Free Reaching Down the Rabbit Hole by Allan H. Ropper

really buy it, did you?”
    “I don’t remember. I mean no, my wife would never let me.”
    Ironically, the “key to this whole thing,” to use Wally’s phrase, was staring me right in the face. He had indeed bought the locomotive, a Lionel Red Comet, a sweet little piece of machinery that was well beyond his budget. (I know this because I had had my eye on the same locomotive, and my wife would go ballistic if I ever bought one.)

    Marsel Mesulam, the prominent and prolific Northwestern University neurologist, has taken the lead in trying to define confusion, and has focused on what he calls “the attentional matrix.” The matrix, as he views it, is a place that serves as a temporary register of items that make up links in a sequential thought process. Confusion, according to Mesulam, disrupts tasks that require attention, and by inference, it represents a disruption within the matrix.
    I think that’s far too limited. When you sit at the bedside of confused patients, this is not what you see. They are inattentive, to be sure, and you can use that as an identifying feature, but many other things enter into it. For example, misperception and illusion (one thing being misinterpreted as another), topographic and spatial difficulty (they can’t draw, they can’t copy boxes), a loss of temporal coherence (difficulty connecting one moment to the next), and a hard-to-define language trouble. Those are all elements of various confusional states, and they do not derive from inattention so much as accompany it.
    Disorientation, for example, a staple of confusion, is not simply a result of inattention. Confused people have little or no insight into their predicament, and they cannot absorb their circumstances when I tell them that their minds are not working. They get lost and, most distressingly, become irascible, agitated, wildly unmanageable, or in some cases, their minds collapse inward, and they become silent and akinetic, as though all of the thin threads of cognitive life that bind thinking into a flowing stream have been severed. There are more interesting, restricted cases of confusion, such as patients who cannot recognize their own paralyzed limb (a condition known as anosagnosia), but unlike the confusional states manifested in Wally and Gordon, these forms of confusion result from structural damage in specific brain regions. Yet each of them in mild form is part of the global confusional syndrome of fuzzy thinking as the sum of a hundred littlefailed areas of the brain, and the disruption of the specialized tasks performed in these areas.
    My dilemma? Wally and Gordon did not fit these patterns or fall into neat categories. Neither man was particularly inattentive. Both were aware on some level that they had a problem. In each case, whatever the problem was, it had to be at a submicroscopic level, too small to show up on a CT or MRI scan. The fact that electrical activity between nerve cells is highly disordered in most confusional states, however, does show up in the slowing of the EEG waves. This was the pattern we found in Gordon Steever’s tests. It did not tell us what was wrong with him. The tests merely confirmed that something was wrong with him.

    Gordon Steever had been living on the ward in a room next to Wally’s for two weeks by the time I arrived on the scene. Elliott had admitted him, had even spoken to the police sergeant who had sent Gordon to the hospital, and was as baffled as I was. Gordon would remain on the ward for two months after my service ended, mostly on the taxpayer’s dime, with the hospital picking up the rest of the tab. Although he was gruff, profane, unpredictable, and given to angry outbursts, he was well liked by every member of the staff. He had the voice of Cliff Clavin from Cheers and the manner of Louis De Palma from Taxi , but unlike Louis, Gordon had no artifice. He was neither manipulative nor conniving. He steadfastly avoided eye contact. At first I thought he might