Risus sardonicus

Published February 22, 2021, 12:54 AM

by Dr. Jose Pujalte Jr.

IF SYMPTOMS PERSIST

Dr. Jose Pujalte, Jr.

“O Jesus, send me a wound to-day” — Siegfried Sassoon (1886-1967), English poet and novelist, The Old Huntsman and Other Poems (1918), Stand-to Good Friday Morning 

Swearing “Ma-tetano ka sana!”(“I pray you get tetanus!”) quickly dates you as an 80s person in this part of the world. It is after all a fulmination equal to the horrors of the infection: drooling and lockjaw, fever, painful body spasms, and even death. Tetanus is a curse a pharaoh will wish to befall anyone who opens his tomb. It has no cure and to this day, mortality from tetanus approaches 50%.

Causes and Types. What causes tetanus? Clostridium tetani. These are bacteria found in soil, animal feces, and even in dust. What’s worrisome is when their spores enter the body through deep, penetrating wounds from gunshot, punctures, (body piercings and tattoos are included), burns, animal bites, surgical wounds, ear and dental infections. A powerful toxin is formed that binds irreversibly to the body’s nerve cells causing damage. It’s basically a poison finding its way to the striated or skeletal muscles of the body. A treacherous variant is tetanus in newborns (tetanus neonatorum) which has a mortality rate of 90%. The point of entry is a dirty umbilical stump. In maternal tetanus, the toxin swarms the uterus after birth.

Signs and Symptoms. “Risus sardonicus” or “rigid smile” is characteristic in the facial spasms caused by tetanus in which the eyebrows are raised and there is a fixed smile. Think of the Joker from Batman movies except that there are more areas that spasm: abdominals, neck muscles, and back muscles. Lockjaw occurs when the masseters, the strong muscles of the jaw go into spasm. Other signs are fever, elevated blood pressure, sweating and rapid heart rate.

Diagnosis and Treatment. Tetanus is a clinical diagnosis. The good doctor will review your immunization history and should unearth that as a child, you must have had five shots of the DTP vaccine (diphtheria, tetanus, pertussis) at 2 months, 4 months, six months, 15 to 18 months, and at 4 to 6 years. A booster shot is given every 10 years. Any deviation from this puts you at risk when wounded. Treatment in tetanus is supportive. That’s doctor-speak for antitoxin (tetanus immune globulin), antibiotics, sedatives, and other drugs to support breathing and runaway heartbeats, and lots of prayer. Death from tetanus can occur with chest spasms that interfere with breathing leading to fatal asphyxia.

Prevention. It is now even clearer why wounds are washed and cleaned. The entry of clostridial spores is the game-changer. Take antibiotics, use an antibiotic ointment and change the wound dressing every day.  A deeper wound, especially with a retained foreign body, needs to be formally debrided in an operating room setting. A tetanus infection does not confer immunity. Even if you should recover from tetanus, you have to be vaccinated again. If you’re a teenager or adult, get your tetanus booster shot. It won’t hurt and considering what you’re preventing, it’s worth the trip to the clinic or emergency room.

As for Siegfried Sassoon’s soldier in the poem, he wanted to be shot in the trenches of World War I, to get out of it, wounded and heroic. Tetanus would have spoiled all that.

Dr. Pujalte is an orthopaedic surgeon. email [email protected]

 

 
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