Reaching Down the Rabbit Hole: Extraordinary Journeys into the Human Brain

by Allan H. Ropper

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...