; he asked me to give you this letter in case something happened to him." He handed Alex an envelope with his name on it in Max Schwartz's handwriting.
"I also thought you'd like to have this---as sort of a memento." He handed him several sheets of crumpled paper. "These were in Dr. Schwartz's hand when the MP's found him. He must have been reading them when he became ill."
He shook Alex's hand warmly and left.
Alex was grateful for the memento; he put down the crumpled article to read later.
Then he sat on the edge of the bed, opened the envelope, and unfolded the several pages, written in Max Schwartz's own hand.
Dear Alex,
I feel the need to write you because I have been having chest pain for the past few months; it has become more severe and more frequent during the past several days, and I am concerned about an impending infarct.
You know, I suppose, that I have already chosen my successor. You, Alex, are my choice. I know you will bring fame and honor to the department I am leaving in your capable hands.
But first you must establish your own image. You will never be entirely successful if you continue to be just Max Schwartz's successor---you must be Alex Kahn, Professor and Chief in your own right.
I know that you and everyone else often think I am the world's biggest bastard. Well, Alex, I've tried hard to be just that. Good departments are run with a heavy ruling hand. Let up, weaken, compromise for only one minute, and the whole thing falls apart or someone who can be a bigger bastard than you will take it all away. Don't let that happen. Perhaps with your personality you can discover how to be a bastard and a gentleman.
Whatever you do, don't lose your love for human life. Fight for it, Alex, with all the knowledge, experience and talent you have; but in that fight, never lose the ability to be kind, to be understanding, to be compassionate.
Whatever I have helped you to be, continue to give a little of that to the many more young men and women you will send out into the world to care for the sick and the dying.
Good luck, Alex.
Max
Alex's tears blurred the last words, causing the ink to run and the words to fade. But he would not have to read them again to remember them.
He knew now that he could handle the buck. He turned off the light, confident that he would finally be able to sleep.
It was starting to rain.
The wind blew in cool gusts from the distant green hills, and sheets of misty vapor seemed to rise and fall.
Alex Kahn saw the empty grave on the hillside and felt a terrible loneliness as he looked at the small group of men who had come to attend Max Schwartz's funeral. He couldn't believe that this was to be the final tribute to a great man's stay on earth.
Max Schwartz's fame had brought him many acquaintances and admirers but no true friends. He had had no time for roots or for the lasting relationship of a family; he had had no real home and did not even own a burial plot. And so these few cubic feet of earth on a hill overlooking the duck pond at Fort Detrick---a gift from the United States Government---were to be Max Schwartz's final resting place.
The rain fell on Alex's cheeks and made his salty tears taste cold. As he watched the plain wooden coffin being slowly lowered into the earth, he realized that it was over---all over. Max Schwartz was only a memory.
The faceless forms began to fill the gaping hole with dirt. Alex heard the brassy echo of a sorrowful bugle in the distance as the notes faded into the cold, gray sky.
There was little time to dwell on grief. Though Max Schwartz's death would always remain as a sorrowful memory, the fight to preserve life now took precedence over all else. And so Alex returned to the laboratory.
All the growth on solid media was monotonously similar. Whether obtained from living patients, from autopsy material, or directly from the packages recovered in the post office, the ultimate visible evidence of bacterial growth was a small, round, creamy yellow colony with little characteristic odor. Microscopic examination and standard biochemical and serologic tests all revealed a single microorganism that appeared to be a common variety of staphylococcus. After many hours' work, the team of investigators knew nothing they hadn't known twenty-four or forty-eight hours before. There seemed to be no explanation why this disease was different from any other staphylococcal infection.
Alex pushed his chair back from the glove box and exercised his fingers to relieve the stiffness resulting from prolonged manipulation in the close confines of the heavy gloves. He stared at the carefully tabulated results on the pages of the laboratory notebook open before him. He tried to think of some explanation for the findings they had obtained over and over again. He tried to think through again what Max Schwartz had taught him to do.
"When you're stuck, Alex," the Professor used to preach, "walk into the patient's room again as if you were doing it for the first time. Start over. Approach the problem as if you had never seen it before."
Alex turned to Sam Ross. "We're stuck. Let's start over again---from the beginning. Maybe we can find something we've overlooked."
"It's about the only thing we've got left to do."
Slowly and methodically, the two men reviewed all the basic information about staphylococci. Neither of them could find an oversight in their previous thinking. The microorganism was a staphylococcus; the disease that killed was staphylococcal pneumonia.
"Sam, are there any anaerobic staphylococci? Could we be dealing with an unusual anaerobic strain of staph?"
"There are a few, Alex, but they're very uncommon. And remember, we're recovering an aerobic staph. Besides, we have to think of the common first and the rare later."
"I know, but this whole thing is weird. Max was convinced an anaerobe was involved; maybe he was right.
"You know, Sam, we know very little about the actual mechanisms of staphylococcal infections. The bugs probably cause disease by the toxins they produce. Maybe this bug isn't different, but maybe it produces a toxin that is---one that causes a disease in man that we're not used to seeing."
Suddenly Alex remembered the reference to the paper by A. Machdi he had seen the night before. "I came across a reference last night to the use of staphylococcal mutants to study bacterial respiration. I didn't think much of it until we started to review staphylococcal infections just now."
"I'm not sure I follow you."
"Look---we've recovered the flasks with staph in them; we can culture staph from the people who get sick. There's nothing different about it as far as we know. Is there?"
"Not as far as I can tell."
Alex went on. "Coming back to that article---if someone could induce mutation in a staph to study some pathway in bacterial respiration, why couldn't someone induce a mutant strain which would produce a toxin that would be capable of killing a man in a way we've not seen before? Also, couldn't it be possible that the production of such a toxin would be the only difference between the parent strain and the mutant? If it were, the cultural characteristic would be exactly the same. We could culture the bug a million times and never see the difference!"
The bacteriologist squinted and rubbed his chin. "You know, Alex, that's a very interesting thought. In fact," he paused, "it's probably the best theory you've had so far. But prove it to me, Doc."
Alex stood up suddenly and went over to the wall phone.
"What are you doing, Alex?"
"I'm calling Marion Slade. If I'm right, we need some help. I'm no expert on toxin identification or bacterial mutants. Are you?"
"No, sir, but what you say makes a lot of sense." He thought for a moment. "Matt Raleigh. Ask him to get Matt Raleigh. Raleigh knows more about bacterial toxins than anyone else I know." He thought for another, longer moment. "And Carl Stafford. Get him, too. He's been playing with bacterial mutants for years. Matt is at Cal Tech; Carl is at the University of Indiana Medical School. By the way, do you have that article? Let's look at it."
"No, but I'll ask Marion to have it picked up at the library. In all the confusion..." he seemed embarrassed---"in all the confusion of Dr. Schwartz's death, I must have left my notes in the library." He paused. "I hope Raleigh and Stafford are still alive. Funny, isn't it? A week ago when you called someone, you hoped they'd be at home---now you pray they're still alive."
He took a piece of paper from his pocket and dialed the number written on it.
"Marion? Alex Kahn. Listen. We've come up with a theory that may be important. Can you do a couple of things for me?"
He told Slade what he wanted from the library and the names of the two men whose help they needed. After he was certain the general understood, he hung up the phone.
"Marion will take care of everything."
"We don't have much time left, Alex. No matter how good those two are, it's going to take time to isolate and identify a toxin or to work out the identity of the mutant."
"You're right, Sam. But maybe we'll be lucky for a change and get a break. We've got to get lucky sometime."
"I hope so, Alex. Some people take five years---or ten---just to get started working on a new toxin, let alone isolate it, identify it, and find a way to counteract it."
"And we have only a few days!"
It was the first progress meeting of the group without Max Schwartz. Alex left the chair at the head of the table vacant and sat where he had before. He wasn't sure whether it was out of respect or just that he wasn't certain he deserved to sit there yet.
He looked around at the small group. Calvin had gone back to CDC to handle the statistics, Rahway was still in Washington attending to his responsibilities at Walter Reed, and Mark McKitridge was at a meeting of the Joint Chiefs of Staff. There were only Sam Ross, Warren Tracey, Marion Slade, Roger Bergen, and himself now. Five men---left behind to look for that needle in the haystack.
The latest reports from the Communicable Disease Center were now available for examination. Alex was pleased that the Teletype reports were handed to him first---as they had been to Max Schwartz at previous meetings.
He opened the folded sheets. There had been a total of 47,840 cases reported! Even more disturbing was the appearance of an increasing number of cases outside of the original forty cities. The "mail" was getting through.
The problems, the theories, the possibilities---all had been discussed before. To go over them all again would merely waste valuable time. The conference was quickly over. With so few participants and so little time, they agreed to dispense with the formality of progress meetings. They would just keep in touch---unless something came up.
When Alex returned to the laboratory, he sat down and tried to plan the work for the next few days. He had finally persuaded Sam Ross to go back to his room to rest.
There were hundreds of flasks of broth containing the staph available for Matt Raleigh to study. If there were a toxin, it would be in the broth, and Raleigh would find it. But how long would that take him?
There was plenty of material for Carl Stafford, too. He would need the bacterial cells themselves. Alex was less sure how Stafford would go about looking for a mutant or investigating its characteristics, if he found one. That was his problem, though.
What was missing? They had gone over the organism, the disease... The treatment! That was it! Hell! Why hadn't they looked harder for a means of therapy? They'd been so busy trying to put a name on the damned bug they just hadn't looked hard enough at the response of the organism to antibiotics in the test tube. All they really knew was that every commonly used drug they had tried so far to treat severe infection in man had failed, and no one had lived long enough to allow them to try anything experimental.
Alex began to prepare the tests to investigate the antibiotic sensitivity of the organism. First he would test the effect of increasing concentrations of single antibiotics. Then he would investigate combinations of drugs---the trick was to find the optimum concentration of each drug that was most effective against the organism in question when two or more were used together. There were many possible drug combinations, and evaluating them could be difficult. If they weren't lucky with the tests under preparation, it might take more hands than were presently available. If necessary, he would ask for more technicians.
He was interrupted by a messenger who handed Alex the notes he had left at the library and a copy of the article he wanted. There was also a message from Marion Slade telling him that both Matthew Raleigh and Carl Stafford were being flown to Detrick and would arrive later that evening.
After several hours, Alex finished inoculating the tubes for the sensitivity tests. He made notations on other things he wanted done, and then sat down to read the article by A. Machdi.
Matthew Raleigh was what Alex called a forty-eight-year-old swinger. His long sideburns and handlebar mustache contrasted sharply with his almost bald head. He wore a double-breasted, light-blue blazer and a wide floral-print tie. Navy-blue bell-bottom slacks and white loafers completed the outfit.
"I hope his mind is as sharp as his clothes," Alex thought as he shook Raleigh's hand and offered him the coffee and sandwiches that had been prepared for the latecomers.
Carl Stafford was a slender, outgoing, humorous man. He had the type of personality that made you feel you had known him for years.
Despite their appearance Alex knew their reputations well. Matthew Raleigh was Professor of Microbiology at Cal Tech, where he had done much important work in the field of bacterial toxins. Carl Stafford was Eli Lilly Professor of Bacteriology at the University of Indiana Medical School at Indianapolis. His major field of interest was alterations in the genetic code of bacterial mutants, and he and his graduate students had developed many methods presently available in the field. His talents would be very useful.
Alex briefed the two men on the situation as they ate. Neither seemed surprised to learn of the origin of the epidemic. They listened with interest as Alex explained the team's attempts to identify the microorganism; they had little to add. Both thought that the most recent theory about a mutant and a toxin was reasonable and worth pursuing.
