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A Phantom in my Brain

by Mary Bernard

This is the story of how I developed horrible distortions of my senses of taste and smell, and of how I was cured over a period of three years. In the Notes in the right-hand column (labelled A, B, C etc.) I try to explain what is known about this disorder.

Its medical name is phantosmia. It is one of the taste and smell disorders known (inaccurately) as anosmia.

You can download this article as a PDF here.

Downhill

It happened fast. In September 1999 I felt great. I’d had a major operation at the end of July, but I was already back to daily Pilates and ballet classes, feeling fit and full of vigour. Four months later I was still fit and vigorous, but I was locked in an invisible prison by a disorder that no one could see, that no one seemed to know anything about, that I couldn’t even find a name for.

The changes were gradual at first. In September tomatoes and oranges started tasting metallic and a bit rotten, and cottage cheese tasted like sour milk. I tried different brands; they were all bad. During October, lettuce began to smell and taste of turpentine, and spinach, apples, carrots and cauliflower tasted slightly rotten. Fish and meat, especially chicken smelt as if they’d been rotting for a week. My partner couldn’t detect the off tastes at all. Was I developing some sort of food allergy?

We were crossing a busy street one misty November evening when I smelt a heavy, rancid smell, not quite like anything I’d ever smelt. ‘Ugh—doesn’t the traffic smell awful?’ I said. Ian’s, ‘Yes,’ had an undertone of surprise that I didn’t register consciously, but remembered later on.

Soon the exhaust fans of restaurant kitchens started smelling weirdly unpleasant. Bread tasted rancid; chocolate, like machine oil. The only meat or fish I could eat was smoked salmon; I started having it three times a week. In early December we ate out with friends. I had to choose carefully, but I enjoyed the meal, except that the mineral water smelt like bleach. But the others were drinking it happily, and I decided that my glass hadn’t been rinsed properly.

It was my last meal out for two years.

Bottoming Out

Smells and tastes [A] got dramatically worse in the next week. Traffic smelt so bad that I had to force myself to go out; I made long detours to get to my Pilates and ballet classes by pedestrian-only routes. Wine smelt revolting; so did anybody who was wearing scent. The smell of Ian’s morning coffee had been getting worse, but between one day and the next it turned into a lurid, intolerable stench that permeated the house and lingered for hours. He started having coffee at work.

By mid-December most food tasted awful. I made a list, hoping to see a pattern in what I could and couldn’t eat.

Tastes OK Tastes bad

smoked salmon any other fish; any meat

white sugar brown sugar, toffee, honey, boiled sweets, maple syrup

apples, bananas, green grapes avocado, red grapes, any other fruit

broccoli lettuce, spinach, tomatoes, almost all vegetables

rice, potatoes pasta bread, cookies, biscuits

milk, cream, butter yoghurt, cheese, cottage cheese, buttermilk

milk chocolate dark chocolate

coca-cola tea, coffee, wine

lemon juice orange juice

egg yolks egg whites

garlic onions, chives

There was no rhyme nor reason to it. How could lemons taste okay but not oranges; garlic, but not onions? What were the triggers of taste/smell distortion? [B]

My GP had never heard of a case like mine. He took blood for kidney and liver tests and said he would send me to a metabolic specialist, warning me that there was a two-month waiting list.

Foods dropped off my list every day: milk chocolate; apples; grapes. Smoked salmon was completely tasteless. On Christmas Eve I saw my GP again. The blood tests were normal—I didn’t know whether to be relieved or not.

The roads were empty on our Christmas morning walk, till a lone bus chuntered past. ‘Oh my God!’ The stink was dramatically worse than a whole traffic jam a week back: worse than rotten eggs, worse than putrid meat. It was as horrible as close-up skunk, as overpowering as concentrated ammonia. It made me gasp and choke. Was this how gassed soldiers had felt in World War I? I knew in theory that I wasn’t being poisoned, but that wasn’t how I felt: I felt as if a few more breaths of it might kill me. I hid my nose in my sleeve and ran. The smell stayed in my nostrils long after I’d reached streets where the bus had never been.

Trying to describe it to Ian, I stopped short.‘Oh! Remember—The New Yorker—way back—those Berton Roueché articles—the chef who sold his restaurant because everything smelt so awful?’

‘Yes—and the solution was zinc!’

‘And we’ve got the books!’—Roueché’s two ‘Medical Detectives’ collections.(1) We rushed home and found the article: ‘All I Could Do Was Go Stand in the Woods’.

A Dr Robert I. Henkin had discovered that the chef—and two other men with distortions—had a zinc deficiency, and had cured them with zinc supplements.

The book dated from 1980; Dr Henkin must be long retired. But I could try zinc. On Boxing Day I went straight out and bought some. The article said it would work within a couple of days, if it was going to work at all. I crossed my fingers.

After three days I knew zinc wasn’t the answer. I was getting worse, not better. Smoked salmon had started tasting rotten—I was now an unwilling vegetarian. My mouth and nose tasted metallic, as if I’d had a nosebleed. The house was full of noxious smells, and they were stronger than ever. Even the steam from boiling water stank. Most of the distortions had little or no trace of their real odours; steak, steam and onions all had exactly the same big bad smell as the bus on Christmas Day. It wasn’t actually like putrid meat or skunk; it wasn’t like anything I’d ever smelt. It was synthetic, unnatural; it clung to my nostrils, invaded my lungs, activated my flight instinct. But there was nowhere to run. We live in a city centre; there were no woods to go stand in.

Most odours that were not—not yet?—distorted were fainter than before: pepper, lemon, bananas, vanilla. Others I could no longer smell at all: cloves, nutmeg, urine and faeces, linseed oil, fresh-sawn wood. On December 29th, working in the garden, I couldn’t smell the earth or grass. So far I had been stoical, but the next morning I woke up and howled with grief.

On New Year’s Eve we had dinner in London with friends. The meal was an ordeal, though Suzie had kindly not used onions or tomatoes. The wine reeked, and so did the hot food—heat releases the volatile scent compounds. I put a good face on it, but I was privately grim amid the Millennium cheer. Most social occasions involve food or drink, and I now knew that I wouldn’t be able to eat with friends, or cook for them, or even offer them coffee or wine.

wire leading to a machine that reminded me of a stereo amplifier. Dr Henkin sat me facing away from it, and sat beside me himself, angling his chair so that he could watch both me and the machine.

