98 The Philippine Journal of Science 
awakened only with difficulty, answering questions intelligently, 
but slowly. Strabismus was usually present. Frequent invol- 
untary twitching of the muscles of the face, neck, and extrem- 
ities was observed. Supraorbital nerves were usually tender. 
Areas of hyperesthesia were elicited in many cases. The neck 
was not rigid, and Kernig’s sign was absent; if present at all, 
it was usually very slight. In all the cases there was marked 
conjunctival injection. There was irregularity of the pupils, 
and they reacted slowly. The tongue was coated; the appetite, 
poor; bowel movements, constipated in most cases. Heart and 
lungs were apparently normal; liver and spleen, not palpable; 
knee reflexes, apparently normal. Slight leucocytosis with in- 
crease of polynuclears was present in the blood. Cerebrospinal 
fluid was clear and came out in drops; differential counts showed 
increased cellular contents; the highest count reached 77 per 
cubic millimeter, usually with predominance of polynuclears, 
rarely with small lymphocytes. 
Clinical course.—The fever was remittent, sometimes inter- 
mittent, ranging from 37.5° C. to 38.5° C., rarely over 38.5° C. 
It lasted from four to twelve days and averaged six days. The 
patients gradually became stuporous, sleeping most of the time. 
In severe cases, deep coma set in with attacks of convulsions 
which continued until the patient died. 
During the convalescent period we frequently observed tran- 
sient rise of temperature, with the mind still unclear and speech 
slow. In all our cases there was accompanying general weak- 
ness and, at times, slight palpitation. Heaviness of the head 
persisted over a long period. In those who recovered no para- 
lysis was observed. 
Three important clinical symptoms are characteristic of en- 
cephalitis lethargica; namely, fever, diplopia, and stupor. They 
are regarded as the triad of symptoms of the disease, and when 
the triad is incomplete, the diagnosis is very difficult. In the 
majority of our cases, we observed symptoms of involvement 
of the third nerve, more than of any other cranial nerve. 
Pothier states that the fourth, sixth, seventh, ninth, tenth, 
and twelfth nerves were said to be affected. Marinesco, of 
Bucharest, states that the motor cranial nerve nuclei are in- 
volved, while the sensory nuclei escape. 
Mortality.—Four out of our eight cases died, giving a mor- 
tality rate of 50 per cent. The French mortality rate is given 
as 50 per cent. Only three of our cases were autopsied, and 
the pathological findings showed characteristic lesions of the 
disease. 