"To determine whether an unusual staphylococcal toxin is produced by this organism isn't so hard, Alex; it will just take time." Raleigh played with the ends of his mustache as he spoke. "Give me a few days to get some of my equipment and one of my technicians, and I'll be ready to start."
"I can't give you more than a couple of hours, Matt. Call anyone you have to to get the equipment; we can have it and your technician flown here by jet as soon as possible."
"Now wait a minute, Alex." Raleigh twirled his mustache a little faster. "What'll I tell them? They'll think I'm nuts."
"Tell them their lives may depend on it. Tell them anything. But get what you need. I've already arranged for laboratory space for you. We don't have much time, Matt." He wished he could tell him it was four days---or else. But he couldn't. "There are almost 50,000 cases of this damned disease, Matt, and it's spreading. In a couple of weeks, who knows who'll be around? You---everybody in this room---could be dead!"
Raleigh whistled. "Show me the phone; I'll see what I can do. I guess I should have known that when the army sends a private jet for you it's not to attend a tea party. Are we really that badly off?"
"Worse, Matt. Whatever you need, we'll get you; but we've got to solve this thing---and quickly."
"Well, I guess it's my turn." Carl Stafford smiled broadly. "I think your theory is excellent. But I'm afraid I'm going to be of little or no help to you. You just can't figure out if a certain bug is a mutant or not in a matter of hours. If you could tell me who the mother was and what had been done to induce the mutation, I might be able to take a crack at it---even then it would be trial and error. Sorry, fellows, but I'm a bacteriologist, not a magician."
"Isn't there anything you can do, Carl?"
"Not really, Alex. I'll be glad to take a look at the bug. But starting from scratch, even if I had unlimited time and help, it would take at least several months to come up with anything. An organism may have ten thousand or more individual characteristics, and you're asking me to tell you which one is different. Why, it could be only a single amino acid in a single enzyme that makes it different from its parent. If I knew how the mutation had been induced, I'd have some place to start. This way, if we're lucky, I might stumble onto it in a day or a week; if we're unlucky, it could take me ten years. And then only to find we weren't dealing with a mutant at all. See what I mean?"
"I do, Carl. Try anyway, will you? We can't afford to overlook any possibility."
"Sure, Alex. I'll give you a list of what and whom I need. And by the way, if you know a good minister, priest or rabbi, ask him to pray for us, will you? I hope the Lord is up on His bacteriology."
Alex Kahn lay on his bed in the dark room and thought. Everything had led to a dead end. They had the talent, the equipment, and even what appeared to be the microorganism. All they needed was time---at least enough time to find the treatment for the damned disease. But there were only four days left. It might as well be four seconds.
He couldn't sleep. His thoughts turned suddenly to Lori and the children.
"My God!" He sat upright in the darkness. "She doesn't even know where I am!" He realized, for the first time since that last day in the office when Max Schwartz had called, that he had been unable to leave a message for her and that she had no knowledge of his whereabouts. "She must think I'm in New York and forgot to call her," he thought, feeling little guilt since Lori was accustomed to not hearing from him for a day or two when he was traveling. He lay down again, promising himself that he would call her in the morning. Then he remembered---he couldn't. The only communications allowed from Detrick were those related to the national emergency. His concern grew rapidly. Although he felt that Lori and the children were still safe in the mountains, he knew she must have heard by now of the cities suffering the ravages of this plague, and New York was one of them. She might think that he was ill---or dead---and be hopelessly trying to get in touch with him. There were so many things he had to tell her. She didn't even know about Max Schwartz's death or that he was now Chief. The thought suddenly occurred to him---he'd write to her; Marion Slade would see that she received the letter.
He got up and turned on the gooseneck lamp on the desk to look for some stationery and a pen.
The red ink caught his eye. It was the article---his memento from Max Schwartz. He picked it up. He hadn't had time to read it before. He glanced at it and was about to put it down to continue looking for writing material when he noticed the author's name, Ahmed Machdi; it was underlined in red, like the title and the inscription. His mind suddenly became alert. This article was by the same scientist whose paper he had found in the library. He couldn't understand why he hadn't been able to find this one, too.
"No wonder I couldn't find it," he muttered, noticing the date of publication. "It hasn't been published yet." Still he was bothered. Most preprints showed the name of the journal in which the article was to be published at a future date; this one did not.
He was puzzled by the lengthy and rather flowery words of the inscription. He couldn't remember Max Schwartz ever having mentioned the man. And it was unlikely that the author had sent the article for Dr. Schwartz's opinion before submitting it for publication since the Professor had never been an authority on bacterial mutants. Odd, too, that someone should send this paper halfway around the world to a man who had little interest in the subject.
What bothered Alex even more were the heavy red lines beneath the title. Max Schwartz was a man of habit, and Alex knew that he always filed his articles by the subject heading written in red pen in the upper right-hand corner of the first page. Alex had seen hundreds of Max's reprints, and all were marked in exactly the same way. Not once had he seen a title underlined like this, though the broad red lines were made by the same type of felt-tipped pen Schwartz used.
What was so important about this article that even coma had been unable to wrench it from Max Schwartz's grasp?
Alex turned up the shade on the gooseneck lamp for more light and started reading, his mind dwelling on certain sentences and paragraphs.
The purpose of this paper is to describe the steps utilized to induce a mutant strain of Staphylococcus aureus (80/81)....
The induction of such a mutant will allow studies of the rapid adaptation of certain species of bacteria to antibiotics....
The induction phase consists of several individual steps each known to affect the transfer of genetic information at a different site.... Each of these steps is outlined below.
Alex read faster.
The ultimate characteristics of such a mutant, therefore, include a high degree of resistance to the antibiotics utilized in its preparation, the ability to reproduce rapidly under suboptimal conditions of growth and ...
But who was this Ahmed Machdi? What role did he play?
Suddenly he remembered the words of Mark McKitridge, and the pieces began falling into place. That was why the article had been a "gift." This Ahmed Machdi, whoever he was, had sent Max Schwarz the article, knowing he could put the pieces together. But why? Alex's euphoria was short-lived. Was this the answer, or was it a trick?
He glanced at his watch. 4 a.m., Friday. In less than two days the President would be sending his messages. After that, it might all be too late.
He reached for the phone.
To save time, Alex had xeroxed a copy of the article for each of them. Now he sat and watched the face of each man as he read from the sheets of paper.
Carl Stafford was the first to speak. "Well, Alex, there's certainly enough information here," he nodded to the pages he had just read, "to enable us to determine if the staph you've recovered is the organism described by this fellow Machdi. I've heard of him. He was awarded the Pasteur Medal for his work with bacterial mutants. He manipulates induction to produce strains with the characteristics necessary for his work in bacterial metabolism. Very unique. I've read his book and most of his papers. He's a careful investigator.
"With regard to your theory, Alex, if anyone could invent a bug like that, this guy could. He's probably the world's greatest expert in developing mutants with specific characteristics. He's even been able to convert aerobes to anaerobes. The guy's a genius. There's no doubt his work can be reproduced. I've done it myself a couple of times. What he publishes is good stuff---really significant contributions to bacteriology."
"How long will it take you, Carl? I mean to tell us if the organism is the same?"
"If we have the equipment and the material to reproduce the induction of the mutant, probably a couple of days. That won't be time enough to get absolute proof, but enough to say that they're probably the same. For the present, I think that will be good enough."
"As far as the possibility of a toxin is concerned, Alex," Raleigh added, "if Carl can produce the mutant described in this paper, I think we can find out if it produces an unusual toxin."
"I've made some notes, Alex. There's still one thing that bothers me."
"Yes, Sam?"
"Knowing the identity of the bug and how it causes this disease is only half the problem--the less important half. Coming up with the treatment is what's most important now."
"I know, Sam. I've already got sensitivity tests for single antibiotics and combinations set up to see just what the hell will kill the son of a bitch. It's got to be sensitive to something!"
"If it's not, Alex, I suggest we all take Carl's advice."
"Huh?"
"That a quick prayer may be all we'll have time for."
The conversation ended abruptly as Mark McKitridge, appearing anxious and distraught, entered the conference room. He was dressed in neatly pressed army fatigues, with four white cloth stars on both ends of his collar; he wore a web cartridge belt around his waist and a holstered revolver over his right hip. Just behind him walked a captain and a sergeant, both wearing steel helmets and fatigues similar to the general's. In addition to side arms, each carried an M-16 rifle.
To Alex Kahn, the intrusion of the three armed men seemed somehow comical, especially the sight of a four-star general in fatigues, packing a revolver. "You here to arrest us, Mark, or are you going to line up the bugs and shoot them?"
McKitridge didn't seem to hear the remark. Motioning to the two soldiers to wait outside, he closed the door, sat down at the table, and removed his cap and cartridge belt, laying the holster down carefully in front of him. There was no change in his expression.
Sam Ross leaned toward Alex and said softly, but loud enough to be heard by all, "I think this is one of those times Max would have said your joke seems to be out of place."
"Right, Alex, this is no time for jokes." Mark McKitridge paused, glanced at his watch, and folded his hands on the table. "Gentlemen, we've got trouble. Big trouble. I guess I'd better start at the beginning.
"Once every year or two during the sixties---usually in July or August---there were demonstrations outside of Detrick's front gate. Nothing serious. Usually thirty or forty college students and a mixture of professional rabble-rousers would camp outside the fence to protest against the biological warfare program. They never did much more than carry signs and pass out propaganda. Once in a while they'd sit around in gas masks for an hour or two, but they looked so silly and the weather was always so hot that they usually gave it up. As long as they made no attempt to get on the grounds, we did nothing; and they usually left when they ran out of money or when a good thundershower cooled them off. They were more of a pain in the neck than anything else. We had to set up a special group of intelligence agents to follow their movements and develop a plan in case they decided to rush the gate. In 1967 or '68---I forget exactly which year---a few did try to get in, but the MP's chased them off with some threats. The whole thing ended without any injuries. And after the BW program was dropped, they had no reason to come back. We haven't been bothered by them since---until now.
"But let me digress for a minute. By any chance have any of you noticed the names of the streets on this base?"
Alex Kahn was becoming annoyed. He had better use for this time than to waste it listening to a history of the problems of Fort Detrick. "To tell the truth, Mark, we've been involved with other things besides city planning. I'm sure the army has good taste in naming streets."
"Yes, Alex, it does. On most bases, streets are named for famous generals." He looked straight at the young physician. "At Fort Detrick, however, the streets are named for accidents."
"Accidents?"
"Not really accidents, Alex, but for the people who have had them."
"You mean if I drive my car into the flagpole, you'll name a street after me?" The entire group laughed---even McKitridge.
"You do that, Alex, and I'll see to it that the army sends you a bill for the flagpole."
Alex reached over and patted the general on the arm. "I'm sorry, Mark. I guess I don't know when to lay off. Go on. I'll shut up."
"Anyway, the streets are named for civilians who have worked at Detrick and who have died as a result of being accidentally exposed to some agent. To save reading the street directory, for the present the only one that's important to us is Beck Place.
"Jerry Beck was a general maintenance man here. In 1964 he accidentally got a whiff of some cultures while he was fixing the ceiling in one of the 'hot' labs and was dead in twenty-four hours. As was the custom, one of the new streets was named for him. Unfortunately, Jerry Beck had a brother who also worked here. Martin Beck had been in trouble a couple of times, but we kept him on because of his brother. When Jerry died, Marty really went off the deep end. He blamed the army and the program for his brother's death. He made such a pain in the ass out of himself that we had to let him go. Two days after he was fired, we found every street sign on the post torn down except the one at Beck Place. For a couple of months we got threatening letters from him; but we took the advice of our security people and ignored him. It seemed that he had forgotten about us, too---until last night."
"What happened, Mark?"
