Reaching Down the Rabbit Hole (6 page)

BOOK: Reaching Down the Rabbit Hole
7.6Mb size Format: txt, pdf, ePub
ads

“Yeah.”

“You’re not confused now,” I said. “You’re very clear.”

“I am now. I told my wife, don’t worry, but I was three towns away. And I made it home alright without any problem at all. The only problem was when I told her let’s go home, she got teary eyed.”

“But that was three weeks ago. What made you come back to the hospital?” Hannah continued.

“I got fuzzy thinking. I was thinking fuzzy.”

It wasn’t clear what he meant by that. As cogent as his answers seemed, two things about Wally were definitely off. One, we soon discovered, was that he would drop off to sleep for short periods of ten or
fifteen seconds in the middle of a conversation. The first time it happened, I was concerned that it might have been a seizure.

“Are you with us now?” I said, trying to assess his orientation.

“Yes.”

“I thought you might have just had a little seizure.”

“No, I fall asleep.”

“You just fell asleep right now?”

I had him count backward from one hundred to see whether it might elicit a blank moment that signaled a seizure, but it didn’t. He made it to zero without an error.

“Are you a talkative guy by nature, Wally?”

“No,” he answered, then thought about it. “Let’s put it this way . . .” Then he paused, and smiled. His neighbor on the other side of the curtain yelled out: “HE GETS STUCK ON THE RED SOX!” That, as it turned out, was Wally’s second problem.

“I guess I am talkative,” he said sheepishly. “I guess I talk a lot.”

This would become evident over the next few days. He routinely parked his wheelchair at the door to his room and flagged me down whenever I walked by, convinced not only that I was his neurologist, but that I was at the same time a heart specialist named Sanjay Sanjanista, and that I had performed the miraculous surgery that had brought his wife back from the brink of death several years earlier.

Wally Maskart had arrived on the ward in the depths of a confusional state that frustrated all of our attempts at diagnosis. He was depressed, sometimes manic, never at a loss for ideas, but frequently at a loss (due to his COPD) for the breath with which to voice them. Upon meeting him, I recognized that the demons besieging him were so deeply entrenched that we might never arrive at a diagnosis. To pass the time, I assigned Gil, one of the medical students on the team, the task of tracking down Dr. Sanjanista. He came back and informed me that no such person existed, and that his best guess was that Sanjay was a chimera inspired by a memorable if not particularly talented contestant on
American Idol
named Sanjaya. Despite his vocal flailings,
Gil informed me, Sanjaya’s looks had earned him a cultish female following known as Sanjanistas, whose mission in life was to stuff the online ballot box in order to overextend Sanjaya’s stay on the show. As if that weren’t enough, Wally also got it into his head that I had scored the winning touchdown for Boston University in a memorable game against Northeastern in 1962. “I was there!” he told me. Alas, I wasn’t.

Wally’s insistence on his personal connection with me could have been discounted out of hand were it not for his precision on other points, such as his ability to recite the decimal expansion of
e
(the base of the natural logarithm) to twenty decimal places. He even wrote it down, and I confirmed that he was indeed correct. He could also diagram the chemical composition of acetone, and seemed well versed on the career of the Red Sox right fielder Dwight Evans, except for his claim that Evans had just died. Evans, Wally insisted, had been callously traded to the Mets near the end of his career, an assertion that Gil was able to refute via a Google search, although Wally wouldn’t accept it. He also claimed he had been at Game 6 of the 1975 World Series, and witnessed Evans make “The Catch.” At that moment, he had turned to his son and said, “Tommy, sit down and relax. God’s on our team’s side. There’s no way they’re going to lose this game.” And he was right. Carlton Fisk won it for the Sox with an historic home run in the twelfth.

Wally also told me that he had his eye on a prewar tinplate locomotive that I knew cost around $2,000.

“You didn’t 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 little
failed 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 have been suffering from Creutzfeldt-Jakob disease, known to us as CJD, and more popularly as the human form of mad cow disease. Because of the rapid decline of his mental state, nothing else seemed to fit. Despite his inaccessibility, his sheer irascibility, I instinctively liked him, and looked forward to our visits. Even on his worst days, I would drop by simply to take a mental break, and I would usually drag a few members of my team with me.