Dr Potolicchio placed the wand on my shoulder and turned it on. I didn’t feel anything, but my shoulder twitched. He placed it on the back of my head, turned it on for a few seconds, then off; moved it to a new position; then another. Each time he turned it on, I heard about twenty clicks; with each, I felt a light tapping on my scalp.

Dr Potolicchio holding

a TCMS annulus

photograph: Ian Fleming

My hands didn’t twitch at all. Henkin leaned closer and closer, staring at them intently. Dr Potolicchio muttered something. Later Henkin told me that Potolicchio had suggested trying a stronger pulse—I was the first TCMS patient whose hands had not twitched. But Henkin said, ‘No.’ He had seen my shoulder twitch, so he was sure it was working.

The whole thing, including hello and goodbye, barely took five minutes.

After we had all three been zapped, we went back to the clinic to give more saliva and blood samples and have more taste and smell tests. Several smells were far stronger than in the morning; and some were new. ‘That’s amyl acetate!’ I exclaimed; and gave it an intensity close to 100. I was surprised; I hadn’t realised how hyposmic I still was. For the past year I’d been aware only of distortions, not of loss.

‘You’ve done much better this afternoon.’ Dr Henkin said when the tests were done. ‘Your taste and smell are much improved—you identified dilutions that you couldn’t detect at all this morning. But only you will be able to tell whether the distortions have stopped.’ He walked me to the reception area. ‘Phone me on Wednesday and let me know how they are.’

‘I’ll be on the road; I won’t be able to telephone.’

‘Make it Thursday’—impatiently.

‘I’ll be on the road till Thursday night.’

‘Friday, then’—even more brusquely. ‘Twelve o’clock.’

During our interview he had said ruefully that, ‘My significant other says my manner with patients needed improving.’ She was right. But his humaneness comes through. By afternoon one of the other patients, an old man, was getting confused, and I overheard Henkin saying sympathetically, ‘You’ve done very well, it’s the end of a long day.’ In the morning he had tested a new patient as well as us three, and I had heard him tell her, as he ushered her back to the waiting room, ‘You’ll have to be patient, and that’s hard. It’s hard. But at least you won’t be running to twenty different doctors any more. You’ll get your smell back—that’s not an issue. There is absolutely no doubt that you’ll be cured. We’re not treating symptoms, we’re treating the underlying cause.’

Back in 2000 he had said the same words to me, in the same forceful tone. And his reasoned and reasonable conviction had kept me optimistic through the slow months and years as I improved by millimetres.

Back to Normal

We stopped at a deli; I bought buttermilk. I had tried it three weeks ago; it had still been distorted. Back in the hotel room I poured out a glass and sniffed. It didn’t smell distorted. I took a cautious sip. It didn’t taste distorted, it tasted delicious. I drank a whole mouthful, then a whole glass. Delicious. I polished off the whole quart in short order.

We set out for New Brunswick the next morning. I had yoghurt for lunch. It tasted grand. I bought a bar of dark chocolate; it was completely undistorted. The next night we had a lobster dinner in Maine—utterly undistorted, utterly delicious. We got home at dinnertime the next day. My mother had just opened red wine. It smelt like red wine: no distortions. I tried maple syrup: divine. I sniffed turps substitute: no distortions.

The next day I rang Henkin to report that my distortions had vanished.

‘You realise there’s a logical reason for this, don’t you?’

‘Oh yes,’ I said obediently.

He told me to stop Mellaril immediately, but continue on valproate for a while. ‘The test will be whether the distortions return after you stop the medications. But I don’t think they will.’

A month later I was still distortion-free, and he got me to start cutting down on valproate. By September I was off it. Over the next few months, little by little, my abnormal fatigue lifted; by Christmas I was completely free of drug-induced fatigue.

No distortions returned after I stopped the drugs; none has since returned. I am completely cured. Yet there are slight differences between my taste/smell perceptions now and before September 1999. Dark chocolate isn’t distorted, but I enjoy it less; it’s a tad over-intense. So is the smell of some prepared foods that contain onion or tomato. Cold, they’re fine; hot, they smell sharper, more metallic than before, with a lingering overtone of cheap restaurant. (Oddly enough, homemade food containing onion or tomato has none of that sharp edge.)

Some months after TCMS day, I began noticing that some smells seemed more vivid than they had immediately after the treatment—they seemed, in fact, as vivid as they had been before my disorder began. I finally emailed Henkin about it, saying, ‘I can hardly believe it, and of course it’s completely subjective.’

He replied: ‘The TCMS acted to change the function of your stem cells, which acted to correct any loss of smell acuity that you had, although you were not aware of it. Your brain then reacted to this positive change with the recognition that, with your smell function normal, its reorganisation, which has occurred following the loss, was now no longer necessary and those pathways which normally are used to deal with smell information could now...respond normally to all olfactory input.’

Or, in plain English: after TCMS, my brain gradually recognised that the old pathways were open again; stopped being defensively abnormal; and began to restore my sense of taste and smell to its old fullness.

Every day of my life I remember how lucky I am: when I drink my morning orange juice or grill a steak; when I walk down the street past cars and lorries. I owe my freedom from the phantom that invaded my brain—owe my chance to live a full life, not a pained and shrunken one—to the Internet, the New Yorker, and Dr Henkin: the Internet for letting me find him; the New Yorker for reassuring me about his reputability; and Henkin himself for doing his job.

Coda

Several years later I still have no real answers to some of the questions I keep asking myself and other people.

One is this. If Henkin can cure most taste/smell disorders, why don’t all ENTs know about him and routinely refer patients with such disorders to him—or else adopt the treatments described in some of his hundreds of peer-reviewed papers?

When asked this question, I usually say that taste/smell disorders are uncommon, the evidence being that an ENT specialist at a major teaching hospital like Addenbrooke’s sees ‘two or three cases a year’. There aren’t hordes of patients clamouring for cures at ENT clinics, just an occasional bewildered sufferer. So specialists are not strongly motivated to trawl the literature for treatments, especially since taste/smell disorders are non-life-threatening and therefore medically unglamorous. Besides, ENTs are specialists in the ear, nose and throat, not the brain. Their textbooks tell them that taste/smell disorders are incurable, and research in their own field is based on that assumption. Even if they were to read neurological papers, they might well ignore Henkin’s work, since, being in private practice, he doesn’t do double-blind trials; he can’t charge patients and then administer placebos. (He has good reason to know that double-blind trials can wreak havoc in patients’ lives: the chef in the Roueché article gave up his restaurant when his distortions returned after Henkin, then at the NIH, gave him a placebo.)