"I'll get to that in a minute, Marion. It must have started earlier. Evidently Martin Beck did not forget about us. He reorganized the radical rabble-rousers, and they've been waiting for just the right moment to strike---and I do mean strike. Well, when this damned disease started, Marty Beck and a few of the other ringleaders who'd seen more than the usual amount of activity here decided we'd never really stopped our BW program and that all the disease and deaths they were hearing about were due to some bug that leaked out of Detrick."
"They really believed that?"
"I don't know, Alex. Maybe it was just the excuse they were waiting for. It doesn't make any difference; they now had their cause. In just a couple of days, they've gathered together a small army."
"That's all we need---a bunch of armed protestors demonstrating around here."
"They aren't just demonstrating any more, Marion. They've become a band of marauding killers!"
"What do you mean?" Slade leaned forward to look at McKitridge.
"They hit Edgewood Arsenal last night. At about 11 p.m., about three hundred of them broke through the main gate. They killed a hundred and forty people and wounded a couple of hundred more. They broke into General Peterson's quarters, bound him and put three bullets into the back of his head." Mark McKitridge's face grimaced with anger and sorrow.
"They executed the commanding officer of Edgewood Arsenal?" Marion Slade slammed his fist on the table. "The dirty, rotten bastards!"
"Why weren't they stopped, Mark?"
"Because, Alex, the public doesn't like the army facing civilian demonstrators with loaded guns, remember? After they got through the gate, the MP's scuffled with them with clubs and rifle butts. Who the hell knew the bastards were armed? It was plain, unadulterated slaughter. They shot up everybody and everything in sight. The place looks like a bloody battlefield."
"Are they still at Edgewood, Mark?"
"No, Marion. They disappeared as fast as they came and are now on their way here."
"How do you know that?"
"From reports of intelligence agents and helicopter spotters."
"Excuse me, Mark. I'm no soldier; but if you know where they are and where they're heading, why don't you just go out and get them?"
"Because, Alex, as soon as they left Edgewood, they weren't under Army jurisdiction; and the Chief of Staff won't let us touch them outside government property."
"What about the police---or the National Guard?"
"It would take too long to activate them. Besides, the bastards have divided up into small groups and are scattered all over the countryside. They'll probably regroup somewhere around here before hitting us. But I'll see Martin Beck and his friends hang if I have to quit the army and campaign for ten years to see that the death penalty is reinstated just for those scum."
"Cool it, Mark. That kind of talk just brings you down to their level."
"Bullshit, Marion! This army belongs to you as much as it does to me---and to those poor bastards who died for nothing last night. Jack Peterson was a good friend of mine." His voice cracked and he cleared his throat. "When somebody breaks into a man's home---any man's home---ties him up, and executes him because someone doesn't like his uniform or what he represents, they've lost the right to be treated like human beings. They're animals, goddamn it, and they're going to be treated like animals."
"Look, Mark," Alex tried hard to choose both his words and his tone. "Don't ruin my respect for the army and its officers. You don't mean what you just said. Do something besides putting on your gun and shouting for vengeance."
"You've got to be kidding, Alex. Kidding or crazy. What should I do, take off my gun and throw rocks at the bastards when they come through the gate? Or just turn around and wait for the bullets?"
"'Bullshit!' to quote you, Mark. Have a little more faith in the American people. Tell the country this disease is no leak from Detrick. Tell them we've been attacked. Maybe they won't panic; maybe they'll get mad and fight. In addition, you'd certainly make Beck look like a goddamned fool and liar. His so-called army would fall apart. Have you ever thought of that? Or is it so important for you to pull the trigger on that goddamned thing?"
"Alex, have you really been so locked in your ivory tower that you haven't had time to see what's been going on around you? I have strict orders"---he held up his index finger---"one, not to engage this group except on government property; and two, under no circumstances to reveal anything about the biological warfare attack." He paused for a moment. "It's not just Martin Beck or Jack Peterson. It's the whole idea that a few hundred mad dogs can kill right out in the open, and I have to worry about the publicity and image of the army, not about stopping the killing and restoring law and order.
"Anyway, enough philosophy. Here's the situation. Intelligence tells us that they're heading this way and that a large part of this group are some of Marty Beck's original bunch. They've just been waiting for someone to tell them what they wanted to hear." He looked at his watch. "They're planning to attack around 11 p.m., when most everyone is in the sack except for a token security force. But this time we'll be waiting."
"Mark, these guys are no fools. They certainly can't expect us to be unarmed two nights in a row."
"You're wrong, Marion. Beck knows the army with its rule and regulations. He figures that if he can hit us within twenty-four hours he's OK. He's betting it'll take us longer than that to cut through the red tape. Well, he's wrong. We'll be waiting for him and his crummy friends.
"We've moved in three fully armed companies of paratroopers and a company of riot police. When Mr. Beck and Company take their first step onto government property, we're going to give them one chance to surrender. If they do, they'll be arrested and get a fair trial."
"And if they don't surrender?"
"We'll cut them to pieces, Alex. We're giving them more warning than they gave the people at Edgewood. It's more than they deserve."
"What irony, Mark!"
"What do you mean, Alex?"
"Because the Martin Becks succeeded in closing Fort Detrick down a few years ago, we are now under attack with a biological weapon. And now Detrick may be the only thing that can save us, and Beck and his band of cutthroats are bent on destroying it. And to stop him, you're probably going to have to slaughter a few hundred people. What a paradox---we must kill in order to live. Maybe Dr. Schwartz was right---'Perhaps it is better that we do not survive.'"
As they walked back to the laboratory in the shadows of armed guards assigned by Mark McKitridge, Alex Kahn and Sam Ross barely spoke.
Somehow everything seemed different. What had happened at Edgewood Arsenal the night before and what might take place at Fort Detrick in about twelve hours was the antithesis of reason.
But once in the laboratory, Alex's depression was short-lived. This was his world, where one made a hypothesis, devised and performed an experiment to prove it or disprove it, and examined the results. Although bedside medicine was a unique mixture of science and art, laboratory medicine was an exact discipline.
In microbiology, time was a variable that was almost unalterable. The species of microbe, the characteristics of the growth medium, the temperature of incubation, the amount of oxygen in the environment---all of these and many other factors could be manipulated and controlled; but despite the technical advances and vast accumulated knowledge, very little was known about ways to accelerate the growth of microorganisms. Growth consumed time---time the group at Fort Detrick did not have. But now, finally, the results of the sensitivity tests were ready to be examined. The survival of mankind---whatever its worth---depended on their outcome.
"That about does it." Alex wrote a "plus" in the last box on the data sheet. "Let's see what we have."
He and Sam Ross bent over to study the multitude of pages on which were written the sensitivities of the microorganism to a wide variety of single antibiotics and combinations.
"It's just as I thought, Sam! Insensitive to everything but a combination of murocillin and ampholysin!"
"What even made you think of those two drugs? About a year ago they were both found to be ineffective against strains of staph that produced penicillinase. We know that this microorganism produces penicillinase. I wouldn't even have included them in the sensitivity tests."
"I tested every damned drug I could think of. To be a successful weapon, the bug had to be resistant to all the antibiotics commonly used; but for the bastards to be able to handle it---or stop it, if necessary---it had to be sensitive to some drug or combination of drugs. To be certain not to miss any possibility, I included murocillin and ampholysin and a few others that had been tried but had never become clinically important. After I read Machdi's article, I realized that I had lucked out by including the two drugs he hadn't used during the induction of his mutant. It's saved us valuable time."
"I wonder why they work together." Sam glanced over the data sheet. "The organism isn't sensitive to either one separately."
"I think I know. As you said, they're not clinically useful because singly they're both inactivated by penicillinase. But when they're used in combination, the murocillin, which has a much greater affinity for penicillinase than ampholysin, binds the penicillinase irreversibly. Once it's bound, none is around to inactivate the ampholysin. If you'll remember, ampholysin is a pretty good antistaphylococcal drug when penicillinase isn't around. Actually, the ampholysin is what kills the bug; the murocillin just takes care of the penicillinase."
"Why did all the other sensitivity tests show something different? If I remember correctly, didn't the ones run by your hospital and others fail to show the pattern of resistance we got?"
"Because I ran these new tests anaerobically. The mistake we made before was a reasonable one. We recovered a staph aerobically, and because most staph are aerobic, we studied it as such. In all the years I knew Dr. Schwartz, very few of his hunches were wrong. I decided to play his hunch that an anaerobe was involved. He was right---but there's only one bug, Sam; and believe it or not, it's probably an anaerobic staph. This guy Machdi was a sneaky bastard. His mutant probably acts like an anaerobe in the body; but it converts to an aerobe in the test tube. I've got an experiment in mind where the trick will be to maintain strict anaerobiosis; if we can do that, we should be able to recover the organism in its pathogenic state. Then we'll be able to study it in the form that causes disease in man."
"Makes sense, Alex. Let's say we are right. Is there much of these drugs available? I would assume the drug companies stopped manufacturing them when they didn't look like winners."
"I've already checked, and there's a fair amount still in stock Anyway, the method for commercial production is simple, and if we are right, the companies will be able to supply us with all we need. In fact, I can probably get them to donate the drugs---the publicity will be worth millions."
"Well, the drugs seem to work in the test tube. When do we try the combination out in a few sick patients?"
"Not until we're sure it works in a human, Sam."
"And just how do you propose to do that? Don't tell me Detrick has a few experimental humans around mixed in with the monkeys."
"Could be, Sam. I'll need a little time to think it through."
"Don't take too much time, Alex." He looked at his watch. "Think fast, hotshot."
He found Mark McKitridge sitting in his jeep near the main gate.
"Mark, I'm sorry to bother you, but if we don't keep on plugging, we're going to run out of time."
"It's O.K., Alex. Everything's just about set, anyway. What can I do for you?"
"I want you to call Jim Rahway and ask him to send me a pump-oxygenator and a surgeon."
"What for?" McKitridge looked at Alex with puzzlement and suspicion.
"For an experiment." Alex sat down next to him. "You see, there's a big difference between what we find in the test tube or in an animal and what happens in the human body. We only have time for a single experiment. The only one that'll make any difference will be the human one. It may give us our ultimate answer---the treatment."
"If you'll tell me what the hell you're talking about, maybe I can help you. You've lost me Alex."
"I think this bug we're working with is a multiphasic staph. It's probably identical to one described in an article I found. It's a typical aerobic staph in the usual artificial culture media and, so far as we can tell, even in experimental animals. But in the human body, it changes its characteristics: it becomes an anaerobe. It probably causes disease by producing a toxin, but only under very specific conditions that could take us years to reproduce exactly right in the laboratory."
Alex handed him a copy of the article. "Read it if you get a chance. In one section, this guy Machdi tells how he uses minute but increasing amounts of a variety of antibiotics in the culture media. By doing so, he induced resistance to each of these drugs. But among the sensitivity tests I ran was a combination of drugs this bug hadn't been exposed to before. Sam and I finished reading the test results a short time ago; this combination kills the bug---at least in the test tube."
"Great! Why not just try the drugs on a bunch of patients instead of doing an experiment on a human first?"
"First, we'd never know whether we gave the drugs early enough, since most of the sick don't come into the hospital until they're almost dead. Second, if my theory is wrong, we'll have gained nothing. My way, we have a chance to study the organism while we're testing the drugs, and we can tell if it does change its characteristics in the human body. Even if these drugs don't work, we'll be in a much better position to evaluate other therapy."
"I'm sorry, Alex. I still don't follow you."
"What I intend to do is a perfusion experiment."
"A what?"