“HELLO!” I yelled in order to be heard over the air handler. “How are you, Gord? It’s great to see you! How ya doin’?”

Hannah and young Gilbert, the medical student, lingered noncommittally just inside the threshold, as if at the edge of a precipice.

“Good,” Gordon muttered almost inaudibly.

“Are you confused?”

“Kinda. Everybody’s always confused.”

“Am I confused?”

He paused. “Nope.”

“Mr. Steever, do you know where you are?”

“Somewhere in this world.”

Gordon spoke with a flat affect, a tone of resigned indifference rather than one of confusion. He sat in the easy chair between the bed and the window, wearing hospital-issue blue drawstring pants and no shirt, perpetually bent forward like a ballplayer in the losing team’s dugout, alternately anxious and agitated. His nurse, Carmen, stood by the bed, poised to intervene if necessary.

“And what kind of place is this, Gordon?” I asked. “Is it a supermarket?”

“I always get mixed up,” he said quietly. “I’m in a box, and it’s the wrong box, and I’m just in another box.”

He was right. Gordon was one of the few patients on the ward with his own private box—a single room with a view. Through its windows he could look down onto Francis Street and see the gleaming metal-and-glass facade of the new Shapiro Cardiovascular Center, and beyond that the Riverway and Brookline Village. It was a beautiful afternoon, with the sun dipping just low enough to produce some contrast in the tree canopy that welled up beyond the nearby rooftops. But Gordon didn’t look out the window. Most patients don’t. No matter how spectacular the weather, no matter how striking the view, no one seems to notice, including the nurses, and especially the residents. As far as they’re concerned, we could be anywhere.

“Do you know what city we’re in, Gordon?” I asked.

“City where people work and live.”

This was the common theme. Gordon responded tangentially. If he were merely demented, he would have said something like “New Jersey.” His was a unique type of confusion, with speech that approached what my professor, C. Miller Fisher, used to call
amphigory
, or nonsense speech.

“He looks a little drugged to me,” I said to the nurse.

“He actually hasn’t had his Haldol for eight, ten hours, because his IV came out.”

“The key,” Gordon interjected, staring blankly at the floor, “is when you ever feel good bowling, you can stand back at the line, and you can say, ‘Look now, count one-two-three.’”

“That’s the key?”

“That’s the key.”

“Are you hallucinating, Gordon? Are you seeing things right now?”

“No.”

“Good. What’s your address?”

“My address? Let’s see. There’s a dog in here talking, so he can just say, ‘Hey, do you want to know the best days? Look here!’”

“How the hell does the brain assemble
that
?” I asked Hannah, somewhat rhetorically. “It’s certainly not just aphasia. His diction and tone are perfect and his comprehension near perfect. It’s his internal conversation that’s muddled.” She responded by puffing one cheek.

Apparently fine just a month ago, Gordon had rapidly degenerated into this state. After two weeks of tests and bedside exams, none of my colleagues could say what was wrong with him or what had caused this. My initial thought was that these strange responses were rattling around in his temporal lobe, but could not connect with each other.

“He’s talking nonsense,” I said, “but there’s no brain module that creates nonsense. The question is: Could this be the result of the degradation or absence of some other function? Is it a problem with the connections between brain modules?”

“My theory on all of this will straighten it all out for all of you,” Gordon interrupted. “You want to know why?”

BOOK: Reaching Down the Rabbit Hole
7.6Mb size Format: txt, pdf, ePub
ads

Other books

The Last to Know by Wendy Corsi Staub
Narrow Minds by Marie Browne
Wolf of Arundale Hall by Leeland, Jennifer
In Pursuit of Eliza Cynster by Stephanie Laurens
Lila Shortcuts by Alderson, Sarah
Mistress, Inc. by Niobia Bryant
Misenchanted Shifter by Zenina Masters
Cronin's Key by N.R. Walker
Second Stone by Kelly Walker
Changing Hearts by Marilu Mann