Yet taste/smell disorders, though uncommon, are not vanishingly rare; and medical treatments for some other non-life-threatening problems are ubiquitous: there is no shortage of clinics for cosmetic surgery or laser eye surgery. Admittedly, taste/smell disorders are far less common than bad eyesight or dissatisfaction with one’s looks. But if the latter problems can enable practitioners in every major town to earn a good living, surely a disorder that afflicts between one and ten percent of the population would support a clinic in every Western country. Setting up such a clinic would not entail training with Henkin: reading his papers would enable an intelligent doctor to offer Henkin-like treatments, which would work. Why hasn’t this happened?

And, since it hasn’t, why don’t more of the sufferers who read about Henkin online take their courage in their hands and go to him for treatment? There is no short answer to that—no satisfactory answer at all.

One half-answer is that most people with taste/smell disorders are hyposmic or anosmic, or have mild distortions, like mine in the early autumn of 1999. Many people don’t even know they’re hyposmic. Even if they do, some would undoubtedly rather live with a blunted sense of smell than pay around $3000 to restore it.

But there are people in online support groups who have put up with severe distortions for years. They lie upside down and sneeze for temporary relief, they irrigate their nasal passages with saline sprays, they try every herb in the herbarium. What about them?

Even if I say that they don’t go to Henkin because they put more faith in their ENTs than in a doctor in a distant place, of whose bona fides they are suspicious, because he is the only doctor anywhere who offers to cure taste/smell disorders, even if I add that many of them want ‘natural’ cures, not treatment with high-tech magnets or drugs meant for mentally ill people—even then I am left with the mystery that some of these same people will use chemicals to tint their hair or alter their moods; or correct their myopia or their wrinkles with surgery; or, indeed, undergo dubious nasal surgery in hopes of improving their disorder.

Maybe it’s something to do with the fact that, for most people, taste and smell are the least important senses. For everyone, I imagine, sight comes first by a very long way; then hearing; then touch; then taste (in the complex sense); then smell. Even at my worst, I wouldn’t have traded sight, hearing or touch for the restoration of normal taste and smell. (During those months I sometimes thought I might be better off completely anosmic, but if the choice had been open to me, I wouldn’t have taken it. But that’s a different question.)

What would I sacrifice to restore my taste and smell, should the distortions recur, and a god offer an exchange. One eye, one ear, a finger or two? My unimpaired mobility? My teeth, my hair? These last I might exchange for taste and smell—there are false teeth, there are wigs—but not the rest. Taste and smell are incredibly important, but not compared to life, health, limbs and the other senses. Perhaps there’s the beginning of an answer there: but it’s only a beginning.

References

We watched the Millennium fireworks on a packed Southwark Bridge. They were wonderful. The air was full of strange smells, though none was intolerable, except when nearby revellers drank wine from paper cups. But the route back to the car was along a street that was now a four-lane-wide traffic jam, every vehicle belching fumes, and no side streets to escape to. The stench said: flee or die. I couldn’t override it. I started to run, feeling conspicuous under the sodium lights: ridiculous, helpless, and sorry for myself, though if I’d been running for fun, I wouldn’t have cared what all those strangers in their cars thought.

I was frightened. Every day I could eat fewer foods. I was down to milk and crème anglaise, fresh lemonade, broccoli, cold boiled rice and potatoes, bananas, green grapes, and Coke. Even these foods sometimes tasted slightly off. Would they soon be as bad as everything else? Would I have to choose between starving and choking on every nauseating mouthful?

Ian brought me a tray of crudités to try out: carrots, cauliflower, cucumber, shallots. As soon as I pulled off the plastic, an aggressive choking smell like concentrated ammonia hit me: the shallots. It filled my nostrils and lungs—filled me head to foot. I’d never had hysterics before, but I did now. Shrieking, ‘Help!’ I ran out into the cold till he’d thrown away the tray. The whole house reeked; I reeked. Opening windows didn’t help. I hadn’t touched the shallots, far less tasted them, but the distortion still filled my nose, and my hands and arms smelt if I’d rolled in them. Ian said they had actually smelt quite mild, and couldn’t smell them on me at all. I had a bath to rub off the smell, but my skin still stank. So did the house. It was morning before the smell was gone.

I went to see my GP. He was away, and the duty doctor looked glum; maybe she minded working during the holiday. I described my problem, said I was scared stiff that even the few things I could still eat would become distorted, and asked if I could possibly see a consultant quickly.

She sniffed dismissively. ‘I don’t think you’ll get an early appointment. Maybe in about six months.’

But surely this is urgent?—couldn’t you recommend...?’

Her tone was contemptuous as she said: ‘Patients and doctors often have very different ideas of what a consultant would consider urgent.’

‘But—if the things I can still eat get distorted?’

She shrugged. ‘You could go privately if you’re so worried.’ She closed my notes. End of consultation.

It beggared belief that she didn’t consider the sudden loss of two senses a matter of medical urgency. I was so stunned that I left without a word.

I had a medical string I could pull, so I pulled it. I asked a doctor friend if he knew an ENT (Ear, Nose and Throat) consultant whom I could see privately and quickly. He did. He got me a mid-January appointment, the first on Peter Ellis’s first day back from holiday—and on the NHS, not privately.

Ellis took a medical history, examined my nose and tongue, and got me to smell three vials of liquid. To me they smelt like alcohol, vanilla and plain water. At the end of testing I asked what they really smelt of. Aniseed, cloves and peppermint was the answer. ‘I see one or two cases like yours a year,’ he said; ‘and I’m very sorry to tell you that nothing can be done for you. You may have a spontaneous remission—it occasionally happens—but it’s unlikely. It’s perfectly awful for you; you have my sympathies.’

‘What if the distortions get so bad I can’t eat anything?’

‘I think they’re unlikely to get any worse.’ Wryly, he added: ‘Though you may think they couldn’t possibly get worse than they are now.’

Ellis’s verdict was probably right, but I didn’t accept it as final: doctors, even consultants at great teaching hospitals, can be incompletely informed or downright mistaken. We knew lots of scientists and doctors, so we started asking around. But taste and smell research in the UK seemed to be purely academic, and the researchers themselves didn’t know of any treatments.

