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This report was commissioned by the National Institute for Health Research Health Technology Assessment programme on behalf of NICE as project number HTA 10/128/01.

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Long-term studies of sodium balance were made in three patients with congestive failure. The data indicate exchange of water and sodium between the intracellular and extracellular spaces. They suggest that a portion of the intracellular cation exists in a form which is not osmotically active. The term "quantometer" is applied to the previously described intracranial volume-regulating mechanism. An hypothesis is offered in which it is assumed that exhaustion of this quantometer may contribute to the retention of sodium as heart failure becomes manifest.T HE starting point of the reports from this laboratory'-7 was the desire to investigate the concept of a central homeostatic mechanism concerned with sodium retention as a means of protecting the body against various types of circulatory failure.With the exception of two reports6' 7 these studies have been limited to normal subjects and are not, therefore, directly applicable to patients with cardiac failure, or to such problems as the importance of the orthopneic position in relation to edema formation. The observations reported thus far seem to indicate that a central homeostatic mechanism concerned with sodium exchange does exist, and that this mechanism is brought into play not by a decline in cardiac output or alteration of renal hemodynamics, but rather by alterations in the renal tubular activity initiated by a change in the distribution and volume of body fluids. Since the results of the data recently collected from studies on patients with congestive failure6' 7 indicate that this homeostatic mechanism is greatly impaired or is inoperative in congestive failure, it seemed advisable to observe patients with congestive failure for longer periods of time. It was hoped that a clearer concept of the role of this homeostatic mechanism in the formation of edema in cardiac failure would emerge. The present report is concerned with the long-range observations of the sodium exchange in three patients with chronic congestive heart failure. METHODSThe observations reported here were made on three patients with congestive heart failure due to rheumatic mitral stenosis (A.S.), senile heart disease (J.T.), and cor pulmonale with senile heart disease (J.M.). All were able to deliver urine with a maximum specific gravity of 1.025 or higher. The clinical course of each patient was followed by frequent determinations of venous pressure, circulation time, vital capacity, and blood pressure. Dietary sodium was calculated from weighed diets.8* Water intake (distilled water), urine volumes and body weight were recorded daily.Serum and urine analyses for sodium were made with a Beckman DU model photometer, utilizing an oxyacetylene type flame.Calculations were based on the assumption that daily weight changes represented changes in extracellular water, that is, edema fluid. Calculations 1. Extracellular sodium concentrations [(NaEcF)] were considered to be 0.95 X serum concentration.2. Changes in extracellular sodium (ANaEcF) equalled change in body weight (Awt.) X extracellu...

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