OBSERVATIONS ON THE QUAN- 
TITY OF DAY AND NIGHT 
URINE. 
BY 
Charges W. Edmunds, M. D., 
ANN ARBOR, MICH. 
Reprinted from the 
new VorK medical Journal 
and Philadelphia medical Journal 
CONSOLIDATED 
for February 6, 1904, Reprinted from the New York Medical Journal and Philadelphia Medical Journal, Consolidated, for Feb. 6, 1904. 
OBSERVATIONS ON THE QUANTITY OF DAY AND NIGHT URINE.* 
CHARLES W. EDMUNDS, M. D., 
ANN ARBOR, MICH. 
ASSISTANT IN PHARMACOLOGY, UNIVERSITY OF MICHIGAN, ANN ARBOR, MICH. FORMERLY INTERNE IN THE 
UNIVERSITY HOSPITAL. 
Ever since physiology and pathology have 
occupied a place in the scientific world, the kid- 
ney and the various problems connected with the 
excretion of urine have taken a place scarcely 
second to any in medicine, and the literature of 
the subject is enormous. We need merely sug- 
gest such purely fundamental questions as how 
the urine is excreted; how the activity of the 
organ can be altered or the composition of the 
urine changed by various factors in health or dis- 
ease, to indicate the wide extent of the field and 
how much yet remains that is unsettled, which 
will furnish material for study and research in the 
future. 
riods of fifteen hours and nine hours—from 6 
a. m. to 9 p. m. for day urine, and 9 p. m. to 6 a. m. 
for that of the night. They consider a normal 
ratio Qd: Qn:; 100: 50, but say that 100: 90 may 
occur, and still be within physiological limits, but 
that in the twenty-four hours thus divided Qn 
should never be equal to or greater han Qd. 
In the following observations the periods are 7 
a. m. to 7 p. m. and 7 p. m. to 7 a. m., thus making 
them of equal length. It was necessary, therefore, 
to obtain a new standard for the normal, with 
which to compare the diseased conditions. For 
this purpose, observations were made for a month 
during the fall of the year upon a young adult in 
active life, making no change in his habits of eat- 
ing and drinking, but the urine passed was meas- 
ured and the bladder always emptied at 7 o’clock, 
morning and evening. In the ratio thus obtained 
the Qd was to the Qn as 67: 33 (or as 100: 50). 
This result, as will be seen, agrees very well with 
those previously mentioned when the difference 
in the daily division is taken into consideration, 
but I think we must allow, with the twelve-hour 
periods, that a ratio of 50: 50 (to correspond with 
the 100: 90 ratio mentioned) may be within phys- 
iological limits although probably it is rather ex- 
ceptional. 
There is one phase of the question of clinical, 
as well as of scientific, interest which does not 
seem to receive so much attention as it merits. 
This is the relative proportion of urine excreted 
during the day and the night in health and in cer- 
tain pathological conditions. 
Several have studied the relation, as it exists in 
health, with fairly uniform results. The figures 
of H. Roger, cited by Certowitch1 will be given as 
being an average. He divided the twenty-four 
hours into two unequal parts—sixteen hours day, 
and eight hours night, making his observations, 
which covered a period of thirty-two days, upon 
an individual aged thirty-four years; during 
which time, while the food was varied, the liquid 
taken was carefully measured, as was also the 
urine, with the average results here given: 
Having settled upon a normal proportion, let 
us now consider the conditions as modified by 
disease, taking first a brief glance at the results 
obtained from cases previously reported. 
24 hours. Day. Night. 
Total 1497 c. c. 1152 c. c. 345 c. c. 
Average per hour 62 c. c. 72 c. c. 43 c. c. 
Quincke4 was the first to call attention to the 
fact that, in cases of oedema, more urine was 
passed during the night than the day. Wilson5 
reported seven cases of kidney and cardiac dis- 
ease, in which the ratio Qd to Qn was disturbed 
and said that this change should be an aid to diag- 
nosis in suspected renal disease. 
The quantity of day urine (Qd) as compared 
with the night (Qn) would thus be Qd :Qn :: 62 ; 
38 (or as 100: 61). 
The earlier observers expressed the ratio by 
taking the day urine as 100 and the night in rela- 
tion to it; but I prefer to consider the total urine 
as 100, and then express the day and night urines 
as parts of it, and this method has been followed 
in the tables given later. Quincke2 and Las- 
peyres3 divided the twenty-dour hours into pe- 
ll jisch6 reported twenty-nine cases of oedema 
and arrived at the same conclusions as to the dis- 
turbed relation in cases with oedema, and also in 
nephritis without oedema. He adds that (1) in 
cardiac disease in periods of compensation the 
relation is normal : (2) as oedema is being lessened 
the On is usua ly m|ffkscll^iffttrqasqrrb;’•ami finally, 
* Made in the Medical Clinic, University Hospital, Ann 
Arbor. Mich. Read before Section in Internal Medicine and 
Pathology, AVayne County Medical Society, Detroit, Mich., Octo- 
ber 12, 1903. 
1 Les quantity's des urines diurnes et nocturnes d Vetat normal 
et pathologique. These Inaugurale, Geneve, 1901. 