I searched the web. I hadn’t thought of it before: in those pre-Google days there was far less information online, and less that was reliable. Most of the hits from ‘taste’, ‘smell’, ‘tongue’ and ‘nose’ were pornographic. But I also found medical sites that mentioned taste and smell loss, calling it ‘anosmia’. They didn’t mention distortions; they didn’t mention cures. Two or three said that it was likely to be permanent if it lasted more than six months. ‘At least it’s not life-threatening,’ said several sites; along with: ‘Install smoke alarms if you can’t smell anything;’ and, infuriatingly: ‘If loss of taste and smell upsets you, go for counselling.’ If? I was upset all right, but I didn’t need counselling, I needed a cure.

I found an anosmia sufferers’ support forum, read the current messages and searched its archive. Various members had, unsuccessfully, tried acupuncture, aromatherapy, homeopathy, organic yoghurt, Chinese seaweed, hypnosis, and surgical removal of nasal polyps. A few, however, were getting better. They were all patients of—Dr Robert I. Henkin! He was still practising, at The Taste and Smell Clinic, in Washington, D.C. One man was now fully cured, after three years of treatment; the others were improving.

One of them lived in England, like me: Mick O’Hare, a production editor on the New Scientist. He had completely lost his senses of taste and smell in 1998, after a bad cold, but only went to Henkin in mid-1999, after looking hard and unsuccessfully for treatment in the UK—and not until he had read a large selection of Henkin’s papers in the New Scientist’s library. When I emailed Mick to ask about Henkin, and about the cost of treatment, we began a friendship that continues to this day. He had already recovered about 40% of his capacity to taste and smell. He told me that Henkin’s charges were in the region of $2500. That seemed an eminently reasonable price for the restoration of two senses.

I asked him why Henkin seemed to be the only doctor anywhere in the business of curing taste/smell disorders. His reply was: ‘ENTs aren’t interested, because the disorders aren’t life-threatening, so they’re medically unglamorous. And they are rare, [C] so drug companies don’t fund research into cures. I was still sceptical—the more so because I didn’t know what I have since learned: that drug companies do not fund research even into deadly diseases if they are too rare to make finding a cure profitable. (Motor neurone disease is one such instance; another is Brugada syndrome.) (2)

Still, it was reassuring that Mick, who vouched for Henkin, had scientific training and was as scornful as I of ‘alternative’ medicine. Even more reassuringly, Henkin had passed muster with The New Yorker’s famous fact-checking department when they published Roueché’s article. Besides, I didn’t know what else I could try, and I wasn’t going to do nothing. If he didn’t cure me, I’d have lost $2500 and airfare—and what else could I do with the money? I couldn’t spend it on holidays or expensive meals, when I couldn’t set foot in a restaurant and dreaded walking down an ordinary street.

I rang the The Taste and Smell Clinic and got an appointment for February 11th.

The Clinic

I flew to Washington on the 10th, with a packed lunch of cold rice. I had dinner in my hotel room—milk and bananas from a nearby supermarket, which to me stank of rot, though it was clean as a whistle. I didn’t keep any for breakfast; Dr Henkin had told me to fast from midnight on.

Early the next morning I took a taxi to the Taste and Smell Clinic, a suite in a Georgetown office building. There were comfortable sofas in the reception area, but the offices were utilitarian cubicles crammed with test equipment and file folders stacked on high metal shelves, desks and no-nonsense straight chairs.

Henkin came out to greet me: a tall man in his late sixties, I thought (in fact he was in his late seventies), powerfully built and bursting with vigour. He had olive skin, thinning white hair curling over the collar of his white doctor’s jacket, hooded, ice-chip eyes, and an impressively deep voice, frank and ingenuous, that went up with incredulity at the ends of sentences.

Dr R.I. Henkin

photograph: Ian Fleming

A medical student named Robbie weighed me, took my blood pressure, and returned me to Henkin, who sat me on a straight chair beside his desk, described the tests he would be administering, and started a rapid volley of questions. Allergies? Similar problems in my family? Mother’s health? Father dead—what of? What about operations? When did my distortions start? What did I notice first? September—orange juice—anything before that?’

I remembered a drive in July when Ian and I stopped at a coffee shop that smelled so horrible—to me but not to him—that I went outside to wait for him, and suddenly felt so giddy that I lay down on a patch of lawn. ‘That night I began a dreadful cold, which turned into bronchitis.’

I expected him to say ‘Aha,’ knowing from Mick that bad colds were a major cause of taste/smell disorders. [D]

Instead, he said: ‘You had the bad smell before the cold?’

‘Yes, a few hours before.’

He frowned, unsatisfied. ‘What else? There must be something else.’

‘Well, I was still on antibiotics when I went in for the hysterectomy, and afterwards I was a long time in the recovery room; they were worried about my breathing.’

‘That was after the bad smell’—dismissively. ‘What about before?’

‘Um...I forgot: in May I had a hysteroscopy.’ (It is a minor diagnostic operation.)

‘General or local anaesthetic?’

‘General. Oh!—and for the next two days food tasted bad; and my skin smelt...chemical.’

That’s when it began,’ he said gleefully. ‘It’s not post-viral. The bad smell never starts before a fever, it always comes after. But anaesthetics can cause it. [E] You suffered a multiplicity of insults. Anaesthetic; hysteroscopy; the cold; bronchitis; more anaesthetic and the hysterectomy—but by then you were on your way.’

He asked about other illnesses, and whether I was on any medicines.

‘No other illnesses,’ I said, ‘except narcolepsy—’

‘You have narcolepsy?’—with that incredulous rising note. He got me to describe the symptoms. ‘Yes, it fits. These sudden onsets of nearly falling asleep—you say you don’t actually fall asleep?’

‘Very seldom; I take medicines that keep it under control.’

He asked about visual sensitivities; I mentioned fluorescent-tube flicker and photophobia, especially during migraines. ‘Migraine?’—hyper-alert again. ‘Of course, it fits. Do you get aura? What’s your first symptom?’

‘Nausea and sensitivity to light. I don’t get aura, except an illusion of having a sort of transparent soap bubble in front of one eye, that I can’t quite see, but I know it’s there.’

‘Those things: nausea, photophobia, the bubble: they are the aura. It all fits. You’re perfect.’ He threw himself back in his chair. ‘But what’s important for you to know is that you’ll get 100% better. Don’t worry...I had a woman come, I got her 95% better, but she said, "No I want 100%," and we did it.’

‘How?’

‘Added another drug.’

As he questioned me further he kept saying variants on: ‘It all fits, you’re perfect,’ smiling exultantly to himself. ‘You’re such a complex example, you have so many factors bearing on the illness—and they all fit. I’ll explain it to you later.’

