Risus Sardonicus

Risus Sardonicus

I have seen many patients in my career in Medicine. Some of these stay in my memory long after my interactions with them. This is the story of one such patient who still haunts me today.

It was the early 1990’s. I was a newly graduated doctor in the Northern Nigerian city of Zaria. I had started my internship at our local teaching hospital. It was a very exciting time for me as I was finally working and every time I was addressed as ‘doctor', I felt a great sense of satisfaction.

I was assigned to Internal Medicine Ward Two. This was one of our four wards. The patients on admission had a wide variety of diseases, and I was kept very busy.

One day, a new admission came in. He was a young boy, perhaps fourteen years old. Some days previously, he had sustained a cut on his leg from a rusty piece of metal. The wound festered a little, but he did not seek medical attention.

About a week later, he developed spasms in his muscles. These were the classic signs of tetanus. The bacteria get into the body by a deep penetrating injury. They then subsequently produce spores which produce the toxin that causes the muscle spasms.

This disease is practically unheard of in developed countries because of widespread immunization against tetanus. Even today, if you go to the doctor in the United States after a cut, you may be given a booster tetanus vaccine, although everyone gets vaccinated as a child. This young boy had never been vaccinated. The mortality in such cases is very high.

He was having frequent spasms when he came in. We gave him large doses of valium to stop the spasms and also gave him anti tetanus serum intravenously. This was supposed to help neutralize the toxin. However, this did not help and he kept having frequent spasms.

We had a meeting of the Internal Medicine team. It was decided that we will attempt to inject anti-tetanus serum into his spinal fluid. This would hopefully get at the toxin better, and was a technique that had been used successfully in other patients. I was his house officer and was assigned to do the lumbar puncture and administer the serum. I was proficient at lumbar punctures and had done many during my training.

This was however a different challenge. Usually in order to do a lumbar puncture, we get the patient to bend forwards so that the needle can easily be passed into the spinal fluid. In this patient however, he was having muscle spasms and he was arched backwards. This was the opposite of the position we wanted him to be and is known as ‘opisthotonus’, which is another sign of tetanus.

I was however fairly confident in my ability to do the lumbar puncture. I gave him a large dose of valium to help relax his muscles and got the assistance of some of the ward nurses to help position him. It was difficult as he remained very stiff.

I got my lumbar puncture kit ready and was elated to get the needle in on the first try. I drained some of the spinal fluid and then injected the anti-tetanus serum. It took a few seconds.

As the serum went in, I suddenly realized that his spasms had stopped. I quickly turned him over and realized that he had stopped breathing. Such periods of apnea or lack of breathing are known to happen in tetanus patients. We called an emergency response and tried to revive him.

I still remember the look on his face while we were attempting to do a cardio pulmonary resuscitation on him. His face was contorted by the spasms and appeared to be smiling sardonically. This is a classic sign of tetanus and is known as ‘Risus Sardonicus’.

This word has it's roots in the Mediterranean island of Sardinia, and derives from the appearance of raised eyebrows and an open "grin”, which can appear sardonic, or malevolent to the lay observer. This was first observed in people poisoned by the ancient poison ‘hemlock’, but is more usually seen in patients with tetanus. Another name for this in lay terms is 'lockjaw'. This refers to the tight clenching of the jaws due to the muscle spasms.

We were unable to revive our patient. His eyes were open and glazed over as he died with the smile still on his face. On that day I became painfully aware of my own limitations as a physician. That sardonic smile still haunts me and will be forever etched in my memory.

 Risus Sardonicus in a tetanus patient.

The Girl in the Tobacco Barn

The Girl in the Tobacco Barn

In my Internal Medicine practice, I see many remarkable people as patients. Many of my patients are elderly and sometimes their stories represent another era in time. I often try to seek out these stories as I find them fascinating. Here is one such story.

The story starts in the early 1940’s in a tobacco farm in a small town in Eastern North Carolina. In those days, tobacco was a major cash crop and tobacco farms were everywhere.

The tobacco was harvested and brought to tobacco barns. There the tobacco leaves were sorted and hung out to dry on sticks that were placed on the rafters and the sides of the barns. The process of sorting the tobacco leaves was time consuming, and very hard work. It was particularly difficult in the high heat of the summer when temperatures would soar.

These barns still exist in North Carolina and dot the landscape, but they are no longer used and are usually seen in various stages of disrepair.

In one of these barns was a young girl, maybe 15 or 16 years of age. She was helping out in the family tobacco farm. The tobacco had been harvested and she was helping sort it out and hanging it up to dry. She remembers that her hands were covered in tobacco tar, she was in a work dress and her hair was messy.

It was then the iceman showed up, delivering blocks of ice for the icebox on the farm. In those days, before electricity was common, this was the form of refrigeration. He was a young man, perhaps 17 years old. His eyes fell on this young girl and he fell in love with her.

He asked her parents if he could take her out. They agreed, but in those days going out meant having a chaperone with you. They went out and got along very well, but war clouds were rolling over and after the attack on Pearl Harbor, our iceman signed up to join the navy.

In the navy, he was on a destroyer manning an anti-aircraft gun. At one time he saw a torpedo heading straight for the ship. As he and his crew mates braced for the impact and possible death, a strange thing happened. A wave lifted the ship and the torpedo passed harmlessly underneath. He later attributed this small miracle to his mother’s prayers.

That night he wrote a long letter to his tobacco girl expressing his feelings for her and his desire to marry her. She never got the letter.

In the meantime, she had also met another suitor who was interested in her, but she could not forget her iceman. She also wrote a letter to him, but unfortunately he also never received the letter. Fate had however destined them for each other and she decided to wait for him.

They met again when he got back and eventually got married. This was seventy years ago. They are still married today.

 They both began to work at a local mill in town. They eventually had six daughters. They were both very religious and regular members of their church. They lived in his childhood home. All their daughters grew up to be strongly religious women. They all got married and had their own children and grandchildren.

At their 50^th marriage anniversary, their church had a special event for them. At that time the former iceman recounted how he fell in love with his wife after seeing her hands stained with tobacco tar, and that she remained the love of his life.

His wife is now in her late eighties and recounted this story to me when she came to see me as a patient. She acted mildly annoyed that the main thing he remembers about that first meeting was her tar stained hands. She however continues to love him deeply.

He is now in a nursing home after developing dementia. She lives with one of her daughters and is increasingly frail. She however brightens up at the mention of her husband and can recount in detail the story their initial meeting and courtship.

Such stories may seem out of place in today’s fast paced world, but I find it extremely heartwarming. The love and affection my patient still has for her husband is absolutely wonderful to see.

An old tobacco barn

Hands stained with tobacco tar