2 Arch. f. exp. Path. u. Pharm, Band 32. 
3 Deut. Arch. f. klin. Med. Arol. Ixviii. 1900. 
* Loc. cit. w" ftMUb 
5 Lancet, June !9, 4 BS9. 
0 Munch, m cd. 1 Ts9tv? f 1 
Copyright, 1904, by the A. R. Elliott Publishing Co. 2 
Edmunds: Day and Night Urine. 
(3) if such patients are out of bed several hours 
during the day the Qn is markedly increased. 
To give some idea of the severity of the ne- 
phritis, figures will be found in the tables giving 
the amount of albumin present. These are ob- 
tained as follows, and can be only approximate, 
owing to variations from day to day. The test 
for albumin employed was heat and nitric acid, 
and if there was only a small amount present, it 
was described as a trace, cloud, or precipitate, as 
the case might be. If a larger amount was found, 
after the reaction was completed the test tube 
containing the urine was set aside for twenty- 
four hours, to allow the precipitate to settle, when 
the bulk of precipitate in the bottom of the tube 
was described as being a certain proportion of the 
amount of urine in the tube. 
Laspeyres7 gave the literature of the subject 
and reported sixty-five cases. Among his con- 
clusions he states that: the greatest nightly 
polyuria occurs in cases of myocarditis; nervous 
tachycardia does not give nightly polyuria, and it 
will serve to aid the diagnosis between organic 
and non-organic diseases of the heart; acute 
parenchymatous nephritis does not give so great 
a disturbance as chronic nephritis, especially if 
the latter is accompanied by a cardiac lesion, and 
this fact may serve in the diagnosis in the case 
where an acute nephritis develops in the course 
of an old or chronic renal lesion; and lastly, in 
cases with oedema, medicines (digitalis, diuretin, 
etc.) begin to provoke the polyuria with noc- 
turnal predominance and, following, the quan- 
tity of night urine diminishes as the equilibrium 
in the circulation reappears. 
Certain other factors will be mentioned in the 
tables as having an influence upon the ratio, such 
as the presence or absence of oedema, of atheroma 
in the vessels, the condition of the heart in renal 
cases, the age of the patient, and medication. 
Certowitch8 has presented the most recent work 
on the subject, and reports eighteen cases, con- 
firming these results in the cardiac and renal cases 
and adds that the approach of asystole augments 
the night urine and as it regulates itself this is 
diminished. He also considers the cause of the 
disturbance and argues that, while the healthy 
man in full activity eliminates during the day 90 
per cent, of fluid taken (Roger), and when con- 
fined in bed excretes y6 per cent. (Andre Mar- 
sin9), the subject of heart disease during failure of 
compensation, and the nephritic eliminate only 
30 per cent, to 50 per cent, of liquid taken in, 
therefore the remainder accumulates in the body 
tissues and has a tendency to be excreted during 
the night, causing the polyuria. 
In regard to the last named factor, the changes 
in ratio caused by various drugs do not seem to be 
very well understood at present. As was men- 
tioned before, Laspeyres says that in cases of 
oedema, medicines, such as digitalis, diuretin, etc., 
at first cause polyuria with nocturnal predomi- 
nance, but afterwards the quantity of night urine 
diminishes as the equilibrium in the circulation 
reappears. In my cases, given later, this state- 
ment does not seem to be verified. As will be 
pointed out, the nocturnal urine was increased 
many times, and in certain of the cases it did pre- 
dominate (as it had before the drug was exhib- 
ited) ; but, on the other hand, the day urine was 
increased to a greater degree, so the final result 
was a change in the ratio toward the normal. 
There are two factors to be considered in this 
relation: first, and most important, is the drug; 
and, second, the time of administration. I think 
my tables will show clearly that diuretin increases 
the day urine most markedly and it may be taken 
as a type of those diuretics which act rapidly. 
Then, being administered during the day time, 
they exercise their effects most strongly during 
the day, and thus aid in restoring the normal ratio. 
The fifty-six cases here reported may furnish 
additional testimony to that already mentioned, 
as they illustrate some facts not brought out be- 
fore, and also confirm some of the earlier work. 
This material was put in my hands10 by Dr. Dock, 
who, for a number of years, has ordered that all 
patients with albuminuria, diabetes, and heart 
disease, as well as some acute infections, shall 
have the urine divided into day and night por- 
tions. As stated above, 7a.m.to 7 p. m. con- 
stitutes the day, and 7 p. m. to 7 a. m. the night. 
These periods of time were selected on account of 
nursing arrangements. Many cases could not be 
utilized, owing to errors in carrying out the meas- 
urements, or to the fact that patients did not re- 
main long enough; but no selection was made. 
Digitalis may be taken as a’ type of the other 
class of drugs causing diuresis, which have a 
slower and more prolonged action. The figures 
obtained in the following cases, however, would 
indicate that their effects are much the same as 
diuretin, only less pronounced; in other words, 
they increase the nocturnal urine to a less extent 
than the day urine and therefore aid the normal 
ratio, but do not cause as great a disturbance in it 
as does diuretin. 
7 Loc. cit. 
8 Loc. cit. 
0 These dc Paris, 99. 
10 Dr. W. H. Morley was associated with me early in the re- 
search and aided largely in collecting the material before he 
found it necessary to give up the work. 