"A perfusion experiment. I want to study what the bug does in living human tissue, but infecting the whole body would be much too dangerous. I think we can get the same information by using an arm. We can isolate its blood supply from that of the rest of the body and supply it with oxygen with the pump-oxygenator. We can then inject the bug into the arm with much less risk. If we're careful and we're wrong, the most we can lose is an arm.
"By taking blood samples from the arm at intervals, we'll have a chance to study the organism as, I suspect, it changes in human tissue. Also we can inject antibiotics into the arm and watch their effect under essentially the same conditions we'd have if we treated a patient. In a nutshell, we'll have a human arm as our laboratory."
"I'm with you. But where does this pump-oxygenator thing fit in?"
"It's a machine that essentially does the job of the heart and lungs." He took out paper and pencil and sketched a diagram. "The blood will go from the arm to the machine where it mixes with oxygen just as it would in the lungs. Then the machine pumps the oxygenated blood back to the arm. In other words, we're going to bypass the entire body except for one arm to keep the blood with the bug in it from mixing with the blood that circulates in the rest of the body."
"I think I understand, Alex. I'll call Rahway right away and ask him to send you a good surgeon and the pump. Now as for a volunteer..." He paused and frowned.
"I've already got one, Mark."
"You have? Who?" He looked surprised and relieved.
"It's a military secret." Alex laughed. "Leave it to me."
"Alex, I..." Mark McKitridge started to ask the question and then thought better of it. "Never mind."
Alex wondered if this was McKitridge's way of trying to make him feel that his word was good enough---or if it was a gesture of silent admiration.
When Max Schwartz died, Alex knew time would run out. Even before his discovery of Ahmed Machdi's recent work, he had begun to plan. As experiment after experiment in the laboratory had led them nowhere, he knew that the time limit would necessitate at least one experiment in which the identity of the organism and the efficacy of antibiotic therapy were tested in a living human host. Only this would give them the ultimate answer.
He also knew that there was only one person he could ask to take the risk---himself. Prisoners, conscientious objectors, and similar persons volunteered for studies testing vaccines, most of them wanting to make a personal contribution to medical science. But Alex felt that no man had the right to ask another to die for him.
He was no hero nor was he a fool. He openly admitted that he would take any way out if he found one. But he knew there would be no other way. It boiled down to honor, conscience, responsibility, and that same old buck---this was his, and he knew it.
He thought long and hard about the odds. They were stacked against him if the organism should spread beyond the perfused arm. There would be only one chance. If the therapy failed, he would lose the arm---and he could lose his life.
He thought about Lori and the children. One of the most important things he wanted for his family was the privilege of living in a world free from oppression, want and disease---especially this kind of disease. He wondered why he had never thought of that as a "privilege" before. It was as Max Schwartz had said about life: its value comes when you're faced with losing it.
The generals could handle the oppression. His life insurance would take care of his family's wants. But if he himself wouldn't fight against disease, who would? Lori and the children had never seemed so precious; they gave meaning to the risk. This right to die for them belonged to him.
Alex was sitting in the cafeteria with Sam Ross and Warren Tracey. Although the monotony of the institutional food was hardly appetizing, mealtime was a welcome break in their demanding schedule.
"You know, Alex, when we get through with this project, we ought to do something really worthwhile---maybe we can get the government to serve better food in these places. If I see chipped beef on toast on the menu once more, I may become psychotic. Why, I'd even vote for you for President if you could only get them to make better coffee." Sam sat back and lit a long black cigar.
"I didn't know you smoked, Sam."
"Ordinarily I don't, Alex. It takes away the taste of the food."
Sam twirled the cigar between his fingers and studied the ashes accumulating at its tip. "I don't mean to look a gift horse in the mouth, but something has been puzzling me. How come none of us have died of the disease?"
Alex thought for a moment. "Probably several reasons. In any epidemic, some people get sick; some don't. Individual resistance must play a role; it's probably a combination of immunity and chance. As far as this epidemic is concerned, we know nothing about the immunity. And maybe it's just coincidental that we all have survived. Whatever the reason, let's count our blessings."
"Agreed!" responded the other two simultaneously and emphatically.
"By the way, did McKitridge get you what you needed?" Warren threw out.
Alex looked around the cafeteria. The three men were alone except for a busboy cleaning up in the corner. He leaned forward to make his voice audible. "He's taken care of it. I wanted to talk to you both about something. I guess this is as good a time and place as any."
"You mean about your 'experiment'?" Warren's expression hardly changed.
"McKitridge talk to you? And to you, too, Sam?" Alex really wasn't surprised. The general was the type who would seek advice about things he didn't understand fully.
"He talked to both of us, Alex," Sam acknowledged. "We both thought it was an excellent idea---with certain reservations."
Warren continued: "I've given it considerable thought. I'm concerned that the arm may not tell us what's going on in the lung. But I agree that the danger of infecting a lung, even in an isolated perfusion system, is far too great. And there's one other thing." He looked at Sam to indicate that he should carry on.
"We're very much against you being the guinea pig."
"I didn't tell McKitridge who the 'guinea pig,' as you call it, would be."
"Come on, Alex." Warren sounded a little annoyed at Alex's coyness. "Mark may be a general, but he's no fool; and he's a damned good judge of men. He knew it was you. That was why he spoke to us. He's dead set against you being involved as an experimental subject, and he asked us to talk you out of the idea. He doesn't want to lose another chief."
"What else did he say?"
Sam Ross interrupted. "Look Alex, I agree that your plan is sound, it's necessary, and it could give us the answers we need---and quickly. But you've got to think of your responsibilities. To the project, to your family, to your new job." He paused. "Max told me some time ago that you were his choice as his successor. Look what you might be giving up. This is no time to be a hero."
"I'm the logical choice, Sam. It's my responsibility."
"No, Alex. I'm the logical choice." The older man's clear brown eyes reflected the sincerity of his voice. "I'm sixty-five, Alex. I've had a good life. What's left? Five, ten years? My children are grown up and married. My wife is well taken care of. I have the least to lose of any of you. You're just starting out, with a young wife, small children---this is the time when they need you most. Besides, if something goes wrong, you're going to be no help to anybody as a physician tied down to a table with tubes stuck in your arm. This is something I can contribute. I want to do it."
"And you, Warren? Are you going to give me a tough time, too? Are you also volunteering, or did you two decide that one volunteer was enough?"
"No, Alex. I'm a realist. My job is to oversee the army's research program, not to volunteer for experiments. I think you are not taking your responsibility fully if you insist on risking your life. You're the chief of a damned important project---probably the most important ever for medical research. As chief, it is your responsibility to choose, not to be, an experimental subject. A good chief considers the facts objectively and delegates the responsibility wisely. I know that it would be easier for you to do it yourself, but you have to live with your decision---and your conscience."
"And what did General McKitridge have to say about all this? You've obviously discussed this at length with him."
Warren laughed, then suddenly turned serious. "He said you were like Max Schwartz---we'd never talk you out of it. You know, Alex, Max didn't want you to do it, either."
"I didn't even get the idea until after he died. Don't tell me the army's got a 'hot line' to heaven."
"No, Alex. The night before he died, Max called Warren, Mark and me to his room. He had a feeling you were leading up to a human experiment, with yourself as the subject. He told us about this chest pains and made us promise that if anything happened to him we would not allow you to sacrifice your life this way."
Sam looked at Alex, who merely stared into space.
"He was right, Alex." Sam placed his hand over Alex's and squeezed it affectionately. "Think about it."
Sam and Warren left, and Alex sat in silence with his thoughts of the past and of the present, but less of the future---he wasn't sure if any of them had a future.
The sun was setting as Alex walked around the parade ground. The breeze bathed his face in the humid evening air, and the green grass was studded with more weeds and dandelions than in the days when men had passed there in review. He kicked a stone and looked out beyond the water tower to the rolling green hills in the distance. The sky glowed red and an occasional wispy cloud floated by. His thoughts turned again to the conversation he had just had about the experiment. When and if all this was over, could he tell Lori he had asked another man to fight for them? He knew that he was right---no one else could do this for him.
The small group was in the conference room because Mark McKitridge felt they would be safe there if, and when, the shooting started.
"Jim Rahway's on the phone, Alex."
Alex Kahn looked up from reading a journal and picked up the receiver.
"Thanks, Sam. Yes, Jim."
"How about Jack Flint as your surgeon? He's Chief of Cardiovascular Surgery here at Reed."
Alex knew Jack Flint was considered an excellent cardiologist but that technically he was a lousy surgeon. One of his own residents had characterized him as "a genius in the laboratory, but a butcher in the operating room."
"No, thanks, Jim. I want an operating surgeon who knows his anatomy---especially the anatomy of the arm---and who's a good technician. I don't want a cardiologist or any other kind of -ologist. I want a good surgeon---a man who won't lose his head if something goes wrong---or faint at the sight of blood."
"I've got you, Alex. That's why I asked. Then how about John Keith? He's a damned good surgeon. He's the guy who would operate on the President if he ever needs surgery."
"That's the kind I want, Jim."
"He'll be up there early tomorrow morning. Paul Ryder, an anesthesiologist who runs the pump-oxygenator for one of the cardiac surgery teams at Reed, will bring it out and operate it for you. I'll speak to Keith about any other equipment he wants and ask him to bring it along."
"Thanks, Jim."
"Alex..." There was a deliberate pause. "Did Sam and Warren speak to you about the volunteer?"
"I see Mark got to you, too, Jim. Yes, they spoke to me. Look---I appreciate everyone's concern. Honestly. But this is something I have to do myself. I've thought it all out. In addition, it will be a distinct advantage to have a physician as the subject. I'll be able to describe the onset and changes in symptoms more accurately than a layman. Just wish me luck, Jim---don't argue with me."
"O.K., Alex. You're the boss. We're all pulling with you."
"Thanks, Jim."
Alex put down the receiver and turned to Sam Ross, who was reviewing some of the data.
"Well, Alex, all the data seem valid, so far. I heard your conversation with Jim. So you've decided to be the guinea pig. Well, I knew we wouldn't change your mind." He turned and squeezed Alex's hands warmly. "In some respects, Alex, I envy you. A person rarely gets a chance in a short lifetime to do something really worthwhile. I don't blame you one bit. If I were you, I'd have made the same decision. I know it'll work. You wait and see. When do you plan to start?"
"Tomorrow, as soon as we can get set up." Alex paused. "That is, if we happen to be on the winning side in McKitridge's war with Beck tonight. If we aren't, all our problems may be over."
"Anything I can do to help?"
"Who? Me or McKitridge?"
"You, of course, wise guy."
"Yeah. You can let me clobber you at gin. It'll be good for my nerves."
"Penny a point?"
"Sure. What have I got to lose?"
They looked at each other and laughed.
Alex Kahn would never forget those forty-five minutes. The sounds of gunfire and screams would remain imprinted in his memory forever. As they sat in the conference room surrounded by protective armed guards, he buried his head in his hands and vainly tried to escape into the darkness.
He had seen only one gunshot wound---when as an intern working in the emergency room, he had cared for a young policeman who had been shot in the chest during a robbery. He would never forget the ragged hole nor the violent stream of blood that erupted from it when he removed the towel the emergency squad had used to stop the bleeding. He had almost vomited when the area had been sufficiently cleansed to show the extent of the damage. Bits and pieces of skin, fat, muscle and bone had been scattered by the bullet's impact. Blood bubbled up and spilled over onto the man's chest as air from the punctured lung continued to escape. He had watched the man gasp for breath and turn cold and blue as he slipped into shock. Then---as now---he could not understand how any person could cherish life so little that he could pull the trigger of a weapon whose missile could shatter and destroy flesh with such indiscriminate violence.
Suddenly there were no more shots, no more screams---only the sounds of the night.
The silence was interrupted as Mark McKitridge opened the door and gestured to the guards to leave.
