He drummed fingers on the desktop, looking at her reflectively. She sat quietly, legs crossed at the ankles, hands placidly clasped in her lap. She was expressionless, composed. Spine straight, head held high.
"I'll tell you exactly what I'm going to do," he said quietly. "I am going to wait until I have the results of your blood tests and urinalysis. If they show what I expect, I am going to call you and ask you once again to go into the hospital for further tests and treatment. If, at that time, you again refuse, I am going to call or wire your parents in Minnesota. I have their names and address in your file. I will explain the situation to them."
"You wouldn't," she said, gasping.
"Oh yes," he said, "I would, and will. At that time, the decision will be yours, and theirs. I'll have done everything I can possibly do. After that, it's out of my hands."
"And you'll just forget all about me," she said, beginning to weep.
"No," he said sadly, "I won't do that."
She stumbled home in the waning light of a summer night. The sky as bronzed as the tainted patches on her flesh. She saw, with dread, how ugly people were. Snout of pig and fang of snake.
It was a city of gargoyles, their lesions plain as hers. She could almost hear the howls and moans. The city writhed. "Special problems" everywhere. She was locked in a colony of the damned, the disease in or out, but festering.
Those answers she had given to Dr. Stark's questions-they were not lies, exactly.
She was aware of everything: her weakness, nausea, vertigo, salt craving, diarrhea. But she sloughed over these things, telling herself they were temporary, of no consequence. To admit them to Dr. Stark would give them an importance, a significance she knew was unwarranted.
And when he asked about emotional and psychological stress- well, that was simply prying into matters of no concern to him. She knew what he was doing, and was determined to block him. Her adventures were hers alone, private and secret.
Still, she was saddened by his threat to turn her away. Rejection again. Just as Kenneth had rejected her. And her father. He had rejected by ignoring her, but it was all the same.
She was still musing about rejection and how men did it with a sneer or a laugh, spurning something tender and yearning they could not appreciate and did not deserve, when Ernest Mittle called her soon after she returned home.
Ernie hadn't rejected her. He phoned almost every night, and they saw each other at least once a week and sometimes twice. She thought of him as a link, her only anchor to a gentle world that promised. No gargoyles or cries of pain in that good land.
He knew she had gone to the doctor for her monthly checkup, and asked how she made out.
She said everything was fine, she had passed with flying colors, but the doctor wanted her to eat more and put on a little weight.
He said that was marvelous because he wanted her to come down to his place on Saturday night for dinner. He was going to roast a small turkey.
She said that sounded like fun, and she would bring some of those strawberry tarts he liked. Then she asked him if he had heard anything about Maddie and Harry Kurnitz.
He said he had learned nothing new, but Mr. Kurnitz was still seeing the blonde, and was very irritable lately, and had Zoe heard about the latest Hotel Ripper killing, and wasn't it horrible?
She said yes, she had heard about it, and it was horrible, and had Ernie definitely scheduled his summer vacation?
He said he'd know by next week, and he hoped Zoe could get the same vacation time, and who was she going to vote for?
So it went: a phone conversation that lasted a half-hour. Just chatter, laughs, gossip. Nothing important in the content. But the voices were there. Even in talking about the weather, the voices were there. The soft tones.
"Good night, darling," he said finally. "I'll call you tomorrow."
"Good night, dear," she said. "Sleep well."
"You, too. I love you, Zoe."
"I love you, Ernie. Take care of yourself."
"You, too. I'll see you on Saturday, but I'll speak to you before that."
"Tomorrow night?"
"Oh yes, I'll call."
"Good. I love you, Ernie."
"I love you, sweetheart."
"Thank you for calling."
"Oh Zoe," he said, "be happy."
"I am," she said, "when I talk to you. When I'm with you. When I think of you."
"Think of me frequently," he said, laughing. "Promise?"
"I promise," she said, "if you'll dream of me. Will you?"
"I promise. Love you, darling."
"Love you."
She hung up, smiling. He had not rejected her, would not. Never once, not ever, had he criticized the way she looked, what she did, how she lived. He loved her for what she was and had no desire to change her.
"Mrs. Ernest Mittle." She spoke the title aloud. Then tried, "Mrs. Zoe Mittle."
He was not an exciting man, nor was he a challenge. There was no mystery to him. But he was caring and tender. She knew she was stronger than he, and loved him more for his weakness.