Potassium acetate and Basham’s mixture 
would be included in the digitalis group (as far Edmunds: Day and Night Urine. 
3 
as our purposes here are concerned) as not be- 
ing so active as the diuretin. 
lation, as shown by a systolic murmur at the apex 
and slight oedema at the ankles- In the leucsemic 
case, No. n (Qd: Qn ;: 34: 66) it is difficult to ex- 
plain the great preponderance of Qn. The heart 
examination was negative and the nephritis not 
very severe. During the time of observation 
there was slight fever to about ioi° F. usually, 
sometimes to 103 °, with slight chills in the after- 
noon, but sweating was also often noted at night. 
This question of the effect upon the ratio, of the 
different medicines and the time of their admin- 
istration, however, is not very satisfactorily set- 
tled as yet, and I am carrying out, under Dr. 
Dock’s direction, some further research upon the 
subject, administering them to patients with car- 
diac and renal disease, not only, as is commonly 
done, during the day time, but also at equal inter- 
vals during the twenty-four hours, and seeing 
what effect it will have upon the ratio; and I 
hope to be able to report later in greater detail 
upon this phase of the subject. 
In the first three tables given herewith the fig- 
ures do not include those days when diuretin was 
given, for the before named reason, but those 
days when digitalis, potassium acetate, and 
Basham’s mixture were given, are included, and 
the drug used is indicated in the “ Medication ” 
column. 
The case of diabetes insipidus (No. 8) is in- 
teresting in this connection, as the patient passed 
on the average over seven litres of urine in 
twenty-four hours, giving a perfectly normal 
ratio, 66: 34. 
TABLE 11. ACUTE DISEASES. * 
From a study of Tables I and II it appears safe 
to conclude that a mild nephritis may not cause 
much disturbance; the ratio probably is changed, 
but in the acute diseases it has not passed the 
physiological limits excepting in the cases of scar- 
Number. 
Case Number. 
Diagnosis. 
Uni 
Quan- 
tity. 
NB. 
Ratio., 
Albumin. 
Casts. 
(Edema. 
Heart Examination. 
<D 
A 
<1 
•92 V j 
£ 
Day. 
Night. 
(A 
as 
P 
Night. 
1 
229.99 
Gastric Carcinoma. 
475 
520 
48 
52 
Granular,Hyaline. Waxy 
0 
Systolic murmur at apex. 
4- 
64 
Unimproved. 
2 
50.01 
Hsematuria. 
660 
500 
57 
43 
Trace. 
0 
0 
' Negative. 
0 
27 
44 
8 
112.00 
Gastritis, Chr. 
200 
375 
35 
65 
44 
Hyaline. 
0 
Indistinct sounds.. 
M'k’d 
60 
Improved. 
4 
286.00 
ii 44 
313 
200 
61 
39 
44 
0 
0 
Negative. 
0. 
31 
Advised. 
5 
120.98 
Arthritis “ 
490 
450 
52 
48 
44 
0 
0 
Systolic murmur at pul- 
0 
25 
Improved. 
6 
95.01 
Hypertrophic Cirrhosis 
Liver. 
288 
264 
52 
48 
A 
Granular. 
0 
monary. 
Negative. 
43 
Not changed. 
7 
213.98 
Pulmonary Tuberculosis 
270 
395 
41 
59 
Trace. 
HyaL, Gran., Epithelial. 
0 
4% 
0 
23 
8 
131.01 
Diabetes Insipidus. 
4700 
2400 
66 
34 
Neg. 
0 
0 
44 
— 
32 
9 
365.00 
Leucaemia, mixed. 
575 
485 
54 
46 
Gran and Hyaline. 
0 
44 
— 
38 
10 
56.97 
44 44 
390 
490 
44 
56 
44 44 
Slight. 
Systolic murmur at apex. 
, 
43 
11 
73.00, 
, 
282 
538 
34 
60 
Cloud. 
Leucocyte and Hyaline. 
0 
Negative. 
27 
TABLE I.—MISCELLANEOUS DISEASES'. 
let fever. That we may see these changes better, 
we will take these cases up in greater detail later 
in the paper.- (See Table IV.) 
In this table of miscellaneous diseases with ne- 
phritis associated there is little disturbance of 
ratio except in Cases I, 3, 7, 10, and 11. 
TABLE I. MISCELLANEOUS DISEASES. 
In Cases 1 and 3 the nephritis, no doubt, ac- 
counts for part of the trouble, but probably a very 
important factor was the atheroma which was 
present in both, but was especially marked in No. 
3. Atheroma itself may not be the important 
factor, but it indicates, or is associated frequently 
with, changes which cause the disturbance, as 
many times where the largest per cent, of noc- 
turnal polyuria is present a greater or less marked 
degree of atheroma is found. 
It would hardly appear necessary to give any 
further history of most of these cases, as the table 
gives the important points in the examination and 
treatment. A study of the details given would cer- 
tainly confirm the contentions of the earlier work- 
ers, that in disease of the kidney and heart, there 
tends to be a disturbance of the ratio between 
day and night urine; this is slightly marked in 
acute nephritis and in chronic disease of the kid- 
ney, but is markedly changed when these are 
associated with cardiac disease, as, for instance, 
in Cases 33, 47, and 53. 
