Starling and the Concept of Heart Failure

ERNEST HENRY STARLING has probably contributed more than any man to our understanding of heart failure. Thus his early experiments on edema formation and his assessment of the factors concerned have formed the basis for all subsequent work on this subject. His work with Patterson and Piper1 2 on the mechanical factors involved in the response of the heart to changes in load have formed the basis for our understanding of how the heart's work as a pump is adjusted to the varying demands made upon it, and have incidentally provided the key to our understanding of heart failure as seen in man. Nevertheless, in the course of time what Starling and his colleagues actually observed, and what they deduced from these observations that was relevant to heart failure, have become somewhat obscured. And since it would seem to the writer that Starling's concept of the nature of heart failure was closely in accord with what actually happens in man, it seems right to present some extracts from the original papers so that cardiologists, whether practitioners or investigators, may be more fully informed than they are. It is to be remembered that Starling was a physiologist, and that though undoubtedly he received much inspiration from human disease, he was more interested in basic mechanism than in the interpretation of morbid phenomena. Hence in his "ljinaere Lecture on the ljaw of the Heart,"3 and in his text book of physiology, it is the relationship between initial length of muscle fiber and the tension developed during contraction that is the center of his interest. Perhaps it is because modern investigators have been more closely acquainted with these works than with the originals that bas led to some of Starling's conclusions, which are most relevant to heart failure, being overlooked.