ON THE
BY
ERNEST H. STARLING
M.D., Sc.D. (Cambridge and Dublin), F.R.C.P., F.R.S.
THE LINACRE L EC TU R E
ON
LAW OF T H E HEART
G I V E N A T C A M B R ID G E , 1915
BY
E R N E ST H. STARLING
M .D ., Sc.D. ( C a m b r i d g e a n d D u b l i n ) , F.R.C.P., F.R.S.
W IT H D I A G R A M S
1918
T H E LAW O F T H E H EART.
h a s sh o w n th a t in th e n o rm a l in d iv id u al a t re s t th e left v e n tric le
p u m p s o u t a b o u t 3 litre s o f b lo o d p e r m in u te. D u rin g m o d e ra te
m u sc u la r ex e rc ise th is q u a n tity m a y rise to 12 litres, o r in an
a th le tic in d iv id u a l u n d e r ta k in g v e ry h a rd w o rk to as m u c h as
21 litre s p e r m in u te. T h is la st figure m e a n s th a t th e h e a rt can
p u m p th e to ta l b lo o d c o n ta in e d in th e b o d y ro u n d th e w h o le
c irc u la to ry sy ste m six o r seven tim e s in th e co u rse o f a m in u te ,
a n d th is in sp ite o f th e fact th a t d u rin g m u sc u la r e x e rc ise th e
a rte ria l p re ssu re a g a in st w hich th e h e a rt h as to w o rk is c o n s id e r
a b ly h ig h e r th a n in c o n d itio n s o f rest, b e in g e q u iv a le n t in th e
la tte r ca se to a b o u t n o m m . H g . a n d in th e fo rm er to 150
to 160 m m . H g .
A sim ila r p o w er o f a d a p ta tio n is sh o w n in cases o f d ise ase .
W e can im ita te th e d ise a se d c o n d itio n e x p e r im e n ta lly b y d e
s tro y in g a n a o rtic valve, so th a t th e a n im a l su ffers from a o rtic
re g u rg ita tio n , o r b y d im in ish in g th e lu m en o f th e a o rta b y m e an s
o f a lig a tu re , so a s to p ro d u c e artificial a o rtic ste n o sis. T h e
a v e ra g e a rte ria l p re ssu re u n d e rg o e s n o a lte ra tio n as a re s u lt of
e ith e r o f th e se p ro c e d u re s, a lth o u g h th e le ft v e n tric le h a s to p e r
form tw o o r th re e tim e s as m u c h w o rk as it d id b efo re in o rd e r
to m a in ta in th e b lo o d p re ssu re a t its p rev io u s level. T h e circu
la tio n o f b lo o d th ro u g h th e b o d y re m a in s th e re fo re unaffected.
T h is a d a p ta tio n o f th e h e a r t to v a ria tio n s in th e d e m a n d m a d e
u p o n it o ccu rs e q u a lly w ell a fte r to ta l d e s tru c tio n o f th e n erv e s
c o n n e c tin g th e h e a r t w ith the' c e n tra l n e rv o u s sy stem . So we
m u s t c o n c lu d e th a t th e g o v e rn o r m e ch a n ism , in v irtu e o f w h ic h
th e h e a rt is a b le to d o m o re o r less w o rk , a c c o rd in g to th e
a m o u n t o f b lo o d w hich h a s to be s e n t on a n d th e re sis ta n c e to
th e flow p re s e n te d b y th e a rte ria l p ressu re, m u s t b e s itu a te d in
th e w alls o f th e h e a r t its e lf an d p re su m a b ly in th e m u sc le fib res
o f w h ich th e s e a re com p o sed . I t is th e n a tu re o f th is m e c h a n ism
w h ich I w ish to d iscu ss w ith y o u to-d ay .
I n o rd e r to ' in v e stig a te it w e m u s t b e a b le in th e iso la te d
h e a r t to c o n tro l e x a c tly all th e m e c h a n ic a l c o n d itio n s o f th e
h e a r t, e.g. volu m e, p ressu re, a n d te m p e ra tu re o f e n te rin g b lo o d ,
a n d th e re sis ta n c e to th e outflow offered b y th e a rte ria l re sist
6 TH E L IN A C R E L E C T U R E
th a t th e re is n o d a m m in g u p o f th e b lo o d o n th e v en o u s sid e
n o r failure o f th e h e a rt to send th e b lo o d o n from th e v en o u s to
th e a rte ria l side. In th is case also th e r e m a y b e so m e in c re a se
o f c o ro n a ry flow, w h ich is n o t h o w ev e r so m a rk e d as w h en
w e th ro w m o re w o rk o n th e h e a r t b y in c re asin g th e a rte ria l
resistan ce.