He started the taste tests: drops on my tongue, in sets of three, from brown glass bottles. ‘Two drops of each set will be plain water; one will contain a tastant. Tell me four things about each set: which one has a flavour; whether it’s sweet, sour, salty or bitter;

the intensity, on a scale of 1 to 100; and whether it tastes pleasant, unpleasant or neither.’ He put a drop on my tongue from one bottle, closed it, opened another. ‘This...now this...now this:’ The instant I reported on one set, he was on to the next. At one point I crossed my legs. ‘Feet on the ground,’ he said. ‘No crossed legs. I want you to work. This is hard. You’ve got to give it 100% concentration.’

Taste testing

photograph: Ian Fleming

All the tastes were faint; in some sets all three drops were tasteless. To describe the tastes I had to use the words ‘pleasant,’ ‘unpleasant,’ or ‘neither.’ When I said, ‘Ugh, nasty,’ to one taste, he just repeated, ‘Pleasant or unpleasant or neither?’ Then came tests using drops of the same tastant in different concentrations; I had to grade the intensities.

Smell tests were also in sets of three; again, two of each set would be neutral. ‘Identify the one that smells, and describe the smell. There aren’t standard words for smells, so use your own—for example: pungent, flowery, fruity, rotten.’ he opened the first bottle and waved it under my nose. It was much harder than the taste tests. ‘Identify the one that smells. What does it smell of?’ All the smells were distorted. For the first two sets I could say which bottle contained an odorant, but not after that. The bad smell was in the bottles, in my nose, in the air. Henkin kept on with the tests, but all the bottles smelt the same: horrible. He wouldn’t take ‘Ugh’ for an answer; I had to say, ‘Unpleasant,’ and specify the intensity on a scale of 1 to 100—not per cent, he insisted, even though percentage is nothing but a scale of 1 to 100.

He kept saying ‘This is hard, I know it’s hard.’

He was right; it felt like struggling to answer impossible exam questions. ‘It’s upsetting, not being able to identify them.’

He smiled sympathetically. ‘It’s not surprising, though. Once you’ve been exposed to a stimulant for one of your bad smells, then for some time other things will smell worse than they otherwise would.’

Next came tests with the same odorant in different concentrations; as with the taste equivalents, I had to rate the intensities. Most of these odorants weren’t distorted. I was able to say that one was like disinfectant, one like floor wax.

He took me back to Robbie, who was to collect saliva samples from me. ‘She’s perfect,’ he said enthusiastically, describing my history and how I’d done in the tests. ‘We could stimulate her electrically and it would stop immediately, but we’re not ready for that. The narcolepsy, the migraine—I wish I could have her on grand rounds. Her distortions are severe. She looks as if there’s nothing wrong with her, and yet she’s incapacitated.’

I could have hugged him. For the first time in months I felt understood. My disorder was absolutely novel to me: I’d never heard or conceived of anything like it before it fell on me like a ton of bricks. I’d been flailing about inside, in need of a word that would help me grasp how it had shrunk and warped my life. ‘Ill’ and ‘disabled’ were too strong; ‘incapacitated’ was exactly right.

Robbie hooked me up to a saliva collection device—a suction cup attached to the inside of my cheek with tubes leading to test tubes. Every ten seconds for five minutes I had to dab my tongue with lemon juice to stimulate the flow of saliva. I could just hear Henkin, down the corridor, saying, ‘Sweet, sour, salty, bitter, on a scale of 1 to 100,’ to another patient.

Soon Henkin called me back to give a provisional diagnosis: ‘It won’t be final till Monday, when we have the results of the lab tests.’ My taste and smell functions were essentially intact. ‘What you have is’—he hesitated—‘a hallucination. A phantom. It’s real; but it’s a neurological phenomenon, not one an ENT specialist would know about. They know as much about problems like yours as the man who makes milk bottles knows about milk.’ (He meant that they focus on the nose and mouth, whereas my problem was neurological. I thought it an unsatisfactory comparison.)

‘It’s essentially an epileptic disorder. Don’t be alarmed at the word. It will never go further than this—you will never have a fit.’

I sounded interested, so he explained further. In a normal person, every stimulus that excites the brain is immediately inhibited, most commonly by a neurotransmitter called gamma-aminobutyric acid—GABA for short. But my inhibition mechanism for the smell receptors had become defective; I wasn’t producing enough GABA in response to smell stimuli. When there is a shortage of GABA, stimuli can flood across the synapses and cause brain synchronicity, a seizure-like state, like a focal seizure in epilepsy—one that affects only part of the brain. [F] The result is taste/smell distortions. (3)

My narcolepsy and migraines were evidence that I was susceptible to focal seizures. [G] ‘You had all the predisposing factors; it was just waiting to happen. And there are thousands just like you.’ He and his colleagues had ‘developed a unified field theory of epilepsy. With theories, there are the unifiers and the dividers, and I’m one of the unifiers’—with a sidelong glance as if wondering if I would get the Einsteinian reference. Deciding that I did, he waxed expansive, describing a paper they had just finished. I understood him in parts. He wasn’t good at guessing my level of scientific understanding, and slid between being too technical and too simple. But he never forgot he was a doctor. His discourse on the brain was interspersed with remarks specific to my case, and with reassurances made in a tone both forceful and matter-of-fact.

It was 12.30; I had been there for nearly five hours. I went back to the hotel to pick up my bag—I was spending the weekend with friends in Virginia. I was weak with hunger, so I went to the supermarket for milk and bananas. Normally I never eat in the street, but I couldn’t wait. Turning down a cul-de-sac to get away from traffic, I stood on the snowy sidewalk and wolfed a banana. I longed to be in a restaurant, eating ordinary food. The snow was grey, the sky was grey, the wind was raw; the optimism I had felt at the clinic oozed away. The memory still makes me shiver.

On Monday morning Henkin told me that the lab tests had confirmed his clinical diagnosis. My taste buds and nasal receptors were fine; the problem was in my brain–a phantom, which masked some smells, but made many more seem foul. ‘You’re a textbook case. It’s a hallucination, but it’s real—don’t forget that. It’s in your brain, but it’s not "all in your mind." You don’t have any control over it.’ The cause was almost certainly the general anaesthetics I had had in May and July—he told me that about 2% of people who receive inhalational anaesthesia develop taste/smell problems, though not usually so severe as mine.

