The First Nerve

Losing the sense of smell might seem trivial, but a person’s identity can go with it

Amrapali Maitra

 
 

As a medical resident, I keep a daily tally of what COVID-19 strips away. First was breath—the jagged inhales of infected patients, the limited supply of ventilators, the hiss of oxygen through masks and tubes. Second was blood—congregations of the fateful clots, the throbbing vessels of sepsis. Third was the vigor of the body itself—an extended convalescence, sapped strength, tired muscles. Last, and most strangely, smell. Recently, a Nature study found loss of smell to be the best predictor for COVID-19, rather than symptoms we might expect—fever, cough, shortness of breath.

Loss of smell—“anosmia”—sounds innocuous: less threatening or visceral than difficulty breathing or quivering with chills. But I know enough of anosmia to recognize its capacity to steal what we hold dearest.

As I write this, I am pregnant, my daughter thirty-four weeks and growing. Not working in person, I miss the hospital in my nostrils in a way I never imagined—the sharp disinfectant, the sweat, the sterile air. In pregnancy, smell constantly declares itself at home: the pungency of cheese, the acidic tang of a pickle, the freshly turned mulch in my neighbor’s daffodil bed. The odor of the trash can is too much to bear. I implore my husband to banish it; he continually hauls limp, half-filled Hefty bags to the bin downstairs. Conversely, a nearby flower or fresh-baked banana bread is a delight. These days, I move through the world nose-first.

As a pregnant doctor at a Boston hospital, I am tasked with caring remotely for young patients who suffer mild symptoms or elderly patients who juggle long lists of chronic diseases. We are united in our desire to avoid the hospital, in our bewildered uncertainty about how the virus might imprison our bodies. On virtual visits, I speak to patients recovering from what we both presume to be coronavirus infections. They tell me their courses were mild, so, advised to recuperate from home, they never got tested. But their illness scripts—fevers, mild tightness in the chest, prolonged and debilitating fatigue, loss of smell and taste—certainly sound like COVID-19.

One woman tells me she has been weak for months. Everything is tasteless; she and her boyfriend, quarantining together in their small apartment, take turns microwaving instant ramen and spooning noodles into each other’s mouths. They are unmotivated to eat. A gentleman with many prior surgeries from a blood vessel disorder has quarantined in northern Massachusetts since March, but before that lived in a crowded house shared with other veterans. He sees no one, spends his days walking along an abandoned creek with his dog. He tells me that everything tastes like tin—bread turns to metal in his mouth, the clangy flavor of canned beans from his days in the army.

* * *

When I was eighteen, a newly announced premed student, my mother lost her sense of smell. Suddenly, the librarian who lived in the musky pages of borrowed books and cooked cumin-spiked curries for dinner every night was unmoored.

That summer, my mother became my first patient. I had returned home from college a few weeks earlier, pale from the winters of Boston, ready for a ninety-degree Texas summer and dips in the pool. A lab had hired me as a researcher, and I began my tryst with biology. Each day, I looked at samples of spit on a slide, clicking green for cells with normal pairs of chromosomes or red for extra copies. We were seeking a test for the early detection of lung cancer. I leaned into the microscope’s owl eye, transporting me to another place—a starry sky, an arcade game. But it didn’t feel like a doctor’s world; no clinic rooms with lines of eager patients waiting just outside. No bodies speckled with rashes to decipher, lumps to palpate. No stories of suffering or triumph.

At home, a different story unfolded. My mother mentioned that while cooking her famous chicken curry, she couldn’t smell the heady blend of roasted chili, garlic, and tomato. I found it puzzling—she never opened a recipe book, and always cooked with her nose. She could even smell salt in a dish without measuring. In the afternoon, tending to her favorite rosebush in the yard, my mother leaned in to take a whiff of the heady fragrance and found none. That night, getting ready for a dinner party at a friend’s place, she topped off her routine with a spritz of Classique by Jean Paul Gaultier—but the perfume had no effect.

We both knew something was wrong. I pored over my grandfather’s old Netter’s Atlas of Anatomy. Smell, I learned, begins in the first nerve of the head and neck. The nerve buries its tendrils in the pink lining of the nose; from there, it meanders through the sieve-like cribriform plate separating nose from brain, peeks past the ethmoid bone, and reaches the surface of the brain. Then, its fibers wrap around two bulbs and send messages down a long tunnel into the sensory atrium. When an odiferous particle reaches the nose, it interacts with the dancing, finger-like projections in the nostrils. The clasping of particle to receptor sparks an impulse that travels toward the brain and announces a smell. It is here that a drop of liquid from a citrus fruit is revealed as the delightful zing of lemon, or the stench emanating from a garbage can is registered as foul. Taste, too, is smell. While the tongue plays a supporting role, taste largely arises from the smell of food as we bite and chew.

