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The escaping blood is, however, not limited to the brain and cervical region,
and may affect the whole cord and the plexuses, so producing pain and hypertonia
of the back and limbs.
Adie18 has described herpes occurring in this condition, due to the irritant
action of the escaped blood on the nerve roots.
The symptoms, therefore, at this stage may be summarised as headaches,
nausea, vomiting and stiffness of the neck.
When the escape is more free the signs are those of cerebral irritation without
focal localisation.
The patient may be found curled up on the side complaining bitterly of headache.
There is cervical rigidity, and both Kernig and Brudzinski signs may be present.
The presence of escaped blood into any part of the body after a short period gives
rise to fever. To this rule, the subarachnoid space is no exception, and it is this
accompanying irregular pyrexia which frequently embarrasses the uninitiated.
Lumbar puncture will reveal, however, the correctness of the diagnosis; the
characteristics of the fluid obtained are pathognomonic. On withdrawal of the stilet
from the lumbar puncture needle, the fluid is found to be under some increased
tension ; it is blood-stained, the blood being intimately mingled with the cerebrospinal
fluid. On allowing the fluid to stand, there is no tendency for the blood to
clot, and the cells precipitate to the bottom of the tube.
Should the puncture be performed some hours after the haemorrhage has commenced,
the supernatent fluid above the cells will be discoloured, due to hæmolysed
red cells. If a cell count is made, it will be found that the white cells are present in a
larger proportion than the red cells, as they are not destroyed so rapidly. A differential
count, however, on the white cells, shows them to be in the same proportion
as they are in the blood.
This apparent leucocytosis in the cerebro-spinal fluid occasionally gives support
to the erroneous impression that the patient is suffering from meningitis, until
checked by the differential count on the blood.
In the third type of case, there is sudden bursting of the aneurysm without
warning. The patient has just time to cry out and then falls unconscious. When
seen, the victim again presents signs of a cerebral catastrophe without localisation
signs. Experience of this condition leads one to an arbitrary sub-division.
The one group is deeply unconscious from the beginning with widely dilated
pupils, stertorous respiration and general flaccidity. Lumbar puncture does not
improve the condition, and necropsy reveals the force of the haemorrhage to have
torn up the brain substance and to have filled the ventricular system.
The other group, although unconscious, are not so deeply so, and may be slightly
if only temporarily aroused, and more especially is this true after lumbar puncture.
On stimulation they respond with "I'm tired, leave me alone,'' resent and often resist
examination, to slip back to their somnolent state when the investigation is completed.
Examination reveals a widespread variety of physical signs, none of which can
be considered constant and few pathognomonic.
Peshaps the following classification will assist in this description:-
Meningeal signs.—The restlessness, headache, vomiting, and even coma, have
already been described, and therefore there is no need to reiterate them.
Ophthalmic signs.—(a) Pupillary changes are frequent. They vary in size,
being small or large, equal or unequal, and generally reacting to light, but sluggishly.
As has already been mentioned, in the large and fatal haemorrhages the pupils are
widely dilated and fixed.
(b) Changes in eye-grounds. Here, there is a manifestation, which although
present in less than 20 per cent. of cases, is of full pathognomonic import, speaking
of the subhyaloid haemorrhage (Riddoch and Goulden).17. This, however, is not the
only fundal change to be found, for papillitis is sometimes present.
Cranial nerve palsies.—The third, fourth, and sixth nerves are the more frequently
involved, although others may also be affected, but the findings are inconsistent
and of little diagnostic value per se.