"It's over." McKitridge sat down, his face reflecting only sadness.
"What happened?" Marion Slade was the first to speak.
"They wouldn't surrender. I asked them three times." His face looked ravaged. "I almost lost my nerve, Alex. Suddenly they weren't animals, but men, right or wrong. At the last minute, I didn't want to have to give the order to fire. Do you believe me, Alex? I didn't want to do it! You were right."
"I believe you, Mark." He paused. "But if they gave you no choice, you had to do it. I'm not sure I would have had the guts." He waited another moment. "What really happened, Mark?"
"It was no contest, Alex. The army's business is fighting, and we know it well. We killed or wounded most of them."
"As a doctor, can I help out?"
"Thanks anyway, Alex. We brought plenty of medics from Walter Reed; the wounded will get good care."
"What about Martin Beck?"
"He got away. And I don't give a damn any more. After what happened here, he'll never get anybody else to follow him. If the authorities don't get him, someone else will."
The shooting and killing were over, and the lawless mob was no more. But the massacres at Edgewood Arsenal and Fort Detrick were minor skirmishes compared with battling the disease, which continued to spread unchecked throughout the country.
Mark McKitridge was changing into his everyday uniform when Alex knocked on the door to the locker room.
"Come in, Alex. Jim Rahway call you?"
"Yes, Mark, thanks. He's taking care of everything."
"By the way, I read that paper of Machdi's. I'm not sure I understand it all, but from the gist your theory certainly seems sound."
"Did you happen to notice where Machdi hails from?"
"I sure did. Washington tells me Intelligence is looking into the situation in the Middle East. The only problem is time. It takes a hell of a lot of time to investigate something like this---too much, I'm afraid."
He wrapped the cartridge belt around the holster and placed it in his briefcase. "I'll never willingly put this on again, Alex. And if the time comes when I have to, I'll know it's time to retire. I've been thinking of going back to school to brush up on my chemistry. I think I'd like a professorship at some quiet college with ivy-covered walls."
"If I know you, Mark, you'd be back in the army twenty-four hours after you retired---still pounding on the front door of the Pentagon asking why you hadn't been made Chief of Staff. Besides, you told me there were no 'quiet' colleges any more."
They both laughed.
In the makeshift teletype center set up by Marion Slade, the latest statistics were being printed by an invisible electric hand:
Time: Saturday, 4 a.m.
Total reported cases: 96,850
Total reported deaths: same
The machine stopped.
What these silent letters meant was the beginning of subtle changes, unseen in that small room, but seen with increasing frequency in the face of the country.
Except in an occasional isolated country farmhouse or a hidden mountain retreat or a lone cottage on some small coastal island, hardly a home or office or factory was spared preoccupation with health. "Pneumonia," "epidemic," and "death" became household words. From a quarter of a column on the back page, the story of this strange illness moved forward to front-page headlines in the daily newspapers. What had been a sentence or two on the late-night news became a topic of discussion on every newscast a dozen times a day every day. Via the immense communications systems of the country, persons who had never before heard the words "epidemiology," "attack rate," "case fatality rate" became as familiar with these terms as they were with the language of the weather report or the sports news. Following the trend of the disease became as much a daily ritual as checking the stock market curve, the racing results, or the major league standings. Politics, pollution, integration and inflation were replaced by health and disease as topics of conversation at the breakfast table, on the train, in the coffee shop, or at the bar. As time passed, the number who could say they did not know someone who was ill or dying or someone who had recently died became smaller---and smaller.
And as the disease and knowledge of it spread, suspicion, superstition and rumor permeated the lives of millions and cast the shadow of fear across their daily existence.
At first, life was the same. But slowly, changes occurred. Isolation became the erroneously conceived prophylaxis for the disease. Each town and city isolated itself from the next; each neighborhood from the one bordering it; each family from its neighbors. The once integrated community became subdivided into small groups, each isolated by the invisible boundary of fear that each person was threatened by, and was a threat to, the next.
Panic, in time, would be the inevitable sequel---and there was not much time left.
In New York, the bustling crowds began to dwindle and the pace of daily business began to slacken. People walked the streets only when necessary. Fifth Avenue at noon looked as it had at midnight only a short week before; now at midnight, it was deserted. Buses and subways ran half filled, and rush hour vanished as people left work at odd hours to avoid crowds. Absenteeism closed many smaller businesses and forced larger ones to consider doing the same. The Stock Exchange shortened its trading day; whispered talk of a prolonged closing sent prices into a ruinous spin. The bright lights of Times Square sparkled down on increasingly empty sidewalks; the few who hurried by walked with heads bent as if against a strong wind. The lights of theater marquees dimmed and then went out as crowds became only memories of the recent past. The few waiters who dared to come to work stood about in their uniforms, unused linen napkins folded neatly over their arms, and talked in small groups and looked at the empty tables and waited for notice not to return the next day. Signs in shop windows announced no enticing sales, no positions to be filled, but told the simple story of the city and all around it: CLOSED.
Chicago's Grant Park was empty except for hungry birds and squirrels that gathered at the bases of statues and scattered through the empty paths to look for food. Their hunger had become constant, and they were angry that no one came to feed them. The wire baskets filled with the debris of last week remained unemptied. The sun shone on empty benches, and the warm breeze caused spray to rise from the fountains. But there were no people on the benches, no faces to catch the breeze. There were only emptiness and silence.
The emptiness and silence spread. Cities took on the appearance of half-empty towns; towns resembled deserted villages; and villages looked like the "ghost towns" of the legendary West. Nothing moved in the countryside except for the trees and the grain that rippled in the breeze. In the afternoon the setting sun's rays appeared as an eerie wave of disease spreading across the land.
Some tried in strange ways to maintain a semblance of their previous existence.
In Los Angeles, masks, designed for protection against smog and air pollution, seemed a logical answer for an epidemic. At first, only a few braved the mocking stares, but as the death rate rose, concern about social acceptance was overcome by the desire to survive. Fortunes were made overnight by the perspicacious who had stocked this commodity. As the idea spread, the populace soon looked as if it had been replaced by men from another planet. Only the eyes were visible, staring above whatever covered the nose and mouth below. Fashion and an air of levity were added to the scene by masks of various colors and patterns. Some masks bore printed sayings: "Through this mask only the purest air may pass"; "Bugs Keep Out!"; "Cover your face and save the race"; "Remove before kissing"; "Keep the bad air out and the bad breath in!" Words and rhymes replaced facial expressions.
But all in vain. Death chose its victims rapidly and indiscriminately without pausing to comment on color, fashion or wit.
The exodus began as statistics showed the predominance of disease and death in the large cities.
At first, only a few left, departing quietly and surreptitiously. The few soon became the many; and instead of leaving, they fled. But there was nowhere to run---death was everywhere. Many refugees became unknowing vectors, and the disease became the traveling companion of a nation fleeing to a haven that did not exist.
All did not flee. The dead and the dying could not leave.
Only the hospitals, the morgues, and the cemeteries remained crowded. Here business was better than ever.
Fear of hospitals became an understandable obsession, for very few who entered survived to leave---those who did had had some other disease in the first place. Babies were born at home; tonsils were removed on the kitchen table as they had been forty years before. And death showed no respect for time or place or person or profession; here and there among the names of the dead appeared that of a nurse, that of a doctor. The white coat, the stethoscope, the M.D. or R.N. that followed their names had endowed them with no immunity.
In the wake of this hospital-phobia, the quack and the faith healer prospered, preying on the frightened and gullible. They gave the hopeless false hope by promising a cure that was not yet known and life to those destined to lose it. But the disease alone was judge and jury.
No gun had been fired, no bomb had been dropped, no foreign boot had touched the soil. Yet in a few short days the mightiest nation on earth was rendered helpless by an invisible enemy that killed swiftly and silently and so disrupted the lives of over two hundred million persons. A mighty Goliath was being slain by a microscopic David. As in Biblical times, the magnitude of the plague was inconceivable and only time would reveal its aftermath.
The rays of the morning sun crept between the worn shade and the chipped window frame. Alex blinked, then stretched contentedly and pulled the covers up around his head. Fatigue had brought the welcome peace of dreamless sleep, and he felt fresh and vigorous.
The equipment for the experiment would not be ready for four or five hours, and he treated himself to the luxury of staying in bed. He dozed for a minute or two, then lowered the covers and bathed his face in the sun's warmth. For the first time since he had decided to be his own experimental subject, he was at peace with himself. His confidence that he would succeed cleared his mind and stimulated him with an almost reckless eagerness to get stated. But his awareness of the risk sobered his mood. The organism was about one micron---one thousandth of a millimeter---in diameter; it would not take a large error to allow it to escape from the arm and into the rest of the body via the bloodstream. He would have to discuss the only alternative to such a catastrophe with John Keith.
John Keith was a tall, lanky man with graying, sandy hair that fell onto his forehead. He looked more like a farm boy than an accomplished, forty-two-year-old surgeon. The soft, southern drawl was deceptive; his words left no doubt that his reputation as a surgeon was well deserved. Keith felt there would be no technical difficulties in isolating the arm.
"But can we isolate it sufficiently to prevent bacteria from leaking into the rest of the circulation, John?"
"I think so, Alex. We'll monitor the system, anyway."
"How?"
"After the system is all set up, I'll inject a fluorescent dye into the arm. Needle probes will be placed at index points in the rest of the circulation beyond the arm. They're capable of picking up one part in ten million of the dye. If there's a leak, the probes will pick it up."
"You know, John, some day surgery may actually become a science." Alex smiled playfully, but then paused and rubbed his left arm, the experimental limb. "Let's just hope we don't have any problems."
"I plan to use a brachial block for anesthesia. Are you allergic to xylocaine?"
"No, but I thought you'd just anesthetize the cutdown areas, not the whole arm."
"Look, Alex, if I should have to amputate the arm, I'm not going to have any time to anesthetize you. Once the arm's numb, I can do whatever is necessary without worrying about further anesthesia."
"Never thought about that." Alex patted him good-naturedly on the hand. "I guess surgeons are good for something."
"What about the prep? What are the possible sources for contamination?"
"The skin for one. The air. The catheters." Alex thought for a moment. "And, of course, the pump."
"We'll scrub the skin with phisohex and zephiran and paint it with an alcohol-iodine solution. In this kind of situation, we'll use adhesive plastic drapes to cover the entire field. I'm certain the OR here has ultraviolet lights, but they're no damned good for sterilizing the air. The catheters are pre-sterilized in sealed packages. Paul Ryder will take care of the pump; but you know the problems in sterilizing it. We'll have to settle for the best we can get there.
"Alex, just go over the indications for amputation once again, will you? I want to be sure I have them straight."
"What we're trying to do is to study the organism in vivo, using the arm as an isolated living human system. We'll try to identify the organism by taking serial samples of blood from the inserted catheters; hopefully, we'll have a chance to study the bug if and as it changes in the body. Also, we'll evaluate means of therapy by injecting antibiotics after we draw the samples for the cultures. But if we can't get rid of the bug with any antibiotics, we can just get rid of the whole system---by amputating the arm."
"Kind of a 'gusty' experiment, isn't it?"
"Let's not go into all that again. It has to be done. Besides, I'd rather lose an arm than my life. Anyway, John, there are two indications for amputation. First, if the bug leaks beyond the limits of the system. In that case, do it quickly to prevent more organisms from spreading into the general circulation. If that probe of yours shows a leak, don't think---just amputate. Second, after the experiment's over, if the drugs haven't worked, you'll have no choice but to amputate---but then you'll have more time."
"How are you going to know if there are bacteria left at the end of the experiment? Certainly you can't culture bacteria in that short time?"