Smell is memory, too. I could have found proof in several studies confirming this, but instead I consulted my copy of Marcel Proust’s Swann’s Way and reread the passage where the narrator takes an absent-minded bite of a buttery madeleine dipped in tea and suddenly recalls the Sunday afternoons of his childhood, his aunt, the gray roofs of Combray: “When from a long-distant past nothing subsists […] taste and smell alone, more fragile but more enduring, more immaterial, more persistent, more faithful, remain poised a long time, like souls.”

That night, I learned the first truth of doctoring: know the shape of your patient’s distress. Anosmia (lost smell) and her cousin dysgeusia (altered taste) dismantle the scaffolding that frames a life. My mother’s response was to recall with determination the scents of her past: damp earth after a Bengali monsoon, freshly brewed coffee wafting from the Lake Market stalls, jasmine hanging from her singing instructor’s braid. She hummed a line from an old Tagore song: Phuler gondhye chomok lege uthecche mon mete (The greatest gift we are given is to be aroused by the perfume of a wayside flower.)

But memories did not suffice. Forsaken by smell, my mother feared gas leaks and burnt bread. She stopped gardening and cooking. She lost the joy of dressing up. Before parties, she spritzed Gucci perfume on her clavicles and sidled up to my father: Gondho paccho? He smiled kindly, saying “You smell like a queen!” but her expression remained aloof. My mother’s identity was insidiously taken from her as I stood by, helpless.

* * *

I tucked away the lesson of my mother’s anosmia during several years of medical training, along with the nagging truth that I had been unable to bring her comfort or relief. It resurfaced just before the coronavirus pandemic struck, during an afternoon of clinic in February that now strikes me as the last memory of normalcy. My third patient that day was Linda, a trim 73-year-old woman. Linda served on the board of many foundations and wore statement necklaces. Her level of health was enviable compared with patients I had seen earlier—a tram operator whose left side went limp every time he had a migraine, and a patient care assistant who worked the night shift even as diabetes ate away at her left toe. Yet she was dejected. “I can’t smell,” she said. “I can’t even taste my food. I douse it with lemon: nothing.” I had found my second chance.

Linda lost her smell in the spring, six years ago, with no particular illness or provocation. It was long after her divorce, even longer after she’d quit smoking. Slowly, during long walks on the Mendocino coast while visiting her daughter, she realized that she could not smell the flowers. It’s not that she had a particularly keen sense of smell before, but a tiny part of herself she had taken for granted had now receded. A self-proclaimed “foodie,” with her smell went much of her life’s allure.

I recited possibilities I had failed to consider for my mother many years ago: allergies, viral infection, tumor, stroke, idiopathic (meaning, we have no clue). Then Linda sat on the exam table with her legs dangling as I conducted an exam. I held coffee (a strong scent) then an alcohol swab (a noxious stimuli) in front of her left nostril, then her right. I tapped on her sinuses, peered into her ear canals, tested the strength of her facial muscles, checked her tongue for symmetry. The study bore no hints.

She was wary. A string of doctors had minimized or dismissed her condition, and I knew I must recognize her loss of identity and provide comfort, even if there was no perfect diagnosis to be found, no lesion or lump to which we could attribute the theft of this sense. So I offered the word anosmia with hushed reverence, explained her suffering was real, albeit mysterious. It worked. Slowly, I gained her trust. I prescribed Linda puffs of nasal steroids in case this could bring down swelling that may be blocking the sensory receptors, and we set up a follow-up appointment for the next month.

After the thirty minutes we spent together, I scoured her electronic chart that evening—the archive of her illness and her body—for past consultations. In the preceding year, Linda came in and out of clinic for various issues—back pain, ear wax, a nagging cough. Each time, she reminded her doctors and nurses about the loss of smell. “I’m willing to try anything,” she told one doctor, who made a mind-body medicine referral. A week later, Linda found herself face-up on an acupuncturist’s table, squeezing her eyes shut as needles were gently advanced into her forehead.

I found a progress note from an ear, nose, and throat surgeon written in terse prose: “She misses lemon, most.” I imagined Linda’s childhood in California, running around lemon trees in the yard with her sisters, constructing lemonade stands on her block—her particular aptitude for the trade, heralding her future success as a businesswoman—then returning home, thirsty and breathless, buoyed up by the smells of her grandmother’s cooking, glistening filets of Pacific salmon studded with lemon slices and sprigs of rosemary, chased down with minty iced tea, followed by peach cobbler and vanilla ice cream. Was it even a doctor’s task to imagine? I didn’t know any other way. Know the shape of your patient’s sorrow, I told myself.