She would not have him different. Oh no. Never. She had her fill of male bluster and swagger. Maddie might call him "Mister Meek," but Maddie was incapable of seeing the sweet innocence of meekness, the scented fragility, as an infant is fragrant and vulnerable, shocked by hurt.
Zoe Kohler showered before she went to bed, not looking at her knobbed, discolored body. In bed, she dreamed that with Ernie at her side, always, as husband and helpmate, she might no longer have need for adventures.
Then the void would be filled, the ache dissolved. She would regain her health. She would blossom. Just blossom! They would create a world of two, and there would be no place for the cruel, the ugly, or the brutish.
July 2nd; Wednesday…
"Goddamn it!" Abner Boone shouted, and slapped a palm on the desktop. "Then you're not certain it definitely is this Addison's disease?"
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."
"Look," Deputy Thorsen said, "let's not go off into left field trying to figure out the emotional and psychological quirks of this woman. We'll leave that to the psychiatrists after we've caught her. But let's just stick to what we've got. You think she's suffering from Addison's disease, and either it's not being adequately treated or she's ignoring the treatment, and the stress of these murders is killing her. That sounds silly, but it's what you're saying, isn't it?"
"Approximately," Dr. Ho said in a low voice.
"So?" the Admiral said. "Where do we go from here? How do we begin finding everyone in New York City suffering from Addison's disease?"
They stared at each other a moment.
"Go to all the doctors?" Sergeant Boone questioned. "Ask them if they're treating anyone with the disease?"
Edward X. Delaney wagged his big head, side to side.
"Won't work, sergeant," he said. "You know the laws of confidentiality regarding privileged information between doctor and patient. The doctors will tell us to go screw and the courts will back them up."
"Edward," Thorsen said, "suppose we go to all the doctors in the city and instead of demanding the names of any patients they're treating for Addison's disease, we just ask a general question, like, 'Are you treating anyone for Addison's'?"
Delaney thought a moment before he answered:
"If a physician wants to cooperate with the cops, I think he could answer a general question like that without violating the law or his code of ethics. But what the hell good would it do? If a doctor answered, 'Yes,' then our next question would have to be, 'What is the patient's name and address?' Then he'd tell us to get lost and we'd be right back where we started."
They sat
in silence, staring at their hands, the walls, the ceiling, trying to come up with something.
"Dr. Ho," the Chief said, "in answer to one of the Deputy's questions, you said an Addisonian victim would not have those skin discolorations if she was receiving the proper treatment. Right?"
"That is correct."
"But our killer obviously isn't getting the proper treatment or, for whatever reason, it isn't working the way it should. Her blood is all fucked up. Does that mean she would have the skin discolorations?"
"Ah, I would say possibly. Even probably, judging by the high MSH level."
"Could the discolorations be seen? On the street, I mean, if she was dressed in everyday clothes? Would a witness notice the blotches?"
"Ah, I would say no. Not on the elbows, knees, palms of the hands, etcetera. If it spread heavily to hands and face, then of course it would be noticeable. But by that time the victim would probably be hospitalized."
"How do the laws of privileged information apply to hospitals?" Boone asked.
"Same as to physicians," Delaney said. "In hospitals, patients are under a doctor's care. All information is privileged."
"Shit," Boone said.
"Perhaps," Dr. Ho said tentatively, "the Mayor would be willing to make a personal appeal to all the doctors of the city, asking for their cooperation in this civic emergency."
The Deputy Commissioner looked at him pityingly.
"I don't believe the Mayor would care to put himself in the position of urging physicians publicly to break the law. He had enough trouble just getting that offer of a fifty-thousand-dollar reward past the Council. No, doctor, don't expect any help from the politicos. They have their own problems."
They all went back to staring into the middle distance.
"The problem here is identification," the Chief said. "How do we identify all the victims of Addison's disease in New York?"
"Wait," Dr. Patrick Ho said, holding up a plump palm.
They looked at him.
"A problem of identification," the doctor mused. "All the papers I read on Addison's were written for physicians, and gave the history of the disease, symptoms, treatment, and so forth. Without fail, every author recommended the Addisonian victim be instructed to wear a medical identification bracelet stating that he suffered from the disease. Also, the bracelet carries his name and address, and the name, address, and phone number of his doctor. This is in case of emergency, you understand. An automobile accident, sudden injury, or fainting."
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