TABLE 111. RENAL AND CARDIAC DISEASES. 
Case No. 7 (Qd ; Qn :: 41; 59) may perhaps be 
explained by the nephritis alone, which appears 
to have been quite marked—granular, hyaline, 
and epithelial casts being found in the sediment. 
In Case 10 the renal conditions were not so 
marked, but there was a disturbance of the circu- 
The change may be more marked with disease 
of the myocardium but the one case here cited 
(No. 54) would of course not be enough to dis- 
prove or to add weight to that claim. Edmunds: Day and Night Urine. 
In certain of the cases here mentioned, it is 
rather hard to tell why the ratio is not disturbed 
more than it is; as, for instance, in Case 37 (Qd: 
Qn:: 71: 29) with marked nephritis, oedema of 
the legs and sacral region, and slight general 
oedema of the skin. Here, perhaps, we should be 
justified in thinking the heart’s efficiency was not 
much impaired. The examination on entrance 
showed “ Shock rather strong, absolute dulness 
upper border fourth rib outside parasternal line. 
Just inside nipple is soft systolic murmur heard 
best in fourth I. C. S. inside parasternal line. 
Aortic second strongly accented,” At a later ex- 
amination “ sounds were less murmurish.” The 
heart then was hypertrophied and slightly un- 
compensated. This was restored during the stay 
in the hospital with a corresponding improvement 
in ratio, as will be shown later. The history of 
the case would bear out the same idea, that the 
main trouble was with the kidneys and not with 
the heart; the latter condition dating back, in all 
Case No. 38 (Qd: Qn:; 61; 39) also shows lit- 
tle change from the normal ratio, resembling No. 
37 in that the history points to kidney disease of 
over one year’s duration—no heart symptoms, 
and heart examination was negative. Case No. 
41 showed albumin present only part of the time, 
as it would disappear for several days and then 
reappear. Special mention of the other cases 
hardly seems necessary, as they practically all 
show the same thing—a greater or less deviation 
from the normal ratio. In functional disease of 
the heart a normal ratio has been found to exist, 
so the observation of the relative proportions of 
day and night urine would aid in the diagnosis of 
this condition from an organic disease. 
Beyond the aid to diagnosis, we may be assisted 
in following the course of a disease by noting the 
changes in ratio as the patient progresses toward 
recovery or the reverse. To do this, a fairly long 
observation of the case is necessary and due re- 
gard to certain factors, especially the medication, 
TABLE lI.—ACUTE DISEASES. 
- u 
Urine. 
' 0) 
cj 
£ 
rC 
o> 
a 
s 
3 
» 
Diagnosis. 
Quan- 
tity. 
Ratio. 
a 
p 
Casts. 
C3 
S 
<V 
Heart Examination. 
a 
o 
u 
0) 
6 
tc 
1 
o 
(Q 
cj 
+3 
A 
◄ 
I 
rO 
< 
o 
& 
bo 
* 
to 
O 
£ 
Q 
"A 
12 
214.02 
Croupom Pneumonia. 
225 
140 
62 
38 
Trace. 
Hyaline, Granular. 
0 
Rapid—weak. 
Negative. 
o 
11 
Recovered. 
13 
14 
206.00 
205.00 
Scarlet Fever, 
571 
562 
622 
626 
48 
47 
52 
53 
u 
0 
o 
0 
12 
10 
15 
207.00 
520 
605 
46 
54 
“ 44 
0 
.4 
o 
13 
tt 
16 
208.00 
631 
554 
53 
47 
“ 
0 
it 
7 
|( 
17 
111.02 
Typhoid Fever. 
480 
405 
46 
Neg. 
0 
0 
*4 
0 
32 
It 
18 
108.02 
“ 
875 
810 
52 
48 
0 
0 
Systolic murmur at pul- 
0 
22 
•* 
19 
71.02 
1407 
1147 
55 
45 
0 
0 
mouary. 
Sounds weak. 
0 
23 
t4 
20 
115.00 
** 
915 
852 
52 
48 
•Cloud. 
Many. 
0 
0 
58 
it 
21 
22 
22.97 
59.02 
566 
780 
463 
450 
55 
63 
45 
37 
Hyaline, Granular. 
0 
0 
Negative. 
0 
0 
21 
20 
4* 
Recovered. 
probability, to an attack of acute inflammatory 
rheumatism four years before, but causing no 
special cardiac symptoms. The kidney condi- 
tion, on the other hand, dated back only three 
months, from a cold, and on the evening of the 
day on which the patient caught cold his feet and 
legs were swollen for the first time, and since then 
he has always been troubled with them more or 
less. The oedema, then, was of renal origin, and 
would not cause so great a disturbance as if it 
had been due to the heart; but even so we should 
have expected a greater nocturnal polyuria from 
the nephritis, and why we did not get it, it would 
be hard to state. Lespeyres also reported some 
cases in which he did not get so great a predomi- 
nance in nocturnal polyuria as he would have ex- 
pected from the conditions present. 
must be paid, mention being made particularly of 
diuretics. The changes caused by these have 
been discussed earlier and need not be taken up 
again here. 