I read a description of her nasopharyngoscopy with curiosity: a fiberoptic camera was threaded through her nostril, extended into the back of her nose, where the doctor was able to look at her tongue, epiglottis, and vocal cords. Inferior turbinates normal, no edema. Middle turbinates no masses. Middle meati patent without purulence. Nasal septum deviated to the right. Base of tongue symmetric. Vallecula without cysts. Post-cricoid edema. Right and left vocal cords exhibit bowing. The nose with all its curious structures: the humidifying pockets, air passages, thin pane of cartilage and bone separating left from right. And the camera’s journey into the pink, puffy unknown, much like Alice tumbling down the rabbit-hole into wonderland. Yet despite the string of words, the interpretation was summed up in a single word: “normal.” She ended where she began, bereft.

The work of healing kept Linda busy. She tried hypertonic saline rinses—running super salty water up one nostril and down the other, letting it tingle and burn in her sinuses in hopes of clearing them out—then spent the first two hours of each day blowing her nose. She swallowed tablets of elemental zinc, advised that this would make her taste more acute.

A month later she returned, elegant as ever, with no real change to her sense of smell. “I can taste strong spices,” she said, “but still no lemon or herbs.” Linda carried around hot sauce in her purse. Yet even the strongest flavors felt distant, as if they wafted in from an adjacent room. I had reached the end of my list and began to fumble for new options, offering advanced testing and specialists. She revisited the ear, nose, and throat clinic. Set up an allergy appointment for testing. Obtained a CT scan of her brain and sinuses, a detailed sketch of each ventricle, lobe, and sulci. In the meantime, I advised her to trick her tongue by emphasizing temperature and texture of food. Perhaps she would find some comfort in eating chips still warm from the oven, salt clinging to her lips, or cold, crunchy lettuce slathered with creamy harissa?

Then the pandemic struck. Caring for Linda is one of my last memories of being in clinic, examining patients, listening to stories in the flesh, back before COVID-19 became a constant refrain. Linda and my mother gave me a repertoire for how to understand and imagine anosmia; they also taught me why smell matters.

Our bodies are remarkable bundles of nerves, which habituate to loss marvelously. A single muscle falters, several others engage to share the load. The left eye stutters, and the right eye steps in. Even when our brains are cut in two, one side makes excuses for concepts it cannot grasp, a process called confabulation—a fancy word for the trickery that allows us to sustain the illusion of wholeness. But smell is singular in its capacity: it carries “ephemeral traces” of the world we move through, and, in the words of philosopher Michel Serres, “specificity is countersigned by aroma.” Smell cannot be found in a screen; it must be lived: through mess, exposure, proximity. It is also a passport to a former version of ourselves—to the scenes that delight us, move us, instill our values, record our quirks. Yet its loss leaves no mark. We appear entirely healthy, unmarred by illness, and secretly we nurse a curious loss. Anosmia is fickle. I cannot say whether and when smell will return for those who have lost it, whether survivors of COVID-19 or patients like Linda.

Doctoring without a path for recovery is like sailing without a compass; yet, in practice, we navigate uncertainty all the time. Linda has not yet recovered; I don’t know if she ever will. She will carry her lost sense like a wound, the first nerve permanently numb. As her smell falters, mine sharpens. I wonder which scents, years from now, will transport me back to this moment of lockdown, this difficult present. And for my recovering patients, how might the absence of smell further the leaden detachment of their illness, its fragmented experience? I yearn to know the shape of that sorrow.

In my last visit with Linda, I told her about my mother. She endured anosmia for seven years, and then, without any fanfare, it slowly receded. One morning, she detected coffee brewing before walking into the kitchen. Another evening, the caramel note of a sautéed onion caught her attention. She tried not to announce it—“It’s back! I can smell!”—for fear of losing the flighty sense again. On the kitchen counter, a pile of catalogs and fashion magazines full of perfume samples waits to be recycled. My mother peels open each one, exposing a sample, taking a deep whiff of the floral, the musk, the citrus, the sandalwood, the lavender, the green tea. Even now, I’ll catch her some days with her nose buried between the glossy pages, inhaling the perfume like a newborn taking her first earthly breath.


Amrapali Maitra is a physician at Brigham and Women’s Hospital in Boston, MA, and a medical anthropologist. She writes about care, culture, and the human experience of medicine. Her essays have appeared in McSweeney’sCatapult, and the Journal of the American Medical Association. She is on Twitter @amrapalimaitra.

Graphic by Bianca Ibarlucea.

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