He proposed to treat me with low doses of haloperidol, one of the oldest anti-psychotics; he prefers to prescribe older drugs, because their side-effects are well documented. I would start on 0.5 mg a day, rising to 1.5 mg. (The dose for schizophrenics is from 2 to 50 mg a day.) At that level there should be no significant side-effects, except possibly raised appetite and some fatigue. ‘Later on we’ll add an anti-convulsant as well. But you mustn’t think you’ve got schizophrenia or epilepsy because I’m prescribing these drugs.’ [H]

I assured him I wouldn’t. He gave me a letter for my GP, who had said he would prescribe, on the NHS, whatever medicines Henkin said were necessary.

I was to keep a daily taste/smell chart, tracking any changes in my taste/smell distortions, on a scale of 100 to 0. 100 was where I was now, severely distorted; 0 was the goal. ‘You won’t notice any change for a while, anywhere from six weeks to six months. But your numbers will go down to 0, no question. The only question is how soon, and whether we’ve got the dosage right.’

‘Even 50 per cent would be wonderful,’ I said.

‘Not per cent,’ he insisted. (Months later I realised that he objected to the term ‘per cent’ in this context because the numbers do not describe a quantifiable phenomenon, just the patient’s subjective perception of stasis or change.)

I was to email him my numbers every week, and ring for a telephone consultation every three weeks. He reminded me that the chef in Roueché’s article hadn’t come back when his distortions returned, because he didn’t want to disappoint Henkin. ‘This was the NIH, we ran double blind tests. I’d told him I might give him a placebo at some point; and I’d told him what a placebo was, and why I might do it. I’d told him to ring if he started getting distortions again. But I was so disturbed that I went to the director of the NIH. My point is—you’ve got to tell me the truth about your distortions. If they don’t improve, you mustn’t feel you’re letting me down. And you’re my patient, under my care. The fact that you’re in England doesn’t mean I’m not treating you. I am, by phone and email. I’m responsible. Your GP is prescribing the drugs, but he’s not responsible, I am. It’s my neck.’

The appointment was over. Walking me back to the reception area, he said, ‘And remember—the drugs are a life sentence. You’ll have to keep taking them even after the distortions disappear, otherwise they’ll come back.’

That reminded me to ask about the ‘electrical stimulation’ he had mentioned to Robbie. His eyes lit up. ‘It’s called trans-cranial magnetic stimulation.’ They were having remarkable success with it; hoped that it would eventually replace lengthy drug treatment as his first choice of therapy. But it was still experimental. It worked immediately on some patients; but some needed two or even three treatments; and for a few it didn’t work at all. He hadn’t tried it on me because I lived so far away, and return trips would be expensive.

His parting words, delivered with great intensity, were: ‘Don’t worry, you’ll get better—100% better. I guarantee it. But it will take time. And it’s hard. I know that.’

I took a cab to the airport and caught my flight home, feeling shrunk in the wash from five days of sitting in buses, aeroplanes, hotel lobbies, waiting rooms, shuttle vans and taxis, all full of horrible smells.

Uphill

Six weeks to six months, he had said. I clung to a protective scepticism: though on one level I believed Henkin, it was hard to keep believing when even toothpaste tasted bad. But I didn’t have to wait even six weeks. I hadn’t been able to smell urine for months. One day, after only two weeks on haloperidol, I smelt urine, faintly, but unmistakably, for the first time since October. The next week, passing a hot dog stand that had reeked of distortion for months, I caught a perfectly ordinary whiff of rancid fat—undistorted. I stopped and sniffed deep in a rapture of perfectly ordinary disgust. I had longed to smell earth and grass again, but urine and rancid fat were just fine.

Some distortions were becoming less florid. Traffic fumes were still horribly distorted, but no longer made me want to flee, and foods that I could eat had a bit more flavour and fewer suspect overtones. The changes were slight—I hoped they weren’t just wishful thinking.

Taste/smell disorders are so uncommon that there are no colloquial words for them. ‘I have a phantom,’ I told friends, but that required a lot of explanation; and there is no single medical terms that covers all the disorders. Anosmia is complete absence of smell, hyposmia, a diminished sense. Dysosmia signifies smell distortions.(4) Each term has its taste equivalent, ending in -geusia. I could hardly tell people that I had dysosmia and dysgeusia, with mild hyposmia and hypogeusia. No wonder the online support groups stuck to ‘anosmia’.

In early March steam from the kettle stopped smelling foul. The world was still full of distorted smells, but most were less overpowering. I tried smoked salmon. It was tasteless, but no longer smelt rotten. Elated, I tried other cold fish and meat. Prawns were distorted, but less overwhelmingly. But salami was unspeakable, and pâté tasted like raw blood; and when Ian tried cooking chicken, I nearly had hysterics again. I jumped into the car and drove round the ring road while he aired the house—not that it did any good: the stink came with me, and was still all over the place when I got back.

But when he cut the grass for the first time, I could smell it. I grabbed a handful of earth. Faintly, faintly, I could smell it. [I]

In early April Henkin raised my haloperidol dose to 0.75 mg. The lilacs bloomed, and smelt very mildly of lilac. And I could eat olives: a pungent taste after months of milk and rice. Tea stopped smelling bad, and I could distinguish between the musty distortion of coffee and the sharp distortion of tomatoes and onions. But I was still a long way from 0. For every odour and taste that had improved, there were hundreds that hadn’t. At the present rate, I might die of old age before I could make coffee for someone, let alone drink it myself.

And the higher dose of anti-psychotic was making me deadly tired. I was fine in the morning, but fatigue set in by mid-afternoon. Sometimes I had to shake myself not to fall asleep at the computer; my legs were full of lead when I ran upstairs, Pilates and ballet were exhausting, not invigorating. By nine-thirty in the evening I was yawning uncontrollably; by ten I was in bed and asleep—for ten or eleven hours, not my usual eight.

The fatigue got worse. I felt profoundly unwilling to put one foot in front of the other. I told Henkin, and he cut the haloperidol dose back to 0.5 mg. But I was still dreadfully tired—and also affectless, I gradually realised. I wasn’t depressed, but my pleasures were temperate. I was never excited, nothing was vivid; and I was completely uninterested in sex. The world wasn’t grey, but its colours were muted. But I put up with the fog for the sake of making progress with distortions.

In June Henkin started me on valproic acid, an anti-convulsant, in addition to haloperidol. It soon had an effect. Coffee still smelt bad, but not intolerable; traffic hardly smelt at all. I couldn’t enter a restaurant or eat strawberries, but in July I ate raspberries, blueberries, and bread. I was beginning to believe that I might eventually get ‘100% better’.