We give below some observations showing the 
changes as they take place, the cases referred to 
being those of scarlet fever recorded in Table II 
and some of the cases of nephritis and heart dis- 
ease of Table 111. 
The scarlet fever occurred in one family, the 
children being from seven to thirteen years old. 
All the cases followed a typical course, making 
good recovery notwithstanding the mild paren- 
chymatous degeneration of the kidneys. To see 
if any change in ratio took place during the course 
of the disease, examinations were made at short 
periods of a week or ten days, with the following 
results: Edmunds: Day and Night Urine. 
TABLE lII.—RENAL AND CARDIAC DISEASES. 
u, 
% 
I 
1 
Urine. 
Diagnosis. 
Qaan 
tity. 
Ratio. 
1 
Casts. 
aj 
1 
<u 
Heart Examination. 
i 
§ 
Medication. 
1 
O 
(A 
<s 
ft 
1 
iz 
Day. 
| Night. 
◄ 
0 
43 
43 
< 
28 
126.99 
Acute Paren. Ne- 
phritis. 
782 
562 
58 
42 
Trace. 
Casts present at 
times. 
0 
Negative. 
0 
18 
— 
Improved. 
24 
253.99 
Acute Paren. Ne- 
phritis. 
516 
733 
42 
58 
44 
Hyaline. 
+ 
Apex 1" impure. Pulm. 
syst. murmur. 
n 
17 
Basham's M. 
“ 
35 
97.98 
Chr. Nephritis 
with acute ex- 
acerbations. 
955 
965 
50 
50 
A 
Hyal., Gran., Epithe- 
lial. 
4 
Sounds very weak. 
- 
55 
Digitalis, nitro- 
glycerin. 
44 
26 
90.02 
Chr. Paren. Ne- 
phritis. 
562 
502 
53 
47 
Va 
0 
+ 
Syst. murmur at base. 
Apex 2 " stron g e r 
than 1". 
0 
20 
Basham's M. 
27 
134.03 
Chr. Paren. Ne- 
phritis. 
233 
534 
30 
70 
Trace. 
Hyal.,Gran., & Blood 
casts; much pus. 
0 
Negative. 
0 
13 
Urotropin. 
28 
8.02 
Chr. Paren. Ne- 
phritis. 
888 
775 
54 
48 
H 
Short and long Hy- 
al. and Granular. 
+ 
Systolic murmur over 
base. 
4 
54 
“ 
29 
368.02 
Chr. Paren. Ne- 
phritis. 
585 
612 
49 
51 
A 
Hyal., Gran. 
0 
Systolic murmur at 
apex. 
0 
18 
Potas. ace tat. 
II 
30 
320.00 
Chr. Paren. Ne- 
phritis. 
419 
527 
44 
56 
% 
0 
Negative. 
0 
18 
Basham's M. 
and Potass, 
ace tat. 
II 
31 
111.01 
Chr. Paren. Ne- 
phritis. 
232 
238 
49 
51 
\ 
10 
0 
0 
Tachycardia (P o s t - 
diph.) 
0 
24 
Strychnine. 
• 1 
32 
178.95 
Chr. Nephritis. 
508 
488 
51 
49 
Va 
Hyal., Gran., Waxy, 
Epithelial. 
Gener’l 
Aortic murmur. 
0 
20 
Basham's M. 
•1 
33 
52.02 
185 
300 
38 
62 
Cloud. 
Hyaline. 
Gen’ra! 
Anas- 
arca. 
Dullness enlarged, arr- 
hythmia. Sounds 
weak, no murmurs 
heard. 
4 
61 
Digitalis, strych- 
nine. 
Unimproved 
34 
109.96 
Chr. Paren. Ne- 
phritis. 
577 
962 
37 
63 
% 
“ All kinds.” 
GenerT 
Negative. 
0 
35 
Basham's Mixt. 
Improved. 
36 
200.00 
Chr. Nephritis. 
920 
939 
49 
51 
Va 
Many Hyal., Gran., 
and cellular. 
0 
“ 
0 
27 
Basham’s Mixt. 
“ 
86 
301.00 
U it 
497 
441 
53 
47 
Cloud. 
Few Hyal. & Gran.. 
0 
“ 
4 
40 
Potas, acetate, 
caffeine. 
II 
87 
41.95 
1012 
381 
71 
29 
Va 
Hyal. Gran. Epith- 
elial. 
+ 
Slight 
general 
Absolute dullness en- 
larged. Mitral sys- 
tolic murmur. 
— 
21 
Digitalis, Bash- 
am’s M. 
II 
38 
36.95 
“ 44 
500 
315 
61 
39 
1 
6 
Hyal. some with 
granules. 
Slight. 
Negative. 
- 
25 
Nitroglycerin. 
il 
39 
186.03 
Chr. Nephritis, 
Interstitial. 
670 
835 
45 
55 
Trace. 
Hyal., Gran. 
0 
Apex 5" I. C. S. 2 ih- 
ches outside nipple. 
Aortic systolic mur- 
mur. 
M’k’d 
60 
40 
65.01 
Chr. Neph r 11 i s, 
Interstitial. 
463 
523 
47 
63 
A 
Hyal,,- Gran., Leu- 
cocyte. 