"Of course we can't, John. But we'll run a line from the venous catheter through a photoelectric counter with special magnetic grids---something like a white blood cell counter. It'll give us a continuous reading of the number of bacteria in the venous blood. If the drugs work, the number won't increase. It can't necessarily differentiate between live and dead bacteria; but if the bugs are being killed, they won't reproduce. We can tell if we're successful by the curve the machine gives us."
"What antibiotics will you be using, Alex?"
"Five hundred milligrams of murocillin and a gram of ampholysin, each dissolved in 100 cc. 5 percent dextrose and water and injected intravenously over a ten-to fifteen-minute period. Murocillin first, then the ampholysin. The rapid injection will give us peak blood levels in fifteen to thirty minutes."
John Keith thought for a moment or two. "I guess that about wraps it up. Who makes the final decisions about any problems once we've started?"
"You, Sam Ross, Warren Tracey and myself."
"And what if we don't agree about something, Alex?"
"Then my decision is final, John. I want that to be clearly understood. If I can't make decisions for some reason, then you're the boss; you're more qualified to make medical judgments than Sam or Warren. I'm counting on your reputation as a person who can make difficult decisions under stress. I asked for you because you're supposed to be the best goddamned surgeon around. Prove it. Just keep uppermost in your mind that I'd rather lose the arm than my life. Now, when will you be ready to begin?"
"As soon as Paul has the pump set up---in about two hours."
"Fine." Alex's watch said 10 a.m. "Let's start the party at noon. Everyone will just have to eat lunch early today. I'll send out the invitations."
"Don't you eat, Alex. I get nasty when someone vomits on my operating field."
"You want me to starve? Besides, the condemned man is supposed to eat a hearty last meal. Want me to spoil tradition?" He realized how out of place his own levity was, but who the hell cared?
He glanced at his watch again. It was an odd, frightening feeling. He didn't know if this wrist would still be his when the hands of the clock swung by these same numbers again---he didn't even know if he would be alive at this time tomorrow. A faltering step could be his last.
\*
Alex walked around the parade ground once more while the others ate lunch. He had no desire to watch them eat. The experiment was due to start in thirty-five minutes---he'd never been a clock watcher before, but time had become a very important variable in his life since his arrival at Fort Detrick. It seemed as if he'd always been there. His life before that seemed unreal now.
He looked out at the peaceful hills again. The sky was still blue, the wispy clouds still overhead.
He walked over to the flagpole and sat down at the base. From here he could see the main gate. The MP's booth was a mass of broken glass and bullet-riddled boards. The asphalt street, too, was pitted with bullet holes, and metal shell casings occasionally sparkled in the sunlight amidst the ruins. A small group of men in fatigues was still cleaning up.
"Dr. Kahn!"
Alex turned and recognized one of Marion Slade's aides running toward him.
When Alex walked into the conference room, the general handed the telephone to him and smiled. "Someone wants to talk to you." Slade picked up his gold-braided hat and left, closing the door quietly behind him.
Still puzzled, Alex put the phone to his ear.
"Dr. Kahn speaking."
"Alex?"
He hadn't heard the voice for so long.
"Lori?"
They talked. Into fifteen short minutes, he crowded what he had to tell her while there was still time. The sudden crisis in their lives, the worry and the fear enabled him to say all the things he now knew he should have said before. Only what he was about to do remained unsaid. This would wait for later---if there was a later.
He put down the phone and felt a sudden closeness to Marion Slade. This was not the gesture of a professional soldier, the military robot, but one that only a warm and feeling person could make.
He looked at his watch again: time to go. But he felt better. For those few brief minutes, the telephone had been his link with the real world outside the fence. He knew Lori and the children were well, and he was at peace with himself. When and if this was over, they would be waiting for him.
Alex stared up at the ceiling and blinked at the bright reflector that covered the large, circular operating-room light suspend above him. It was uncomfortable lying on his back with both arms extended at right angles.
Inserted into the vein in his right forearm was a stainless steel needle through which an intravenous solution of nine-tenths percent saline dripped slowly via a coil of thin polyethylene tubing. This was a "safety access" to his central bloodstream should some emergency medication have to be administered rapidly.
His left arm was more uncomfortable, as John Keith, his features barely visible behind the light-green surgical cap and mask, scrubbed it vigorously with phisohex, an antiseptic soap solution, and warm water.
Sam Ross and Warren Tracey worked behind the surgeon, their faces similarly covered. Both wore light-green scrub suits that looked like poorly fitting pajamas. The bacteriologist checked to be certain he had all the necessary culture media and anaerobic equipment. Tracey, his back to the operating table, fidgeted with the dials on a battery of electronic consoles to be used for monitoring the central venous pressure, the arterial pressure, the electrocardiogram, the electroencephalogram, and a variety of other parameters used in specialized surgery.
In a corner of the room, Paul Ryder sat hidden by the pump-oxygenator he was checking and adjusting.
Alex was startled by the sudden, smarting coldness of the alcohol-iodine solution as John Keith began the second part of the surgical prep. He turned his head to the left and watched as the surgeon carefully painted his skin with the yellowish-brown antiseptic.
"Maybe you should anesthetize the arm before you put that damned alcohol on, John. Man, would you have made a lousy barber! You must have nicked me a dozen times," Alex kidded him.
"Just keep talking like that, Doc, and I'll slip some pentathol into that IV," he nodded to the needle neatly taped in place in Alex's right arm. "I just love talkative patients." His eyes smiled sarcastically. "Or better yet, I'll do the whole thing without anesthesia."
"You win, John. Can't fight in this position."
The surgeon applied the transparent adhesive drapes to the cleansed area. "Help me change gloves and gown-up, will you, Warren?"Warren stopped his work on the electronic panels and came over to help the surgeon strip off the rubber gloves, now contaminated from the cleansing procedures. He opened a folded surgical gown and allowed Keith to pick it up by the corners, being careful not to touch that part of the gown that would come into contact with the patient. As Warren held up a pair of new, sterile rubber gloves, Keith slipped in his hands; then he walked behind the surgeon to tie his gown.
"If you'll just open that pack on the Mayo stand for me, Warren, I can do the rest. Also, will you get the catheters for me from Paul?"
Warren peeled off the tape that sealed the surgical pack. Unfolding the green wraps by touching only the under-surface, he avoided contaminating any of the surfaces or equipment the surgeon would need to handle.
The catheters were wrapped in double cellophane envelopes. Warren separated the ends of the outside package of each and let the inner, sterile package drop onto the covered Mayo stand, a large, flat, stainless steel tray attached to a curved, vertical stand on the floor which made it possible to move the tray over the operating table within the surgeon's easy reach.
John Keith took careful inventory of the instruments and equipment and rearranged them for his convenience.
There was a pile of sterile green towels for draping the operating field: one had a circular opening in the center for access to the area in which he would cut. There were two neatly arranged piles of gauze sponges and scalpel handles and scalpel blades in a variety of sizes and shapes. There were rows of a variety of stainless steel instruments, including straight and curved scissors, clamps, hemostats, smooth and saw-toothed forceps, and several needle holders. Transparent plastic packages containing black suture material lay beside needles for sewing. A pyrex shot glass contained hypodermic needles; glass syringes and plungers lay next to an empty shot glass for liquid anesthesia or antiseptic solution. The remainder of the tray was covered with test tubes and plastic syringes to be used for the many blood samples to be taken.
The surgeon was satisfied that everything he would need was readily available. He draped his field with the green towels and clipped them in place with special snaps. "Everybody ready? Sam? Warren? Paul? Shall we start, Alex?"
Alex Kahn looked around. Over their surgical masks, four pairs of eyes wished him luck. "Let's go."
"Hold the xylocaine, will you, Warren?"
Warren took a small rubber-stopped bottle of the anesthetic from a shelf and held it up so John Keith could check the label. The surgeon attached a small needle to the first syringe and filled its body with air. He waited for the top of the rubber stopper to be cleansed with alcohol, and then he plunged the needle through the stopper of the bottle and injected the air. The pressure caused the syringe to fill with the colorless solution. He held it up to the light to check the volume, squirted a little into the air, picked up a gauze sponge, and glanced up at the clock on the wall. "Mark it down, will you, Paul? First anesthesia at 12:45 p.m." The levity was gone from his voice. This was serious business.
Alex felt a small pinprick and a fleeting sting as the surgeon made a small wheal of xylocaine in the skin high up on the inner arm in line with the major nerve trunk he would anesthetize next. With the exception of another second of stinging, Alex felt no pain. John Keith continued to infiltrate the area, slowly allowing the anesthetic to numb the nerve endings before advancing the needle farther in each direction. He withdrew the needle, and Warren helped him fill a second syringe with xylocaine, replacing the small needle with a thin one about six inches long. When he reinserted it, he was careful to puncture only the previously anesthetized skin so that Alex felt no pain.
He paused for a moment. "This will ache a bit, Alex. It's the big one; but the whole arm will go numb. Then you can sit back and watch."
He adjusted the angle of his thrust and plunged the needle to the hub upward and inward.
Alex winced at the severe, aching pain. It felt as if someone had just torn his arm off at the shoulder. His arm felt warm as the sting of the injection subsided, and it began to tingle with the sensation of pins and needles. In about thirty seconds, he could feel nothing distal to the left shoulder. It was an odd sensation. He looked to be certain the arm was still there; it seemed to belong to someone else.
"Feel anything?" John Keith tested the adequacy of the anesthetic block by pricking here and there with the point of a needle.
Alex shook his head.
The surgeon then inserted a blade into a scalpel handle and picked up a pair of forceps. Leaning over the part of the arm visible through the window in the drapes, he cut through the plastic covering. With the forceps, he pulled aside the adhesive protective covering to expose only the small area in which he would work. He discarded the now-contaminated, used instruments and picked up a sterile blade and handle for the incision through the skin.
Alex watched him work. His steady hands literally flew; and their clean, smooth motions reassured the observers about his surgical skill and flawless technique.
With a single motion, he made a clean, straight, two-inch incision through the skin, the subcutaneous tissue, and the thin layer of fat. As beads of blood welled up along the cut edges, he quickly sponged them dry and stopped the bleeding with small hemostats. When several bleeders had been clamped, he stopped to tie them off before going further. The wound appeared sharp and clean. With forceps and the blunt end of a curved clamp, he pushed the connective tissue aside and exposed the glistening surfaces of the walls of the major artery and vein to be catheterized. Unlike artist's sketches in which the artery is painted red and the vein blue, there was little gross difference between the two when seen in the living person. The artery was recognizable by the visible and palpable pulsations; the vein, by the slightly darker hue of the blood as it flowed back toward the right side of the heart and from there to the lungs for oxygenation. With blunt dissection, the surgeon exposed and freed up about two inches of each vessel.
Then Keith paused to open the sterile inner packages that contained the catheters, examining each to be sure it was intact. He chose two that appeared to be the correct size.
Before Alex could decide exactly what was going on, the catheters were neatly in place to occlude the vessels and were connected to the tubes leading to the pump-oxygenator. When this was done, Keith checked the flow of blood with his eyes and finger to make certain that the system was operating properly. All was in place.
Stopcocks were placed at the various junctions between the catheters and the tubes leading to the pump into which a syringe could be inserted to inject fluids and withdraw blood samples.
With another deft motion, Keith inserted the monitoring probes and had Warren Tracey attach them to the monitor on his electronic panel.
John Keith viewed his work with satisfaction. The entire procedure had taken thirty-five minutes. "We're all ready to go any time you are, Alex. How do you feel?"
"Fine, John. Man, are you fast! I'm ready if everyone else is."
Each motioned that he was ready to start the rest of the experiment. Sam Ross held up a small, sealed flask of cloudy broth containing the organism, as if to signal it was ready for injection.
