London's Pulse: Medical Officer of Health reports 1848-1972

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London County Council 1934

[Report of the Medical Officer of Health for London County Council]

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SIGNS, SYMPTOMS AND SEQUELÆ OF SUBARACHNOID HÆMORRHAGE
DUE TO RUPTURED CONGENITAL ANEURYSMS.
By B. Barling, M.T)., B.S., M.R.C.P., M.R.C.S., Senior Assistant Medical Officer,
St. Mary, Islington, Hospital.
Advance of physiological and pathological knowledge of an organ or structure
brings certain clinical conditions from the obscurity of our previous ignorance and
illuminates them with the light of our better understanding. With knowledge comes
interest, and with interest keener observation, so that erstwhile unobserved symptoms
leap into significance.
Intracranial hæmorrhage of all types has entered the sphere of better understanding.
Bleeding from the middle meningeal artery is readily recognised and
treated, and recent light on the subdural hæmatoma has saved many a victim that
previously had been allowed to perish. And now with the information gained during
the past ten years on the effects of subarachnoid bleeding, we are able to avert in a
proportion of cases their demise.
In this paper, it is desired to review the signs and symptoms of subarachnoid
hæmorrhage, and more particularly the subarachnoid hæmorrhage that follows a
ruptured congenital aneurvsm of the cerebral vessels.
The arachnoid is a delicate membrane investing the brain and spinal cord and
lying between the pia internally and the dura mater externally. It is separated from
these structures on the one hand by the subarachnoid cavity and on the other by the
subdural space.
The cerebral portion of the arachnoid invests the brain loosely, and does not
dip into the sulci nor the fissures, with the exception of the longitudinal fissure.
The subarachnoid cavity contains the cerebro-spinal fluid and the cerebral
blood vessels, the space itself being small on the surface of the hemispheres; but
on the base where the contour is less regular, the spaces produced in bridging over
these irregularities are larger and termed cisterna. These cisterna themselves bear
a certain relationship to the present discussion, for they emphasise the lack of tissue
support of the cerebral vessels and furthermore are preformed sacs for the accumulation
of escaping blood.
The subarachnoid space is not in communication with the subdural space, but
is with the ventricles of the brain through the foramina of Luska and Majendie in
the roof of the fourth ventricle.
The spinal portion of the arachnoid invests the medulla spinalis loosely and is
continuous above with the cerebral arachnoid and below it widens out and surrounds
the cauda equina and the nerves proceeding from it.
Before leaving the question of the anatomy of the arachnoid, mention must
be made of the arachnoid villi, for although they play no part in the production of
haemorrhage, the recent work of Winkleman and Fay2 suggests that it is the blocking
of these villi, through which the cerebro-spinal fluid is normally absorbed, that gives
rise to certain sequelae.
Weed3 has shown that the cells of the arachnoid show reaction and proliferation
to the irritation set up by red cells, which suggests therefore a method of blockage
of the villi.
The presence of blood in the subarachnoid space affords an easy diagnosis, for
by means of the cistern or lumbar puncture, it is possible to withdraw fluid and
study its composition.
Anatomy.
Birth injuries arise from difficult labour and consequent excessive moulding of
the foetal head. There is tearing of the dura and arachnoid in the region of the
tentorium cerebelli and blood flows into the subarachnoid space. The majority of
these cases die at birth. Of the others, their ultimate destiny is difficult to determine,
as in few cases has the presence of the haemorrhage been ascertained during the life
of the child.
Traumatic
causes.
Other traumatic causes are injuries and blows received in accidents with or
without fracture of the skull. The subarachnoid bleeding may be local in the region
of the injury, or on some distant part of the brain as the result of contra coup.
(101)