A Different Diagnosis by Ayako, Dei
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[Dei speaking]

Last week or so, while being ignored in the doctor's office (a state of affairs to which I am generally not disagreeable), I happened to glance through one of those huge total health guides that have become so popular in recent times. My eye happened on a couple of interesting things. An idea formed. It would have been bad enough if I had just posted my hunch, but noo, I had to drag Ayako into this, over her protestations that she is not a neurologist. She patiently listened to my babbling, corrected me and proof-read this piece. All blame for any misdiagnosis however, rests on me since I'm the one who read up the symptoms.

Now sight unseen, I intend to try and provide a differential diagnosis for Joe's illness. If I've misunderstood or misrepresented any part of Joe's illness or its progression, I humbly apologize.

A few other things. If you're not fond of medicalese (believe it or not, I don't like it either), there's a glossary of terms at the end. Also, if you would like to see where I got some of this rot from, I can supply a list of sources I glanced (and I mean glanced) through. And yes, in case anyone was thinking of it, this piece of unenlightened nonsense is archivable.
And now to begin.


At the request of a certain Very Pissed Person in Blue, I must declare that the following piece is NOT Nose-Cola. If you find someone's suffering amusing then perhaps you had better book an appointment with Dr. Nambu's centrifuge.
No one here belongs to me, yet.
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One of the highlights of Gatch I was the illness and decline of Konduru no Joe. According to the story, Joe's problems first started when he got hit in the head with shrapnel while trying to save a puppy. Although the shrapnel was successfully removed, he nevertheless continued to suffer after-effects of the injury which were eventually compounded by a couple of hard blows on the head, suffered in the course of his work. At least that is how things stood until ep. 103, when we have to add internal injuries suffered at the hands of Galactor, a matter that is outside the scope of this post.
His illness manifested itself as dizziness, blurred vision, occasional bilateral muscular incoordination, sometime numbness in extremities (most marked in one hand) and photosensitivity. On the surface, it seems to make sense -- all the symptoms seem to have a clear neurological origin. Why then do I have a problem with it?

First of all, let's talk about the shrapnel. If I understand the relevant episode correctly, the piece (or pieces) of shrapnel penetrated Joe's brain, rattled around there for a while before being eventually expelled via centrifuge. (I make no comment here). If that were really the case, we would expect a different set of symptoms. Shrapnel and the like generally produce what are known as focal lesions (injuries with a definite locality). The effects of such injuries depends on their location, but they usually include: a reduction in cognitive or sensory abilities, seizures, unilateral paralysis or weakness (unless the injury is symmetrical). Not quite what is bothering Joe.

A better candidate would seem to be increased intracranial pressure. Such a condition can arise from complications of meningitis or encephalitis, brain tumors or trauma such as hard blows to the head that lead to a subdural hematoma (the so-called 'blood-clot in the head'). The symptoms of increased intracranial pressure include But they often come along with vomiting and a loss of bladder and rectum control.

But it's not the symptom mismatch that is the most telling argument against the head-injury theory proposed in the series, since one can conceivably construe unlikely but possible explanations for them. The main problem is that Joe's symptoms are all highly intermittent -- sometimes he recovers partially or fully by the end of an episode, he appears perfectly normal between attacks and they are associated with periods of high stress. Now, if his symptoms point to a neurological dysfunction, such a state of affairs is completely impossible. Seizures aside (which Joe does not have), any and all physical manifestations of brain damage are not episodic. Once they occur, any recovery from them takes time, usually on the order of weeks -- they do not simply disappear after a few minutes or hours. Hiding them is difficult to impossible.
Another problem I have with the theory is the manner in which they mainly manifest themselves when he is under stress. While a vast panoply of diseases and disorders are aggravated by stress, in a true case of head injury you do not expect to see such a marked response to the imposition of external stress.
A word about willpower. There is hardly anyone here who has not seen Joe force himself to get up and come to save the day. The fact that he can do so also detracts from the head injury theory. If one cannot get up because of some form of neurological damage, then one cannot get up -- the functionality simply isn't there. If on the other hand one cannot get up because one is in agony, then with a lot of willpower one can force oneself up because the functionality is there, it's just that exercising it is difficult.
(I make the above statement with caution: victims of strokes and the like regularly show tremendous determination in overcoming their problems. However, you will note that they work within the limits of what functionality they have and cannot simply will their problems away. Recovery is made in slow, determined steps.)

Frankly, his symptoms are more compatible with some form of cardiac or blood vessel disorder. Such disorders often manifest themselves as neurological problems because what happens is that parts of the brain are starved for blood, while there is still enough blood-flow to maintain consciousness. (Aside: As a matter of fact one symptom of an impending heart attack is intense dizziness that lasts for longer than a minute).
Given the intermittency of the problem, its sudden appearance after years of apparent perfect health and its stress-sensitivity, the most likely candidate is an arteriovenous malformation (AVM). AVMs are basically congenital malformations and are made of abnormal blood vessels. Less than 1% of the population is believed to have them, though the true proportion may be greater since in at least half the sufferers never show any symptoms of one. They can occur anywhere in the body but the most dramatic and best studied ones are cerebral AVMs. If an AVM is going to cause trouble, it usually starts manifesting itself sometime between 20-40 years of age. Depending on the size and location of the AVM, the symptoms vary quite a lot but include dizzyness, headaches, numbness, incoordination. Joe's symptoms would seem typical of what is known as a 'steal' syndrome in which the AVM 'steals' oxygenated blood from the surrounding brain. For example, NORMAL blood vessels will constrict when there is an increase in carbon dioxide in the blood. AVM's will not. This means that there will be less blood flowing through the normal blood vessels, and more blood flowing through the AVM. They are characterized by being intermittent in nature and becoming more marked during periods of high stress.