I was still apathetic, and in July I told Henkin about it. ‘I’ll change the drug,’ he said instantly. ‘I don’t want to solve one problem only to land you with another one. That’s not the point at all.’ He told me to cut down gradually on haloperidol, then start on another anti-psychotic, Mellaril (thioridazine).

Once I was off haloperidol the apathy slowly lifted—though not the fatigue—and my sexual appetite and delight in life returned. If the flatness had been like the grey English winter, the return of emotion was like the slow English spring, a bit brighter every day.

By September I could eat cold sausages—the first meat for nine months. By October—thirteen months after it all began, and seven after starting treatment—my distortions were at about the level they had been the previous October. I could eat out again, if the restaurant was well ventilated (no coffee shops, no pizza joints). Smell distortions were noticeable, but tolerable. Taste distortions were also milder; but I couldn’t eat foods that were even slightly distorted. Why not, when I could tolerate mild bad smells? I am suspicious of explanations that appeal to evolution, but I did wonder, and still do, whether we may not be hard-wired to reject food that tastes or smells even slightly bad. Most bad smells are not actually noxious, but spoiled food can kill you; an ‘off’ taste does serve as a danger sign.

Mick O’Hare and I still participated in the online anosmia support group, though it made us impatient. Most of the members wanted ‘natural’ cures, and were deeply averse to drugs. Some American members were reluctant to go to Henkin because their insurance providers refused to cover out-of-state treatment. A couple of them actually asked Dr Henkin to share his expertise with their own doctors, gratis, and were offended when he refused. Even when they got to the Clinic, a few found obstacles. One woman was put off by the absence of wraparound sleekness: the starkly utilitarian offices with their stacks of folders on metal shelves. Another walked out because she found him overbearing.

As indeed he was—Mick and I jokingly called him God. He was genuinely kind. He asked about my fatigue every time I rang, and there was real concern in his voice. But he lacked bedside manner. He knew his treatments worked, and was brusque when people’s questions indicated that they didn’t believe in Western science.

He could be brusque even with those who did. When Mick, who was close to being completely osmic, said thank you in one of his three-weekly telephone calls, he emailed me that: ‘Dr Henkin quite sweetly said: "No thanks is necessary Mr O’Hare. It’s what I do."’

A month later I too told Dr Henkin, on the telephone: ‘I’m so much better, and I’m very grateful to you.’

‘You don’t need to be grateful to me, Miss Bernard,’ he said gruffly. ‘It’s my job.’

‘Yes, it is. But I can still be grateful’—at which he gave in.

By late November 2000 my numbers were down to 17. I was tired of being tired; I vividly understood why some schizophrenics stop taking their pills, for though I well remembered Henkin’s warning that the pills were a life sentence, I kept having fantasies of stopping them once my distortions were down to zero.

By February 2001, after a year of treatment, my numbers had dropped from 100 to 15. But Henkin had warned me that the curve of improvement would begin to flatten, and he was, as ever, right. I was stuck at 15 all through March. I alternated between pessimism—was this as good as I would ever get?—and optimism, when I remembered my desperation a year back. The distortions hadn’t vanished, but they were no longer imprisoning me at home.

Henkin increased the dose of valproate. By late April I was down to 12, and I improved throughout the summer. By September, two years after the distortions had begun, I was down to 7.

After the September 11 attacks on New York and Washington, both Mick and I emailed Dr Henkin, hoping that he and his family and colleagues were safe. His reply to Mick read:

Dear Mr. O’Hare: It would take more than a terrorist to inhibit me from helping you and the other patients who require the expertise I want to employ for your benefit.

RIH, MD

No wonder we called him God.

For the next year my numbers crept down, very slowly. By September 2002—three years after the disorder began—I was at 1.25. By February 2003, after two years of treatment, I was down to 1. I could eat steak, tomatoes, orange juice, even onions and chicken. Zero was tantalisingly close, but a few things, principally foods, were still distorted: yoghurt, buttermilk, dark chocolate, caramel, maple syrup, red wine, coffee, lobster, . Coffee still smelt distorted, though bearably; so did white spirit and ethanol; and a number of odours that were no longer distorted were still muted.

My mother was dying of emphysema, and in March I went to New Brunswick to spend six months with her. March, April, May: no progress. I kept remembering the woman Henkin had described who got 95% better, but said, ‘No I want 100%.’ I was 99% better, but I, too wanted 100%. And I was tired most of the time. I thought this must be how I would feel in my eighties. I was a fit woman of sixty-one; by my reckoning that was late middle age. I didn’t want to be old yet.

In our telephone conversations Henkin had told me more about trans-cranial magnetic stimulation, the ‘electrical stimulation’ that he hadn’t tried on me because I lived overseas. It still didn’t work for everyone, but when it did, it worked immediately, and often permanently. I wanted to try it. I was only seven hundred miles from the Taste and Smell Clinic, and I had my mother’s car.

Back to Washington

Ian came over in June, and we drove to Washington together. I was glad he could go with me: the memory of eating bananas in that cold Georgetown cul-de-sac had given me an irrational horror of going alone.

I had arranged to interview Dr Henkin for this article, so we met at the Clinic the day before my appointment, and talked for nearly three hours. I had come prepared with questions, but for an hour I hardly got a word in edgewise.

Henkin talks and moves quickly, and has the impatience of the quick thinker. Some of his self-confidence is perhaps defensive—a reaction to having his work ignored by most ENT clinicians—but much of it is innate. He started out in music, not medicine, and studied with Schoenberg at UCLA. ‘I worked out what he got wrong with the twelve-tone system,’ he told me. I doubt whether many of Schoenberg’s students have made that claim. Henkin then became an assistant film-music composer; the cat-burglar music in To Catch a Thief is his. But he started wondering about the mechanisms by which music affects the emotions, and became a doctor in order to do research in auditory physiology.

He became a taste/smell specialist by accident. While still a medical student, he read an article about animals who gobbled salt because of an adrenal insufficiency, and wondered whether the same was true of humans. In 1957 the standard tests for adrenal insufficiency took three days. Henkin devised one that worked immediately, and the newspapers picked it up; so he was asked to do his test wherever his medical studies took him: ‘I became the resident adrenal insufficiency expert.’

