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.
one
two
three
four
five
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seven
eight
nine
ten
eleven
twelve
thirteen
fourteen
fifteen
sixteen
seventeen
eighteen
nineteen
twenty
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
one
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 not
e 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.
two
“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 o
utside 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.
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