John Keith injected 10 cc. of a greenish-yellow fluid into the arterial catheter stopcock.
"What's that, John?" Alex tried to lift his head to see what the surgeon was doing.
"It's the dye for monitoring for leaks. Put your head down. If the system isn't closed, it may make you feel light-headed and warm. Feel anything?"
"Nothing."
"Good. The system is sealed."
For the next several minutes Keith obtained blood samples. Then he turned to Sam Ross. "Ready for the bug, Sam." He turned back to Alex. "Last chance to chicken out, Alex. What do you say, Doc?"
"Let's get on with it. I'm hungry."
By means of a carefully constructed closed siphoning system, John Keith was able to fill a syringe with the suspension of the organism without contaminating his sterile gloves or exposing himself or the others to the deadly solution.
Paul Ryder checked the readings on his board, Warren Tracey the equipment before him, and John Keith the system of tubes and catheters through which blood was flowing smoothly. Consciously or unconsciously, each hoped he would find something wrong, something missing, which would preclude continuing this dangerous experiment. But all was functioning properly; everything was in place; there was nothing to stop them.
"Here we go, Alex. God help us, I hope we're doing the right thing. I hope this damned experiment tells you what you want to know."
As if he were afraid he would change his mind if he hesitated, John Keith swiftly attached the syringe to the arterial stopcock, opened the valve, and injected the entire contents into the arterial system in one smooth motion.
It was done. There was no turning back.
Alex Kahn glanced up at the wall clock. Two p.m. The bacteria had been circulating in his arm for thirty minutes. With the exception of a two-degree rise in the temperature of his left arm, almost no demonstrable changes had occurred. The counter showed the presence of the organism in the blood and the expected increase in numbers as it multiplied.
They had agreed to allow the experiment to proceed for thirty minutes without instituting therapy unless something occurred to force their hands. Now Sam Ross handed the bottle of murocillin to Paul Ryder.
"This is 500 milligrams of murocillin dissolved in 100 cc. of five percent 'D and W,' Paul."
The anesthesiologist hung the bottle on an IV pole and removed the plastic cover from the needle at the end of the tubing. He inserted the needle into the tube leading to the arterial catheter, fastened it in place with adhesive tape, and initiated the flow of the antibiotic solution.
They all watched in silence as drop by drop the bottle slowly emptied its contents into the blood of Alex's arm. It took about fifteen minutes. They obtained samples of blood at five-minute intervals during the next fifteen minutes and then repeated the procedure with the ampholysin solution.
Over and over again, drops formed at the tip of the small plastic tube, swelled, and then dropped into the small reservoir hanging beneath the inverted glass bottle. Although the flow-rate and volume were the same as those for the murocillin, it seemed to take forever for the small bottle to empty. Each of them stared at the dripping solution, knowing that this was it. This was the end of the line. They had pooled their knowledge and experience to place their bet on these two drugs. Soon they would know if they had won or lost. If they lost this time, who knew if they could win---ever. Then mankind would drown in a flood of disease against which no dike could be built---it was a frightening, unthinkable thought. If they won---but at that moment the idea seemed beyond their reach.
The quiet was interrupted only by the whirring of the pump-oxygenator, the clicking of the spools of paper recording data in the monitoring equipment, and their own movements as they obtained blood samples.
They all knew they should see some effect in fifteen to thirty minutes as the level of ampholysin in Alex Kahn's blood reached its peak and began to subside. Each silently rationalized that perhaps it would take a while for the organisms to die after the peak drug level had been reached. The minutes passed.
Alex Kahn watched the silent group. His dilemma was unique. If the drugs did not kill the organisms, how long could the arm remain isolated from the rest of him? Unless the drugs worked, John Keith would be forced to amputate the limb. He looked at the arm. At least it was his left one; he was right-handed.
To pass the time, he began to recall what he knew about the recent advances in artificial limbs. He remembered reading about a battery-powered prosthesis controlled by the wearer's own nerves and muscles. Special transistorized microcircuits in the artificial fingertips provided an actual sense of touch. He tried to think of things he did with his left arm and hand. For some reason all that came to mind was that he wore his old baseball glove on it---how long ago was it that he and Peter had last played? It seemed both like yesterday and yet years ago. He wondered when and if they would play again.
The white face of the clock seemed stark against the shiny beige tiles of the wall. Was the second hand really stopping and starting, or was it a combination of his imagination and anxiety? He tried to stop thinking and looking.
It was fifteen minutes since the ampholysin had been administered. Sam Ross sat bent over the bacterial counter, his eyes glued to the oscilloscope screen. The pattern of light electrically bent into a curve reflected the number of bacteria in the blood that flowed from Alex's arm into the counting chamber and between the magnetic grids of the equipment.
Twenty minutes.
Twenty-five minutes. The slope of the curve continued to rise slowly as each bacterial cell divided; two became four; four became eight; and so on.
Thirty minutes. By every previous study with the drug, this was when the concentration of ampholysin should reach its peak in the blood. There was no change in the curve.
Sam Ross felt the beads of sweat form on his forehead as hope began to fade into frustration and fear. He knew only too well what failure meant, and he hoped he would not live to see its consequences. He continued to watch the screen.
Thirty-two minutes. With each full circle of the second hand, the chance of success became more and more remote.
Their anxiety filled the air. The silence became deafening.
Thirty-three minutes.
"It's dropping!" The scream shattered the silence.
Sam Ross jumped up and bent over the screen. He grasped the machine by its sides as if he were shaking success out of some unseen human being with an oscilloscope for a face.
"They're dying! The dirty, rotten little bastards are dying!" He continued shouting as he watched the curve of light turn downward and begin to head toward the zero mark "They're all dying! The curve is going to hit bottom! There's no doubt about it! They're not even intact any more. The drug is breaking them up! We've done it! My God, we've done it!" Losing all inhibition, he laughed, he wept, he danced around. He ran up to Warren Tracey and threw his arms around him. "We've done it, Warren! We've won! Do you understand?"
Warren couldn't tell if his cheeks were wet with Sam's tears or his own. He was seeing what he had really felt would never come to pass. In those few days they had managed to solve what was perhaps the greatest single puzzle ever to challenge the talents of American medicine.
John Keith stood and watched them, his gloved hands thrust into the pocket of his surgical gown to maintain their sterility. "Well, Alex, as you can tell from the rather subdued antics of your two associates, the experiment seems to have been a success." The drawl revealed little emotion, but the expression in his eyes above the mask revealed what his voice did not.
Alex just lay there, tied down to the operating table and chained to the pump. He did not have to shout or dance. No words, no actions, no expression, could show what he felt. He watched the group until his tears blurred their images, and then he just smiled. It had been a long road from that day in his office when the ringing telephone had interrupted life as he had known it.
"Repeat it, John."
"What, Alex?"
"I said we've got to repeat the experiment. You know one successful experiment doesn't make a cure. As long as I'm all set up, anyway, let's take advantage of it."
They all knew he was right. They had to be certain.
"I'm satisfied now, Alex. Are you?"
"Yes, I am now, Sam. We've done it four times. At least by the counter, we've eliminated the organism each time in twenty-five to thirty-five minutes. I think the drugs will work. Do you agree, Warren?"
"Absolutely, Alex. I'm convinced."
"Then call Marion Slade, will you, and ask him to inform the President? It's getting close to midnight. And John, untie me."
"Wait just a minute, John." Sam Ross interrupted him. "When you remove those catheters, the blood that's been in his arm will get into the rest of the circulation. Right?"
"Right, Sam."
"I want to have some drugs mixed and ready to go, as a precaution in case a few of those little bastards are hiding someplace. We don't want to lose our hero now." He turned back to his bench and mixed the antibiotic solutions. He labeled each and set them on a table near the IV stand. "OK. You can disconnect him now."
Alex turned his head to watch the surgeon disconnect the tubes from the pump after certain adjustments were made to insure that his arm would be adequately supplied with blood. Keith worked quickly to prepare needles and suture material to close the incisions.
"I'm going to remove the catheters now, Alex."
In a moment, the circulation would be intact.
Alex Kahn felt suddenly warm. For a brief moment everything looked yellow. He started to speak, but no words came. He felt only panic as he recognized the tightness in his chest as air hunger. He couldn't breathe. He moved his chest, but the motion caused no air to fill his lungs. He fought for breath, but none came. He tried to move but felt no movement. The rest of his body began to feel like his left arm---numb. His vision blurred and then grew dim. He was left in darkness, isolated from the world around him. The last voice he hard was that of John Keith; the last word, "Adrenalin!" His last thought was, "After all this, we lost." And then the peace and loneliness and silence of coma let him rest alone in endless darkness.
He could hear voices through the silence and see the light penetrating the darkness. His chest still felt tight, but the air hunger was subsiding. As his mind began to clear, he could remember what had occurred until coma had blotted out his memory. Multicolored bright shadows danced before his eyes and beyond his closed lids. For a brief moment, he squeezed them tight in fear of what he would see when he opened them. But then he recognized the voice of John Keith and realized he could not be dead. First the right eye opened, and then the left. As his eyes adapted to the uncomfortable brightness from the operating lamp, the familiar faces came into focus.
"Welcome back to the world of the living, Doc." Keith's face broke into a broad smile. "Enjoy your nap?"
Alex looked around. He was still lying on the operating table, but his arms were free. The tubes were gone, and neat gauze bandages covered the sites of their insertion. The electronic equipment was silent. His left arm was less numb; he could move his fingers. He touched the tip of his index finger to that of his thumb; he could feel the contact---barely, but he could feel again.
Sam Ross bent over the table and patted his cheek with fatherly tenderness and then gave it a playful slap. "You couldn't be satisfied with an uneventful recovery? You had to go ahead and have an allergic reaction to the dye."
Alex looked at John Keith.
"That's right, Alex. You had an anaphylactic reaction to the dye I used as a monitor. It had nothing to do with the bugs. You gave us an uncomfortable second or two, but you'll be OK."
"A second or two?" Sam made a feigned, painful expression. "That's the understatement of the year! You can thank John that you're still around---he recognized what happened immediately. I was certain you were going to die from the damned infection."
"And spoil the experiment?" Alex laughed. It felt good. He reached out to grasp Keith's hand. "Thanks, John. Remind me to say something nice about surgeons someday, will you?"
The experiment was over. It had been a dangerous gamble, but they, and mankind, had won---at least for now.
The atmosphere in the conference room was far different from that first morning six days ago. There was laughter, and there was hope; and it appeared that tomorrow the sun would rise on a world that would survive to enjoy a healthy future.
Marion Slade had taken off his jacket and even loosened his tie. "I sent out your messages to the major hospital centers about 2:30 this morning, Alex. At nine the first report came in from Boston; three patients treated with your drug regimen have survived so far, and it looks like they'll recover." He held up a handful of teletype messages. "At least twenty-five hospitals report the same. There are still deaths, but the Communicable Disease Center reports the data is coming in so rapidly, it'll take them another twelve hours to sort it out."
"I'm sure we'll still see many deaths, Marion. Some of the people were far too sick to be saved. But I think we'll see a leveling off in the number of cases in the next few days and a decrease in four or five days. By my rough calculations, we should have everything under control in ten days to two weeks."
General McKitridge puffed contentedly on a black cigar and motioned to Roger Bergen to speak first.
He rose. "Alex, the President has asked me to inform you that he did not send the messages. We were able to get word to him in time." He paused. "It's not my place to extend his gratitude or that of the country to you; I know he'll do that himself. But I want to thank you---all of you." He sat down. They all knew the sincerity with which he spoke.