Ascites 
and 
mark’d 
CEd’ma 
Apex 5" I. C. S. Dull- 
ness enlarged. 
Sounds impure. 
It 
52 
Digitalis, nitro- 
glycerin, 
strychnine. 
4- 
41 
83.02 
Albuminuria. 
313 
249 
56 
44 
% 
Hyal., Gran. 
0 
Negative. 
0 
22 
Improved. 
42 
147.95 
Pyelonephritis 
465 
675 
41 
59 
Hyal., Gran., Leu- 
cocyte. 
Ascites 
and 
CEd’ma 
Mitral systolic mur- 
mur, arrhythmia. 
88 
Boric acid, etc. 
Worse. 
43 
258.01 
Nephrolithiasis. 
505 
635 
44 
56 
A 
Hyal., Gran. 
0 
- 
29 
Potass, acetate. 
Improved. 
44 
4.99 
Fibroid Heart. 
625 
440 
59 
41 
Trace. 
Hyal.,Gran, and Leu- 
cocyte. 
4- 
Dullness arr- 
hythmia. 
- 
55 
Digitalis. 
4- 
45 
111.03 
Mitral regurgita- 
tion. 
566 
668 
46 
54 
% 
Many Hyal. & Gran. 
+ 
Dullness enlarged. Mi- 
tral systolic mur- 
mur, arrhythmia. 
f 
51 
Digitalis, nltrp- 
glyoerin. 
Improved. 
46 
188.08 
Ascites,Mitral re- 
gurgitation. 
323 
200 
62 
88 
Neg. 
Hyal., Granular. 
Ascites 
and 
CEd’ma 
Mitral systolic mur- 
mur, arrhythmia. 
0 
57 
Helleborein. 
II 
47 
274.03 
Mitral regurgita- 
tion and sten- 
osis 
248 
612 
29 
71 
X 
6 
Hyal., Gran., Leu- 
cocyte. 
0 
Dullness enlarged. 
Apex 5 " I. C. S. out- 
side nipple. Mitral 
systolic murmur. 
Arrhythmia. 
4 
64 
Digitalis, Potas. 
acetate. 
48 
118.00 
Double aortic, 
Double mitral, 
Hypertrophy 
and dilatation. 
590 
862 
41 
59 
Cloud. 
Hyal., Gran.. Leu- 
cocyte. 
0 
Apex, 6" I. C. S., ante- 
rior Axillary line. 
Dullness enlarged. 
0 
32 
Nux vomica. 
4 (apoplexy) 
49 
56.00 
Double aortic, 
Mitral regurgi- 
tation. 
200 
220 
48 
52 
H 
Hyal., Gran., Leu- 
cocyte. 
+ 
Heart dilated. Mur- 
murs over heart, no 
localized apex. 
4 
67 
Digitalis, strych- 
nine, nitrogly- 
cerin. 
4- 
50 
231.00 
Aortic regurgita- 
tion, Mitral 
stenosis. 
262 
367 
42 
58 
Cloud. 
Granular. 
0 
Arrhythmia. 
4 
58 
Digitalis, nitro- 
glycerin. 
Unchanged. Edmunds: Day and Night Urine. 
51 
122.01 
Mitral regurgita- 
856 
585 
59 
41 
Neg. 
0 
+ 
Heart enlarged. Mi- 
4- 
72 
Nitroglycerin. 
Improved. 
tion, Aortic 
tral and aortic sys- 
stenosis. 
tolic murmurs. 
52 
129.96 
Dilatation, athe- 
201 
284’ 
41 
59 
30 
0 
_ 
Slight dilatation of left 
4- 
62 
Nux vomica. 
roma. 
ventricle. 
53 
286 99 
Mitral regurgita- 
tion. Pleurisy 
598 
1044 
37 
63 
* 
Hyal., Gran., Waxy. 
+ 
Mitral systolic mur- 
mur. 
4 
31 
B 'k sham’s M. 
Digitalis. 
with effusion. 
54 
193.03 
Mitral regurgita- 
tion. Myocar- 
345 
410 
46 
54 
Trace. 
U u 
+ 
Apex 6" I. C. S., 1" 
0 , 
32 
Digitalis, s t r o - 
u 
outside nipple. Gal- 
phanthus. 
ditis. 
lop rhythm. Apex 1" 
sound impure. 
55 
20 97 
Anasarca, H y - 
pertrophy of 
left ventricle. 
436 
400 
52 
48 
% 
“ All kinds.” 
Marked 
Apex 6" I. C. S. Foetal 
4 
50 
Digitalis, nitro- 
4- 
rhythm. No mur- 
murs heard at first; 
later, mitral syolic. 
glycerin. 
56 
50.95 
Mitral stenosis. 
570 
515 
52 
48 
0 
0 
Trace. 
Arrhythmia. Mitral 
— 
30 
Strychnine. 
Improved, 
diastolic murmur at 
times. 
TABLE IV.—SCARLET FEVER. 
Case 31. Chronic paren. nephritis, postdiphtheritic tachy- 
cardia, partial paralysis of throat. 
10 205 : 270:: 43 ;57 Strychnine. 
10 227 : 195 :: 54: 46 Strychnine. 