D o e s th is a u to m a tic a d a p ta tio n o f th e w o rk o f th e h e a r t to
th e d e m a n d s m a d e u p o n th is o rg a n m e a n th a t a g r e a te r p ro p o r
tio n o f th e chem ical en e rg y o f th e c o n tra c tin g m u scle is tr a n s
form ed in to m ech an ical en e rg y , o r d o es th e h e a r t m u sc le a c tu a lly
se t free m o re e n e rg y w h en its w o rk is in c re a se d ? T h is q u e stio n
h as b een an sw e re d b y L o v a tt E v an s. J u s t as th e r e s p ira to ry e x
c h a n g e s o f th e w hole b ody, viz. th e in ta k e o f o x y g e n a n d th e
o u tp u t o f ca rb o n ic acid, m a y b e u se d as a m e a su re o f th e ch em ical
ch an g es, a n d o f th e to ta l e n e rg y se t free in th e b o d y , so th e re
s p ira to ry e x c h a n g e s o f th e h e a r t m a y be u tilize d for d e te rm in in g
th e to ta l e n e rg y se t free in th is o rgan. In th e h e a rt-lu n g p re p a ra
tio n th e re s p ira to ry m e ta b o lism o f th e h e a rt c a n b e in v e stig a te d b y
m e a su rin g th e o x y g e n ta k e n u p from th e lungs, a n d th e c a rb o n ic
acid g iv e n o u t b y th e lu n g s. W h e n w e d o th is w e find th a t a n y
in c re ase in th e w o rk o f th e h e a rt, h o w ev e r cau sed , w h e th e r b y a
rise in th e a rte ria l p re ssu re o r b y a m o re ra p id v en o u s inflow, is
a tte n d e d b y a c o rre sp o n d in g a u g m e n ta tio n o f th e to ta l ch em ical
changes. T h is is sh o w n in th e follow ing ta b le s :
EXP. I . A R T E R IA L R E S IS T A N C E V A R IE D . IN F L O W C O N S T A N T .
H eart, 57 gm s.
130 8 371 60
* I have recently found that in these experiments both the work done and the
mechanical efficiency were underestimated. In exp. 2 (p. 11) the mechanical effi
ciency w ith an inflow of 62 litres per hour was probably about 25 per cent, and the
other figures must be increased in proportion.
T H E L A W O F TH E H E A R T 11
EXP. 2. A R T E R IA L R E S IS T A N C E C O N S T A N T . V E N O U S IN F L O W
V A R IE D . , .
H e a rt, 53 g m .
62 331 + 86 9 70 60
In these tables the oxygen consumption serves as an index o f the total chemical
changes and o f the chemical energy set free. T his may be measured in calories,
and compared w ith the total work done by the heart in the same time, the result
being the mechanical efficiency o f the heart as a machine.
The work o f the heart in kilogrammetres was determined by m ultiplying the
output per hour by the average arterial pressure (in metres o f blood).
In the first experiment the work o f the heart was varied by altering the arterial
resistance, in the second by altering the venous inflow.
A.P. = arterial pressure. V.P. = venous pressure.
The heart volume is measured from an arbitrary base line, viz. the volume at
the beginning o f the experiment. Note the marked enlargement o f the heart which
attends increase in venous inflow.
W e th u s find th a t th e h e a r t h a s a m a rv e llo u s p o w e r o f a d
ju s tin g n o t o n ly its o u tp u t o f m e ch a n ica l e n e rg y b u t also its to ta l
e n e rg y c h a n g e s to th e w o rk w h ich is im p o sed u p o n it b y th e
m e ch a n ica l c o n d itio n s o f th e c irc u la tio n . In m u sc u la r ex e rc ise
fo r in sta n c e , w h en th e inflow o f b lo o d in to th e la rg e v ein s is
in c re a se d b y th e p u m p in g a c tio n o f th e m uscles a n d th e a rte ria l
p re ssu re is raise d b y th e c o n tra c tio n o f th e sm all a rte rie s g o in g to
th e a lim e n ta ry ca n al, th e h e a rt picks u p all th e b lo o d w hich co m es
to it a n d se n d s it o n w ith in c re a se d force in to th e a rte ria l sy stem ,
w h en c e it ca n be d is trib u te d in ric h m e a su re to th e c o n tra c tin g
m u sc le s ; so th a t, as K ro g h has show n, its o u tp u t p e r m in u te m a y
rise from 3 litre s to th e e n o rm o u s fig u re o f 21 litres. W e m ay
form so m e id e a o f th e p ro cesses in v o lv ed in th is a d a p ta tio n b y
c o m p a rin g th e h e a r t to a m o to r cycle. H e r e also th e e n e rg y is
d e riv e d from th e o x id a tio n o f c e rta in co m b u stib le su b stan ce s, in
th is case p e tro l sp irit. W h e n o n ce a d ju ste d th e m o to r cy c le w ill
12 TH E L IN A C R E L E C T U R E
Fm. 3. Effect o f alteration in venous supply on volume o f heart. (Read from left
to right.)
