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.