Dr. Patrick Ho blinked at the sergeant's violence.
'Ah, no,' he said regretfully. 'Not certain. Not definite. But Addison's was first on the lists of possibilities from all computers queried. When a definite diagnosis cannot be computed because of lack of sufficient input, a list of possibilities is given with probability ratings. Addison's had the highest rating on all the lists.'
'What probability?' Boone demanded. 'What percentage?'
'Ah, a little above thirty percent.'
'Jesus Christ!' the sergeant said disgustedly.
They were jammed into Boone's cramped office: the sergeant, Dr. Ho, Delaney, and Deputy Commissioner Thorsen.
'Let me get this straight,' Thorsen said. 'There's a thirty percent possibility that our killer is suffering from Addison's disease. Is that correct?'
'Ah, yes.'
The Admiral looked at Delaney. 'Edward?'
'Dr. Ho,' the Chief said, 'what is the possibility rating of the second highest ranked diagnosis?'
'Less than ten.'
'So Addison's disease has three times the probability of the second diagnosis?'
'Yes.'
'But still only about one chance in three of being accurate?'
'That is so.'
'Mighty small odds to move on,' Boone said glumly.
'Even if it was only one percent,' Delaney said, 'we'd have to move on it. We've got no choice. Doctor, I think you better tell us a little more about Addison's disease. I don't believe any of us knows exactly what it is.'
'Ah, yes,' Dr. Patrick Ho said, beaming. 'Very understandable. It is quite rare. A physician might practice for fifty years and never treat a case.'
'Just how rare?' Delaney said sharply. 'Give us some numbers.'
'Ah, I have been studying the available literature on the disease. One authority states the incidence is one case per hundred thousand population. Other estimates are slightly higher. There is, you understand, no registry of victims. I would guess, in the New York metropolitan area, possibly two hundred cases, but closer to one hundred. I am sorry I cannot be more precise, but there is simply no way of knowing.'
'All right,' Delaney said, 'let's split the difference and say there are a hundred and fifty cases, with maybe thirty or forty in Manhattan. That's rare enough. Now, what exactly is this Addison's disease?'
Dr. Ho stood immediately and unbuttoned the jacket and vest of his natty tan poplin suit. A soft belly bulged over his knitted belt. Enthusiastically, he dug the fingers of both hands into an area below the rib cage.
'Ah, here,' he said. 'Approximately. Near the kidneys. Two glands called the adrenals. I will try to keep this as nontechnical as possible. These adrenal glands have a center portion called the medulla, and a covering or rind called the cortex. All right so far?'
He looked around the room. There were no questions from the other three men, so the doctor rebuttoned his vest and sat down again. He crossed his little legs slowly, adjusting the trouser crease with care.
'Now,' he went on, 'the adrenals secrete several important hormones. The medulla secretes adrenaline, for instance. You have heard of adrenaline? The cortex secretes cortisol, which you probably know as cortisone. The adrenals also secrete sex hormones. Of sex, of course, you have probably also heard.'
The doctor giggled.
'Get on with it,' Sergeant Boone growled.
'Ah, yes. Sometimes the cortex, the covering of the adrenal glands, is damaged, or even destroyed. This can be the result of tuberculosis, a fungal infection, a tumor, and other causes. When the cortex of the adrenals is damaged or destroyed, it cannot produce cortisol. The results can be catastrophic. Weakness, weight loss, nausea and vomiting, low blood pressure, abdominal pains, and so forth. If untreated, the course of the disease is invariably fatal.'
'And if it's treated?' Delaney asked.
'Ah, there is the problem. Because it is such a rare disorder, and because so few doctors are familiar with the symptoms, the disease is sometimes not diagnosed correctly. The early manifestations, such as weakness, nausea, constipation, and so forth, could simply indicate a viral infection or the flu. But as the disease progresses, one symptom appears that is almost a certain clue: portions of the body-the elbows, knees, knuckles, the lips and creases of the palms-become discolored. These can be tan, brown, or bronze patches, like suntan. Sometimes they are bluish-black, sometimes gray. The reason for this discoloration is very interesting.'
He paused and looked about brightly. He had their attention; there was no doubt of that.
'There is a small gland in the brain called the pituitary, sometimes known as the 'master gland.' It produces secretions that affect almost all functions of the body. The pituitary and the adrenals have a kind of feedback relationship. The pituitary produces two hormones, ACTH and MSH, which stimulate the adrenal cortex to produce cortisol which, in turn, helps keep the ACTH and MSH at normal levels. But when the adrenal cortex is damaged or destroyed, the levels of ACTH and MSH build up in the blood. That is what has happened to our killer. Now, MSH is a melanocyte-stimulating hormone. That is, it controls the melanin in the skin. Melanin is the dark brown or black pigmentation. So when there is an abnormally high level of MSH, there is an accumulation of melanin, which causes discoloration of the skin and is an indication to diagnosticians that the patient is suffering from adrenal cortical insufficiency, or Addison's disease.'
Dr. Patrick Ho ended on a triumphant note, as if he had just proved out a particularly difficult mathematical theorem. QED.
'All right,' Delaney said, 'I've followed you so far. I think. And the high potassium level and the other stuff?'
'Also classic indications of Addison's disease. Especially the low sodium level.'
'Tell me, doctor,' Thorsen said, 'if someone has Addison's disease, can you tell by looking at them? Those skin discolorations, for instance?'
'Ah, no,' Dr. Ho said. 'No, no, no. With proper medication and diet, an Addisonian victim would look as normal as any of us. They are somewhat like diabetics in that they must take synthetic cortisol for the remainder of their lives and watch their salt intake carefully. But otherwise they can live active lives, exercise, work, have sex, raise families, and so forth. There is no evidence that Addison's disease, adequately treated, shortens life expectancy.'
'Wait a minute,' Delaney said, frowning. 'Something here doesn't jibe. Assuming our killer has Addison's disease and is being treated for it, her blood wouldn't show all those characteristics, would it?'
'Ah-ha!' Dr. Ho cried, slapping his palms together gleefully. 'You are absolutely correct. One possibility is that the killer is in the primary stages of Addison's and has not yet sought treatment. Another possibility is that she has sought treatment, but her disease has not been correctly diagnosed. Another possibility is that her disorder has been properly diagnosed and prescribed for, but she is not taking the proper medication, for whatever reason.'
'That's a helluva lot of possibilities,' Boone grumbled.
'Ah, yes,' the doctor said, not at all daunted. 'But there is yet another possibility. Addisonian crisis may be brought on by acute stress such as vomiting, an injury, an infection, a surgical procedure, even a tooth extraction. And, I venture to say, by a prolonged period of severe mental, emotional, or psychic stress.'
They stared at him, slowly grasping what he was telling them.
'What you're saying,' Delaney said, 'is that you believe the Hotel Ripper is suffering from Addison's disease. That she is being treated for it. But the treatment isn't having the effect it should have because of the stress of ripping open the throats of six strangers in hotel rooms. Is that it?'
'Ah, yes,' Dr. Ho said placidly. 'I believe that is a definite possibility.'
'That's crazy!' Sergeant Boone burst out.
'Is it?' the doctor said. 'What's so crazy? Surely you will not deny the influence of mental and emotional attitudes on physical health? The close relationship has been firmly established. You can will yourself to live and will yourself to die. All I am saying is that the physical health of this woman could be adversely affected by the strains and fear connected with her horrible activities. There may be a psychological factor at work here as well. If she acknowledges the evil of what she is doing, sees herself as a worthless individual not fit for society, that too might affect her health.'