But I hear you say now, 'Well, what about his reaction to light, huh? You haven't said anything about that.' That's right, I haven't. The initial explanation for Joe's reaction to light was that it was a psychological reaction to the explosion of the rose that was thrown at him, but his problem continued long after that ghost was exorcised. The explanation for it is so mundane that you may well be mad at me: Joe has migraines, bad ones.
Contrary to popular imagination, a quarter of migraine sufferers are men -- it's just that most male sufferers don't know to seek medical attention.
Characteristics of migraines are extremely varied but typically last anywhere between 10 minutes and 3 days, may be associated with visual problems, hallucinations, numbness and/or unusual sensations in various parts of the body and severe ones often leave the victim nearly unable to move. What triggers them is also varied but includes bright flashes of lights, loud noises, stress, anger, hostility, imposition of responsibilities, chemical and/or food sensitivities, etc. Highly driven individuals seem to be more prone to them than more laid-back ones. A brief speculation here. Since migraine attacks are associated with changes in the blood-flow patterns in the brain, if a migraine attack in any way leads to relatively more blood flowing through the AVM, we then have the full spectrum of what is troubling Joe.

So what's the prognosis like? Once an AVM has begun to cause its sufferer trouble, it typically tends to develop, eventually beginning to hemorrhage. With prompt and aggressive medical treatment, people with hemorrhages typically see a 10% mortality rate and a 15% morbidity (out of commission for a long, long time) rate and it recurs in survivors unless it is removed. Given where such an event would be most likely to occur (in the middle of a mission) and the apparently abysmal level of health care Science Ninjas seem to have, the most likely outcome for Joe would have been death. Safe, effective treatment exists (and indeed has existed since 1951) in the form of radiotherapy with surgery as an alternate treatment.
As far as migraines are concerned, again there are drugs that help manage the problem. Many of the newer ones avoid some of the worse side effects of older drugs. There is just no excuse for Joe to be suffering this way, other than he's too ignorant and frightened to ask for help.

What reservations have I got in applying this explanation? Well, hero plagued (unnecessarily) by uncommon congenital malformation and bad headaches simply does not have the angst appeal of brave hero tragically wounded while performing selfless deed, so I may very well go with the Tsatsunoko line when writing fanfic (after a couple of derisive snorts at the story-writers). In other versions, well I think I can tar Dirk with the same brush.
However in the case of BotP, I think we all agree that anyone who judges the lives and livelihoods of hundreds of people to be more important than that of a defenceless puppy deserves whatever is coming to him and I have absolutely no reason (apart from my being wrong) not to apply this explanation to Jason, it being far and away the most logical explanation.

[Ayako's two yen]

The least Dr. Nambu could have done before tossing Joe into that centrifuge was angiography. (MRI would have been a bad idea...the magnetic field could have ripped the shrapnel out through brain tissue...wait a minute, wasn't that what Dr. Nambu was trying to do in the first place?)

Comments? Objections?

Naa-Dei and Ayako
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Angiography: Procedure in which material X-rays cannot penetrate is injected directly into the blood vessels. If an X-ray is taken right after the injection, the blood vessels will show up on the X-ray.

Arteriovenous malformation (AVM) : An abnormal connection of the blood vessels. Remember your Junior High School biology? The arteries are connected to the capillaries (really really tiny blood vessels where the exchange of oxygen and nutrients between the blood and the cells of the body occur) which are connected to the veins...of course you remember.

An AVM is a tangled mess of blood vessels, without capillaries in between. This is a congenital malformation, and sometimes can cause symptoms such as seizures, or even burst and cause a subarachnoid hemorrhage or subdural hematoma (see below.) Or it could sit there and do nothing for the rest of the person's natural life.

Cardiovascular: Something that has to do with the heart and the blood vessels.

Cerebrovascular: Something that has to do with the blood vessels of the brain.

Disorder: A fancy way to say something's wrong. Hey, medical personell have to make people
think they are worth the two cents an hour extra they earn somehow...

Encephelitis: Infection of the brain.

Episodic: When something that happens, for a short while, and then goes away after a while, as if nothing ever happened.

Hematoma: Fancy way of saying blood clot. Again, one of those words people in the medical field use to feel important.

Intracranial pressure: Pressure inside the head. Think of the skull as a container, which can only hold so much. If you try to put too much into the container, you are going to end up squashing the stuff inside (i.e. the
brain. Brain tends to not respond too well to being squashed.) Examples of "too much stuff" include blood clots and tumors.

Focal: In a small area. In this discussion, Dei is talking about how an injury to a small area of the brain will sometimes cause a limited set of problems.

Lateral: Of a side. Unilateral is one-sided, bilateral refers to both sides.

Lesion: A fancy way of saying that there's something wrong in a small area. Again, people in the medical field have to use difficult words to pretend they are important.

Meningitis: Infection of the layer of tissue between the skull and the brain.

MRI: Magnetic resonance imaging. Uses the principle that different substances will respond to magnetic fields in different ways to make pictures. People with metal objects in them should not be in the same room as an MRI scanner, for obvious reasons.

Neurological: Having to do with the nerves and brain.

Subdural:When something is between the brain and the layer of tissue over it.

Symptom: A sign that something is wrong with the person's health. Because many different diseases can have similar symptoms, doctors like to hedge their bets and make differential diagnoses.
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