12 258: 248:151:49 Strychnine stopped. 
Urine, 
Days observed. Quantity and ratio. Albumin. 
Case 15: 10 580: 5501:51149 “Negative” to “trace.” 
11 465: 6501:42: 58 “Trace” to “cloud.” 
Case 13: 10 840: 710:154; 46 “Trace.” 
10 390: 527:: 43: 57 “Trace.” 
10 357 : 655 :: 35 :65 “ Faint cloud.” 
7 750: 670:: 53 :47 “Faint cloud” to “neg.” 
Case 16: 10 895 : 580:: 61: 39 “ Trace.” 
10 567; 600:: 49: 51 “Cloud.” 
15 495: 505 :: 50: So “ Faint cloud.” 
Case 14; 10 872: 1132 :; 44: 56 “Trace.” 
10 464: 336-58142 “Trace.” 
15 410: 450:148; 52 “Trace” to “negative.” 
General improvement. 
Note.—The last ratio will be noticed as not quite so favor- 
able as the former—this has been noticed in several of the 
cases, and is probably due to the patient, as he improved, 
moving about more, which has a tendency to increase the 
nocturnal urine. 
Case 32. Chronic nephritis. 
8 425 : 564:: 43 ;57 Basham’s mixture. 
10 283 : 352 :: 45 :55 Basham’s mixture. 
12 661; 493 :: 57 :43 Basham’s mixture. 
7 594: 529:: 53 :47 Basham’s mixture. 
In thus examining these cases for the shorter 
periods we see the changes in ratio taking place 
which resulted in those given in Table 11. As the 
kidney lesion progressed, the proportion of night 
urine rose, and finally, as improvement came on 
with the disappearance of albumin, a readjust- 
ment backward toward the normal took place. In 
Case No. 14 the ratio is more irregular than in the 
others, but no explanation can be given for this. 
By studying the cases in this way we can see the 
changes caused by the disease more clearly, al- 
though, as mentioned, they are not so marked as 
we get in some other conditions. In the typhoid 
cases it was not possible to watch the changes as 
we could in the scarlet fever, because the albumin 
and casts were either present or absent in a cer- 
tain case when the urine began to be measured 
separately, and continued about the same during 
the whole course of the disease. 
Gradual improvement with few exceptions during whole 
case. See Note Case 31. 
Case 34. Chronic paren. nephritis. 
6 375 : 640:: 37: 63 Strontium lactate. 
16 605 : 1015 :: 37; 63 Strontium lactate. - 
11 500: 1015 :: 33 :67 Basham’s mixture. 
8 680: 1085 ;: 39: 61 Basham’s mixture. 
16 620: 1060 :: 37 :63 Basham’s mixture. 
Here we get very little change in ratio, only a 
slight improvement, which corresponded with 
some improvement in the general condition- 
There was a good deal of oedema present and 
much albumin in the urine when the patient went 
home. Heart examination was negative. It will 
also be noted that Basham’s mixture caused very 
little diuresis. 
Case 35. Chronic paren. nephritis. 
10 875 : 959:: 46: 54 
15 1092 : 1097:: 50 :50 Basham’s mixture. 
16 835 : 788:: 52: 48 Basham’s mixture and 
Improved. strontium bromide. 
Case 36. Chronic paren. nephritis. 
17 537: 5S8:: 49: 51 Caffeine, potass, acetate. 
18 435; 329:: 57: 43 Caffeine, potass, acetate. 
Improved. 
Case 37. Chronic paren. nephritis. 
6 897: 3511:72:28 
8 1171: 422:: 74: 26 Digitalis, 
n 1118: 373 :: 75: 25 Digitalis. 
8 828: 350:: 71:29 Digitalis. See Note 
Improved. Case 31. 
(This case was discussed in detail earlier in the paper.) 
From Table HI we give the following cases; 
Case 25. Chronic parenchymatous nephritis with acute 
exacerbations. 
Days. Urine. Medication. Result: 
5 1080; 1190:: 48: 52 Nitroglycerin Improved. 
5 830: 740;: S3 :47 and digitalis. 
Case 29. Chronic nephritis, anaemia, epilepsy. 
7 575 : 565 :: 50: So Potas. acetate. 
6 595 : 660:: 48: 52 Potas. acetate. 
Case 40. Chronic interstitial nephritis, atheroma. 
2 250: 500:: 33 :67 Digitalis and nitroglycerin. 
4 530; 520:: 50; 50 Diuretin and nitroglycerin. 
5 39°: 4TS :: 48 :52 Digitalis and nitroglycerin. 
6 500: 633 :: 36: 64 Digitalis and nitroglycerin. 
7 850: 890:: 49: 51 Diuretin and nitroglycerin. 
9 630: 610:: 52: 48 Strychnine. 
6 445: 425 :: 51 :49 Strychnine. 
6 220: 265 :: 45 :55 Strychnine. 
Died. 
Result; General condition improved, but there 
was more albumin in urine at end than at the be- 
ginning of the observations. Edmunds: Day and Night Urine. 