"I can't really add much to what Roger has said." The general now spoke, remaining seated. "It's funny how a crisis brings together men who might otherwise never have met. It's been a privilege to have worked with this group, and I hope we'll meet again under different circumstances. I think we've demonstrated that, even in this day and age, at a time of crisis men can still work together unselfishly for the common good. It's too bad that it took this epidemic to show that patriotism and devotion to humanity are still in vogue."
Alex rubbed his left arm. "Well said, Mark. You'll excuse me if I don't stand up. I think I can sum it all up by saying that without the contribution, large or small, of any one person here, we were doomed to failure. All I would like to add is that if we're still around to talk about it next year at this time, the treat's on me. We'll have a blast and celebrate in Boston."
They applauded loudly.
"To get back to business for a moment. I've been thinking about the immediate problem of getting the drugs to those who need them.
"Ordinarily, I'm very much opposed to mass antibiotic prophylaxis; but I see no other choice in this situation where there's no way to determine who's been infected until they get sick." He pushed a folder toward Marion Slade. "I've outlined a program to administer murocillin and ampholysin orally, especially to those in areas where the density of the disease has been greatest. The two companies that make the drugs assure me that 250 milligrams of each drug taken four times a day for three days will provide the necessary antibacterial effect. They're evidently well absorbed when taken by mouth. Marion, can you have the Public Health Service take care of this?"
Slade took the folder. "Consider it done. Anything else?"
"Yes. I want the signs and symptoms of the disease and the recommended treatment advertised from one end of the country to the other. I want every person who gets the first symptoms to get his ass to a doctor fast, and I want every doctor to recognize the disease the minute it walks in the door and know how to treat it properly. Can do?"
"We'll start a publicity campaign that'll make the guys on Madison Avenue look like a bunch of amateurs. Anybody who doesn't hear about it will have to be out of touch with the rest of humanity. Leave it to me."
"I guess that's it, then. I know where to reach you all if I need you. Let's finish up. I want to go home!"
Alex was starting to get up when an MP entered and handed two messages to Mark McKitridge.
The general opened the first, glanced at it, and then read it aloud without emotion. "'Martin Beck died at Hagerstown Memorial Hospital at 2 p.m. today from overwhelming pneumonia.' I guess you could call that poetic justice."
He opened the second message and paled; his hand trembled as he handed it to Alex Kahn.
Mrs. Lori Kahn and son Peter acutely ill with pneumonia. Condition of both poor after receiving last murocillin and ampholysin available to us. Unable to get more drugs for 6 to 12 hours. Please advise Dr. Alex Kahn that ...
Alex dropped the note. Had he come this far only to have it all end this way---to have to sit by and watch his wife and son die from a disease for which he knew the cure---a cure which he could not administer because of time and distance? His sudden grief and his terrible frustration left him numb and void of rational thought.
"Alex!" Sam Ross had read the note and handed it to Marion Slade. "Get off your rump. They're not dead yet. Maybe the drug they've had will hold them for a while. We've got enough of the two antibiotics to spare some. Don't sit there and mourn, man! Get some medicine to them!"
"He's right, Alex." Marion Slade stood up and reached for the phone. "We can get you to Andrews by helicopter, and I can arrange to have a jet take you to the air force base outside Manchester." He glanced at the message again. "They're at Nashua Memorial Hospital---how far is that from Manchester?"
Alex sat upright. The sudden ray of hope seemed to revitalize his mind. "About fifty miles, but it's all good highway."
"This message was sent only a short while ago. I think we can get you there in about two hours. Do you think whatever drugs they've had will keep them alive that long?"
"I don't know." Alex Kahn's voice was barely audible.
Sam Ross did some quick mental calculations before he spoke. "It's possible, Alex. Peak blood level occurs after about thirty minutes, but some drug may remain in the blood for four to six hours." He stood up and turned toward Marion Slade. "Get those travel arrangements made, Marion. I'm going to pack up some of the drugs for you, Alex. Take some extra along for the other patients at that hospital with pneumonia. They can probably use all the drugs we can spare." He started to leave.
"Sam?"
"Yes, Alex?"
"Thanks."
"Go save your wife and boy. Then you can thank me." He smiled affectionately.
Alex held the small hand and watched each precious breath cause the slight frame to rise and fall. The hemorrhagic rash was starting to fade, and the sickening blue color of the skin was turning into a healthy pinkish glow. He reached down and pushed the brown hair away from the still shut eyes and ran the back of his hand lovingly across the hot cheek.
At his touch, the eyelids fluttered open.
"Hi, Dad." The voice was soft and weak."Hi, Pete. Feel better?"
"Some." He took a deep breath. "I can breathe better."
"Good. Go back to sleep. You need your rest. I'll see you later." Alex Kahn turned to hide his tears, picked up his coat and tiptoed to the door.
He walked slowly down the corridor to see Lori again. He was very tired, and his left arm still ached from the surgery. The hospital was dark and quiet. Although one hospital or another had been his home away from home for so many years, this one was now just a lonely, empty place where Lori and Peter must do battle with this disease. He watched his shadow extend down the long, dimly lit corridor---the lonely shadow of a lonely man.
He stood at the window and watched the sun of the new day begin to rise above the pine trees. The room was still except for the sounds of Lori's labored breathing behind him and the monotonous, mournful, hissing sounds of the oxygen escaping from the plastic mask which covered her face.
With all the vigorous rebound of youth, Peter was well on his way to recovery. At 4 a.m. he had become afebrile; he was resting comfortably and was even taking fluids by mouth.
Lori was still in coma, but Alex's fear was mixed with gratitude that she was still alive. If she would just wake up.
For a moment, he was lost in thought. From the little Carl Stafford and Matt Raleigh had been able to find out, they had hypothesized that a mutant strain of Staphylococcus aureus: 80/81 caused this disease by producing an exotoxin, a substance made within the bacterial cell and then released into its environment. They further speculated that this toxin was fatal because it destroyed surfactant, a type of fatty material in the lungs necessary to maintain optimum conditions for oxygen to get into the bloodstream and for the lungs to function properly; it also destroyed red blood cells to cause acute anemia, damaged the walls of small blood vessels or capillaries to cause bleeding into the skin and vital organs, and prevented white blood cells from acting properly in defense against infection. The result of these pathologic processes was the terrible disease that had taken so great a toll of life.
"Alex?"
He spun around at the sound of Lori's voice and ran to the bed. "I'm here, Lori." He grasped her hand and brought it to his lips. It was hot and blue.
"How's Peter?"
"All better."
"Really?"
"Really, hon. He's sleeping in a room right down the hall. His temp is down and he's just about over it. How are you doing? Are the girls OK?"
"They're fine, and I feel much better now that you're here." She squeezed his hand. "I was frightened, Alex, that I would die without seeing you again. How did you know we were ill?"
"It's a long story. I'll tell you about it someday. Rest now."
He bent over and lifted the oxygen mask to kiss her lips. She was a little cooler and the blue was beginning to fade. He knew now that she would be there tomorrow to share a new day with him.
Alex returned to Fort Detrick to tie up loose ends.
His predictions had underestimated the efficacy of the drugs. Within twenty-four hours of the first survivals, the number of deaths had started to decrease. As the program of prophylaxis was instituted and knowledge of the disease and the therapy were disseminated, the number of deaths dropped precipitously. The number of new cases decreased more slowly, but almost all recovered.
For the first time, a day had passed during which no deaths from the disease had been reported.
It seemed to be over.
Alex had an hour before the army courier assigned to drive him to Dulles Airport would pick him up. In the bright sun he walked around the small fort where he had spent that terrible week. He passed the parade ground. The grass had been freshly cut, and the smell was sweet. Only the rhythmic sound of the flag rippling in the breeze interrupted the peaceful silence.
He quickened his pace past the main gate. The guard booth had been rebuilt and fresh paint covered the burns of yesterday. A lone military policeman nodded to him and then turned back to watch the wire gate now open to the outside world. It seemed that life had returned to normal.
He walked along the black asphalt road surrounded on either side by the fields used previously for growing experimental corn. The old and naked stalks, now overgrown with weeds and sunflowers, bent in the breeze as if parting to allow the road to pass. He turned left onto the gravel path near the old barn, once a laboratory for large-animal experiments, and continued up the hill and then down toward the duck pond. His steps echoed across the small stone bridge. He continued around the far end of the pond and up the grassy knoll to the small plot of freshly turned dirt, and he stopped.
A few blades of new grass were making their way between the clumps of dry earth. He listened to the quiet and felt the warmth of the sun on the back of his neck. In the peaceful silence, head bowed, hands folded in front of him, he had come to say a last farewell to the man who lay beneath his feet.
"Max," he said the name hesitantly. Never in life had he used Dr. Schwartz's first name, but in death it reflected the closeness he had always felt and only now could put into words. "Your death has been a loss to all of mankind---but most of all to me. Part of you will live forever---in the minds and hearts of all who were fortunate enough to have shared in your wisdom. I will always remember you as many things---but, above all, as an extraordinary human being."
Alex stood for another moment in silence and then turned and left without looking back.
Lori and the children would be waiting for him, and that was all that mattered now. The scars on his arm would remain his only visible reminders, but the past few days were imprinted forever in his memory.
He looked down at the Boston skyline as the plane banked into its final approach to Logan International Airport. He could see the runway rushing up to meet his plane. Other aircraft were taking off and landing; the parking lot was crowded with cars; people came and went. Life had returned to normal. This generation had survived; it would never know how close it had come to extinction or what might be the consequences to those yet unborn.
Luis St. Jerome closed the copy of the Journal of Infectious Diseases and paused to listen to the thunder heralding the birth of the season's first hurricane as it gathered momentum in the distant Caribbean. Alex Kahn's article, reread for the hundredth time, had convinced him. "It will work! And this time, no mistakes, no hidden clues, no easy cure!" He slammed his fist on the desk and walked quickly from the small, humid office into his large, air-conditioned laboratory across the hall.
It was the laboratory of the commanding officer, Biomedical Warfare Institute; and he had worked very hard to earn it. Medical school in Amsterdam, internship and residency at Columbia's Presbyterian Hospital, and finally three difficult years as a Fellow in Infectious Diseases with the famous Alex Kahn in Boston. He had gone to Boston for many reasons---most of all to prepare himself for today.
He unlocked the door of the large glass cabinet and removed the rack of cotton-plugged test tubes. He lifted a single tube and held it up to the window. Clusters of small, round, creamy yellow colonies glistened in the sunlight. "Staphylococcus aureus: 80/81. The Machdi strain." He said the words in a hoarse whisper. He had memorized its every characteristic; he had studied its life history in detail.
The Machdi strain. A mutant strain of a simple, ubiquitous microorganism that had been fathered to study adaptation and that had almost destroyed the world. Now it was to be changed again---in a different place, at a different time, by a different "parent." But its ultimate use would be the same---to attack, to kill, to conquer with disease.
Luis St. Jerome had no conscience, no allegiance to science for the good of mankind, no hesitancy to use any weapon to win for his country what he considered to be its rightful place among the nations of the world. The years of learning, the frustrations, the sacrifices had all been endured to discover the key to changing the Machdi strain---to make it the ultimate weapon.
His plan was complete. He had chosen his target; he had selected the method of delivery; all that remained was the final step in the mutation---to arm his weapon.
He looked again with satisfaction at the tube in his hand and then returned it carefully to the rack. He opened the door to the small computerized radiation source on the laboratory bench to his right, removed the cotton plugs from the tubes, placed the entire rack into the small dark chamber, and closed and sealed the door behind them. He paused momentarily with his thumb on the switch. Once it was pressed, there would be no turning back. Without hesitating further, he pushed the button.
It was done.
Those terrifying days when disease had dominated life were beginning again. Had they ever really ended?

