Last Meal In Budapest

The immediate impetus for this blog was the experience of watching my father's last two months as he was dying of multiple cancers. Those two months made me look in a new way at the relationship between the brain, the body and the mind, so it's a period I expect to come back to fairly often for a while.

On one of his last days, my father, delirious from the cancer, pneumonia, the long weeks in the hospital, and the cumulative effects of a half dozen medicines, believed that he was in Budapest. He had never, in fact, been to Budapest, and was eager to get out and see the city. He was angry that the taxi that was to take us from the airport was taking so long to arrive. He wanted some good Hungarian coffee. He ordered four espressos. He couldn't understand why the waitress was taking so long to bring them.

The waitress, who was in fact the nurse, called down not for espressos but for a meal of beef stew. We'd ordered it for him several times before, but my father could never eat more than a bite. It was good, reminiscent of goulash. But for most of the last weeks that my father spent in the hospital, he was essentially unable to swallow, and so unable to eat. His doctors seemed to think that this had to do with with a lack of appetite. The hospital's "swallow lady" had come by and conducted a brief test. A spoonful of juice, a bite of vegetables.The test went fine. But as soon as the swallow lady went away, the problem returned.

On the day that he thought he was in Budapest, my father was suddenly able to swallow. He ate half the stew, then the rest of it. Then the potatoes that came with it. He ate like a starving man, which in fact he was. The delirium lasted only a day. That was the last day he ate a real meal.

I've thought a lot about that day since, and tried to understand this strange fact that something that seems as automatic as swallowing would be affected by the kind of delirium that made my father believe he was in a country he'd never seen. But in fact in retrospect it is not at all difficult to explain. We often think of swallowing as a reflex but in fact it is a voluntary action. Like other voluntary actions, it requires the action of the neurotransmitter dopamine to disinhibit central nervous system signalling. Difficulties in swallowing are routinely the first sign of issues in the dopaminergic system. They are often the earliest of the string of problems--foot shuffling, tremor, repetitive muscle movements and rigidity--that characterize Parkinson's syndrome (Symptoms that in fact as the weeks went on my father would develop). Parkinson's disease arises from the destruction of dopaminergic neurons in a part of the brain called the substantia nigra. But very similar symptoms, known collectively as Parkinson's syndrome, can be caused by a more general shortage or imbalance of dopamine.

But dopamine has much more than a muscular function. The disinhibition of the voluntary muscles that is necessary for swallowing is intimately related to the disinhibition of nerve impulses that is needed for higher order thinking--and that is in turn related to delirium. The change in dopaminergic functioning that made my father able to swallow was in fact, in retrospect, clearly the very same change that made him imagine he was ordering espressos from a truculent Hungarian waitress. It is surprising, but ultimately it is not difficult to explain. Seen in this light, even the fact that a person would be unable to swallow except when the swallow-expert comes to check is no longer baffling: it is a consequence of the ratcheting up of the dopaminergic system--a physical manifestation of something that you can see all the time when people with Parkinson's or Alzheimer's "perk up" for a short while when visitors come by before retreating back into the shell of their illness.

What makes this especially worth noting is that it underlines in a striking way the falseness of hard distinctions between neurological, psychological, and physical symptoms. It is something that is very clear to, say, people who treat illnesses like Parkinson's. But that such disparate actions of the brain can be so closely linked is something that is easy to overlook, and difficult to harness in a therapeutic way, because it departs so dramatically from our ordinary intuitions.