7 
This case shows the changes caused by medica- 
tion very well. When the patient entered the 
hospital he was placed on digitalis and nitro- 
glycerin and kept on these about two weeks; his 
ratio was 33 :67 at the end of this period. Under 
diuretin the day urine was most markedly in- 
creased and the ratio became 50: 50. When 
diuretin was stopped, the proportion of day urine 
fell gradually to practically the same point at 
which it was when the patient entered. Under a 
second course of diuretin it came back to 49: 51, 
and remained there for a week after the drug was 
stopped and strychnine substituted, after which 
the night proportion rose gradually and the day 
proportion fell until death occurred. This illus- 
trates the action of diuretics like diuretin, which 
act rapidly and, when administered only during 
the day time, as is commonly done, increase the 
day urine most markedly. 
Case 55. Arteriosclerosis, contracted kidney, hypertrophy 
of left ventricle, anasarca, nephritis. 
6 334: 397:: 46: 54 Digitalis. 
6 449: 385 :: 54: 46 Digitalis. 
S 764: 527; 159: 41 Digitalis. 
2 550: 450:: 61: 49 Digitalis. 
Died. 
This case is one which does not follow the rule 
as laid down by the previous cases. The patient 
gave a history of obscure symptoms on the part 
of the liver, pain in that region, and occasional 
jaundice for over eleven years. There was irregu- 
larity of the heart, with swelling of the legs and 
abdomen, for two years, so that he could not work 
for some months. Five months before his en- 
trance to hospital he became short of breath and 
thinks he was jaundiced- Four months before 
entrance, he had pain in the back and frequent 
micturition, especially at night, swelling of the 
legs, etc. Examination at hospital showed “No 
cyanosis or jaundice, large amount of oedema in 
back and below wrist; Cheyne-Stokes respiration, 
heart dilated, no murmurs heard; foetal rhythm; 
liver and spleen enlarged.” As is shown in the 
table, the ratio improved during his entire stay 
in the hospital, and so apparently did the patient 
until a few days before the end. The oedema 
grew softer and the heart became stronger, so 
that a loud systolic murmur was heard at the 
apex. While, however, the urinary ratio con- 
tinued to improve, the patient took a turn for the 
worse, cyanosis increased, Cheyne-Stokes respir- 
ation reappeared, the heart dilated, and the pa- 
tient died about a week later. Why this change 
was not reflected in the urinary condition cannot 
be stated, and this one case stands alone in the 
whole number as an apparent exception. 
Case 45. Mitral regurgitation, arteriosclerosis, chronic ne- 
phritis. 
S 550: 730:: 43 :57 Diuretin, digitalis, nitro- 
glycerin. 
10 600: 730:: 45 :55 Diuretin, digitalis, nitro- 
glycerin. 
4 433 : 580:: 43 :57 Diuretin, digitalis, nitro- 
glycerin. 
Result; During first two periods there was im- 
provement. During the last period the patient 
was much worse; he was unable to lie down and 
there was marked cardiac arrhythmia. By some 
error the separation of urine in the case was 
stopped at this point. As will be seen, with the 
change for the worse in the condition came also 
a less favorable ratio. The patient died two 
weeks later. 
Case 46. Mitral regurgitation, ascites, chronic nephritis. 
8 310: 365;'.54: 46 Helleborein. 
8 335 : 135 :: 71: 29 Helleborein. 
Improved. 
From a study of these observations we can con- 
clude, as mentioned before, that the changes in a 
certain case from or toward the normal ratio are 
but expressions of the changes which take place 
in the patient’s renal or cardiac condition, and 
therefore they can be used as an index to his 
progress. Certowitch noted this fact in one of 
his cases. 
Case 50. Aortic regurgitation, mitral stenosis, chronic in- 
sterstitial nephritis, enlarged spleen. 
7 254; 475 ;; 35 :65 Digitalis and nitroglyc- 
erin. 
7 310; 364:; 46: 54 Digitalis and nitroglyc- 
erin. 
9 231: 264:147:53 Digitalis and nitroglyc- 
• erin. 
Improvement in ratio, but not in general condition. 
To make a brief summary of the results ob- 
tained in this study, I would (1) confirm the 
earlier writers’ views as to the nocturnal polyuria 
occurring in renal and cardiac disease. (2) Point 
out the value of this fact as a diagnostic sign, 
especially in cardiac disease. 
Case 51. Mitral regurgitation, arteriosclerosis, chronic in- 
terstitial nephritis. 
5 680; 490:; 58: 42 N itroglycerin. 
5 1120: 825:: 58142 Nitroglycerin. 
7 796: 410:166:34 Nitroglycerin. 
Improved. 
Case 54. Mitral regurgitation, myocarditis, chronic paren- 
chymatous nephritis, chronic gastritis. 
5 240; 570:; 30; 70 Digitalis. 
6 445: 455 ■•■•49; 51 Digitalis and strych- 
nine. 
9 320: 403:; 44-.56 Strophanthus and 
strychnine. 
8 310: 340:148:52 Strophanthus and 
strychnine. 
Improved. 
I would add (i) the possibility of tracing the 
course of a nephritis or of a cardiac disease by 
observing the changes in the relative amounts of 
day and night urine for short periods of time, and 
(2) when drugs which cause diuresis' are admin- 
istered during the day they tend to restore the 
normal ratio. Che new Vork medical Journal 
and Philadelphia medical Journal 
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