Dog, 5*15 kilos; heart, 67 gms.
O .P. per
O .P. per beat
A.R. B.P. V .P. Rate. O .P . beat calc. observed.
A. 100 124 95 22 86 3'9 57
B. 100 130 145 22 140 6-4 8-0
C. 100 122 55 22 33 1-5 2-5
N ow h e re a re tw o co n d itio n s in w hich th e w o rk o f th e h e a rt
is increased a n d in w h ich th is o rg a n a d a p ts its e lf b y in c re a sin g
th e chem ical c h a n g e s in its m u scle a t ea c h c o n tra c tio n to th e in
cre ase d d e m a n d s m a d e u p o n it. I t is e v id e n t th a t th e re is o n e
fa c to r w hich is co m m o n to b o th cases, a n d th a t is th e in c re ase d
i8 TH E L IN A C R E L E C T U R E
v o lu m e o f th e h e a rt w hen it b eg in s to c o n tra c t. S o th a t w e m a y
m ak e th e follow ing g e n e ra l sta te m e n t. W it h in p h y s io lo g ic a l
lim its th e la r g e r th e v o lu m e o f th e h ea rt, th e g r e a t e r a re th e
e n e r g y o f it s co n tr a c tio n an d t h e a m o u n t o f c h e m ic a l c h a n g e
a t ea c h co n tra c tio n .
40
F i g . 6. Diagram showing relation between fillin g , in itia l tension, and final tension
in a heart contracting isom etrically (abscissa = volume o f heart contents,
[T"_ ordinates = intracardiac pressure in mm. Hg).
h e a r t is in c re a se d th e re is a c o rre sp o n d in g rise in th e h e ig h t
of th e p ressu re d e v e lo p e d d u rin g c o n tra c tio n . I t w as fo rm e rly
t h o u g h t o n th e b asis o f F r a n k s e x p e rim e n ts th a t th e e sse n tia l
fa c to r d e te rm in in g th e s tre n g th o f c o n tra c tio n o f th e card iac m u scle
-was th e te n sio n it w as u n d e r a t th e b e g in n in g o f th e c o n tra c tio n .
I t w ill be o b se rv e d , how ever, from th is d ia g ra m th a t th e rise o f
diastolic te n sio n is a t first n eg lig ib le a n d th a t as soon as th e
p re s s u re w ith in th e v e n tric le d u rin g d ia sto le b e g in s to in c re a se
thus serves to measure the amount o f tension produced in the heart muscle at each
contraction. The arrangement o f the experiment is shown in the diagram (fig. 4)
a nd the actual record o f a series o f contractions w ith different fillin g is given in fig. 5.
20 THE L INACRE LECTU RE
a p p re c ia b ly , so as to ca u se a passiv e s tre tc h in g o f th e m u s c le
fibres, th e a b s o lu te te n sio n d e v e lo p e d d u rin g c o n tra c tio n rise s
v ery little m o re o r m a y even fall. T h e r e ca n b e n o q u e s tio n
th erefo re th a t it is th e v o lu m e o f th e v e n tric le s a t th e b e g in n in g
o f co n tra c tio n ra th e r th a n th e p re ssu re w ith in th e ir c a v itie s,
w hich d e te rm in e s th e a m o u n t o f e n e rg y se t free d u rin g th e c o n
tractio n . T h is free en e rg y d isp la y s its e lf as c o n tra c tile stress*
a n d causes a rise o f p ressu re w ith in th e c a v ity o f th e v en tricle.
Pressure
30 60 90 120 150 180 210 240 270 ^ , H # .
* ------------- ------------ '--------------------------- 0
<
o 30-
c
3n>
F i g . 7 . See
text. The abscissae represent pressure in m m . Hg, and the ordinates
measured from above the capacity of the ventricles. The left-hand curve re
presents the condition of the heart during diastole. The right-hand curve
that during systole.
i
fO
o
>
u.
0
T
>-
1ca
3
o
3
Ci
a.
F ig .
8. Curve showing the relation o f tension, in itia l length, and energy evolved
in an isometric tw itch. (Note the resemblance o f this curve to that o f the
heart in fig. 6.)
A , Condition o f maximum shortening.
B, Condition o f maximum extension of muscle in its normal relationships in the body.
P R IN T E D IN GR EAT B R IT A IN BY T H E U N IV E R S IT Y P R E S S , A B ER D EEN .