In the late 1960s he went to the National Institutes of Health to specialise in neuro-endocrinology. Here, too, he was asked to do his test. ‘One thing led to another. I published papers; patients started being referred to me with other types of taste and smell problems.’ That was when he first saw patients with drastic taste/smell loss or distortions. There were no treatments available. He experimented, and found that in some patients zinc stopped distortions and cured hyposmia. One such patient rang the National Inquirer: and said, ‘There’s a magician in Washington who can cure taste and smell.’ When the Inquirer piece appeared, the NIH got hundreds of letters asking for treatment. Henkin was still trying to work in neuro-endocrinology; taste/smell was just a sideline. But: ‘The NIH is a political organisation. I became the taste and smell doctor. And it was fascinating.’

In 1969 he founded the first NIH program to evaluate and treat taste/smell disorders. He was still a neuro-endocrinologist; in 1975 he became Professor of Neurology and Pediatrics at the Georgetown University Medical Center—and also director of their Center for Molecular Nutrition and Sensory Disorders and its clinical arm, The Taste and Smell Clinic. He took the clinic into the private sector in 1986.

Zinc was something of a blind alley; only a few patients responded to zinc sulphate tablets as dramatically as the trio described in the New Yorker article. The most useful drugs for distortions turned out to be psychotropics: anti-convulsants and anti-psychotics. Because of that, he was always on the lookout for new treatments for depression; that is how he came to TCMS.

Trans-cranial magnetic stimulation uses powerful, rapidly changing low-frequency magnetic fields to induce electric fields in the brain by electromagnetic induction.(5) It has been used since the late 1980s with some (though variable) success to treat depression, epilepsy, tinnitus and migraine. Its effect is to change brain activity in particular areas; the change can last for a period, or in some instances be permanent. It can be applied with high or low frequencies. Low frequencies, in the region of 1 Hz, activate GABA; higher frequencies inhibit it. No one knows how it works, except that it either increases the production of GABA, or makes GABA more efficient at inhibition.

It is non-invasive and painless. The doctor places a wand on the head and turns it on for a few seconds, then does it again in a different position, and again, for several minutes in all. The pulse feels like gently tapping fingernails.

Dr Henkin and his colleagues did their first trials of TCMS in 1999. Their first TCMS patient was a wine grower with post-viral anosmia. Henkin and his colleague, Dr Samuel Potolicchio, gave him trans-cranial magnetic stimulation at George Washington University Hospital. The wine-grower had to fly to California right after his session; he rang from the airport to say that he could now smell normally. He has never had to return; he sends Dr Henkin a case of wine every year.

Henkin next tried TCMS on a woman who worked in a nearby office. She had had distortions ever since a head injury eighteen months before, and couldn’t taste salt or sweet at all. He gave her the usual tests, and he and Potolicchio administered TCMS. Back at the clinic he tested her again; her taste and smell were now absolutely normal.

Stunned by their success, they began regular trials of TCMS, and soon found that it did not work for everyone. They were at this stage when I visited the clinic in 2000. By the time of my return visit in 2003, they had used TCMS on over 100 patients. Some were cured immediately and completely. A few had not responded at all. Others required two or more treatments for a full and permanent cure.(6)

Drug treatments for taste/smell disorders work slowly and have unpleasant side-effects, such as the fatigue I suffered from. When TCMS works, it is far faster than drugs, even for patients who need several sessions; and its only known side-effect, in a few people, is transitory headaches.

An off-label testimonial to the efficacy of TCMS in treating taste/smell disorders comes from a 2004 double-blind study in which it was used to treat depression. When asked about side-effects, one patient ‘reported a marked improvement and sharpening of taste and smell.’(7)

TCMS Day

My appointment was for 8.30; two other patients would be having TCMS that day. We all arrived at the same time. I filled in the same forms I’d filled in in 2000; then Henkin called me into his office. His desk held the same array of dropper bottles in the same taped-up cardboard box; the tests had the same protocol. ‘Sweet, salty, bitter or sour?' he would ask, dropping a drop on my tongue. ‘Don’t cross your legs; we’re here to work.’

By late morning he had tested us all. He got us together and described the treatment in simple terms, then drove us to George Washington University Hospital, where Dr Potolicchio would administer TCMS, applying it first to one shoulder, to check that we responded to it, then to our heads. We shouldn’t worry if our hands twitched; it was normal, and the procedure was harmless.

At the hospital there was a delay, because Dr Potolicchio was involved in what Henkin apologetically described as an ‘intense procedure.’ During the wait he took me to meet another colleague, Dr Lucien M. Levy, to see some smell-related fMRI scans that he had mentioned during our interview the previous day—fMRI allows them to quantify olfaction reactions by administering taste/smell tests during a scan. Until fMRI, they had no objective evidence of what happened in the brains of patients exposed to taste/smell stimuli; they could only report the patients’ subjective responses.

Dr Levy’s fMRI kingdom was sleek and minimalist—just a few multi-million-dollar machines. Dr Potolicchio’s TCMS room, crowded with machines on tables and trolleys, reminded me of Henkin’s office. The magic TCMS wand was a black annulus with a

1 Berton Roueché, “All I Could Do Was Stand in the Woods,” The New Yorker 52 (30) (12 September 1977): 97–117; and in The Medical Detectives (New York: Truman Talley/Times Books, 1980), 255–70.

2 Duncan Graham-Rowe, “Death in the Family,” New Scientist 175, no. 2361 (21 September 2002): 34-?

3 L.M. Levy and R.I. Henkin, “Human taste phantoms can be related to specific regional areas of decreased brain γ aminobutyric acid (GABA) by magnetic resonance spectroscopy (MRS),” Saturday afternoon poster session (1998), Vol 47, number 3, p 219A.

4 Dysosmia is subdivided into phantosmia (a hallucination of smell in the absence of a real smell) and aliosmia or parosmia (distorted perception of an existing smell).

5 This definition was taken from Wikipedia in 2006: http://en.wikipedia.org/wiki/TraDB=C:\Data\Dropbox\Ibidem\Taste\TASTE;tic_stimulation. The page has changed; the definition is no longer there.

6 Lucien M. Levy and Robert I. Henkin, “Brain Gamma-Aminobutyric Acid Levels Are Decreased in Patients With Phantageusia and Phantosmia Demonstrated by Magnetic Resonance Spectroscopy,” Journal of Computer Assisted Tomography 28, no. 6 (November/December 2004): 721–27.

7 Hagit Cohen, et al, “Repetitive Transcranial Magnetic Stimulation of the Right Dorsolateral Prefrontal Cortex in Posttraumatic Stress Disorder: A Double-Blind, Placebo-Controlled Study,”

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