Volume 3 Issue 5 - 2020
Goodbye Starling's Law, Hello G Tube
Ahmed N Ghanem*
Consultant Urological Surgeon, Faculty of Medicine, Mansoura University, Egypt
*Corresponding Author: Ahmed N Ghanem, Consultant Urological Surgeon, Faculty of Medicine, Mansoura University, Egypt.
Received: March 18, 2020; Published: April 15, 2020

Substantial physics and physiological evidence with clinical relevance and significance currently exists that affirms Starling’s law is wrong [1]. Starling [2] based his hypothesis on Poiseuille’s work of uniform diameter tube [3] in which the hydrostatic pressure causes filtration, and the oncotic pressure force of plasma albumin causes re-absorption [4]. Recent evidence demonstrates Starling’s law is wrong on both oncotic [5-10] and hydrostatic pressure [11] forces and provides the correct replacement of hydrodynamic of the porous orifice G tube [1] (Figure 1).


  1. Ghanem AN. “The Correct Replacement for the Wrong Starling’s law is the Hydrodynamic of the Porous Orifice (G) Tube: The Complete Physics and physiological Evidence with Clinical Relevance and Significance”. Cardiology: Open Access Cardio Open1 (2020): 7.
  2. Starling EH. “Factors involved in the causation of dropsy”. Lancet (1886): 1266-1270.
  3. Folkow B and Neil E. “Circulation”. Oxford University Press: London (1971): 1-125.
  4. Keele CA., et al. “Sampson Wright Applied Physiology”. 13th Oxford University Press Oxford (1982).
  5. Karnovesky MJ. “The ultra-structural basis of capillary permeability studied with peroxidase as a tracer”. Journal of Cell Biology 35 (1967): 213-236.
  6. Hendry EB. “The osmotic pressure and chemical composition of human body fluids”. Clinical Chemistry3 (1962): 246-265.
  7. Cochrane Injuries Group. “Human albumin administration in the critically ill patients: systemic review of randomized controlled trials: Why albumin may not work”. British Medical Journal 317 (1998): 235-240.
  8. Finfer S. “Effect of baseline serum albumin concentration on outcome of resuscitation with albumin or saline in patients in intensive care units: analysis of data from the saline versus albumin fluid evaluation (SAFE) study”. British Medical Journal 333 (2006): 1044-1046.
  9. Vincent JL. Editorial. “Resuscitation using albumin in critically ill patients: Research in patients at high risk of complications is now needed”. British Medical Journal 333 (2006): 1029-1030.
  10. Futier E., et al. “Effect of Hydroxyethyl Starch vs Saline for Volume Replacement Therapy on Death or Postoperative Complications Among High-Risk Patients Undergoing Major Abdominal Surgery: The FLASH Randomized Clinical Trial”. The Journal of the American Medical Association3 (2020): 225-236.
  11. Ghanem AN. “Magnetic field-like fluid circulation of a porous orifice tube and relevance to the capillary-interstitial fluid circulation: Preliminary report”. Medical Hypotheses3 (2001): 325- 334.
  12. Rhodin JA. “Theultra-structure of mammalian arterioles and pre-capillary sphincters”. Journal of Ultrastructure and Molecular Structure 18 (1967): 181-222.
  13. Guyton AC and Coleman TG. “Regulation of interstitial fluid volume and pressure”. Annals New York Academy of Sciences 150 (1968): 537-547.
  14. Calnan JS., et al. “Lymphatic surgery”. Journal of the Royal Society of Medicine 65 (1972): 715-719.
  15. Renkin EM. “Some consequences of capillary permeability to macromolecules: Starling’s hypothesis reconsidered”. American Journal of Physiology 19 (1986): H706-H710.
  16. Ghanem KA and Ghanem AN. “The proof and reasons that Starling’s law for the capillary- interstitial fluid transfer is wrong, advancing the hydrodynamics of a porous orifice (G) tube as the real mechanism”. Blood, Heart and Circulation 1 (2017): 1-7.
  17. Ghanem KA and Ghanem AN. “The Physiological Proof that Starling’s Law for the Capillary-Interstitial Fluid Transfer is wrong: Advancing the Porous Orifice (G) Tube Phenomenon as Replacement”. Open Acc Res Anatomy2 (2017).
  18. Ghanem AN. “The Adult Respiratory Distress Syndrome: Volumetric Overload Shocks in Patho-Etiology Correcting Errors and Misconceptions on Fluid Therapy, Vascular and Capillary Physiology”. Surgical Medicine Open Access Journal 2 (2).
  19. Ghanem AN. “What are Misleading Physicians into giving too much Fluid During Resuscitation of Shock and Surgery that Induces ARDS and/or AKI?” Asploro Journal of Biomedical and Clinical Case Reports (2020).
  20. Woodcock TE and Woodcock TM. “Revised Starling equation and the glycocalyx model of trans-vascular fluid exchange: an improved paradigm for prescribing intravenous fluid therapy”. British Journal of Anaesthesia 3 (2013): 384-394.
  21. Ghanem AN and Ghanem SA. “Volumetric Overload Shocks: Why Is Starling’s Law for Capillary Interstitial Fluid Transfer Wrong? The Hydrodynamics of a Porous Orifice Tube as Alternative”. Surgical Science 7 (2016): 245-249.
  22. Pindoria N., et al. “Volumetric overload shocks in the patho-etiology of the transurethral resection prostatectomy syndrome and acute dilution hyponatraemia”. Integrative Molecular Medicine (2017).
  23. Ghanem KA and Ghanem AN. “Volumetric overload shocks in the patho-etiology of the transurethral resection prostatectomy syndrome and acute dilution hyponatraemia: The clinical evidence based on 23 case series”. Basic Research Journal of Medicine and Clinical Sciences 4 (2017).
  24. Ghanem SA., et al. “Volumetric Overload Shocks in the Patho-Etiology of the Transurethral Resection of the Prostate (TURP) Syndrome and Acute Dilution Hyponatraemia: The Clinical Evidence Based on Prospective Clinical Study of 100 Consecutive TURP Patients”. Surgical Medicine Open Access Journal 1 (2017) 1-7.
  25. Ghanem AN. “Volumetric overload shocks (VOS) causing the acute respiratory distress syndrome (ARDS): The Complete Evidence”. EC Emergency Medicine and Critical Care2 (2020): 01-08.
  26. Ghanem AN and Ward JP. “Osmotic and metabolic sequelae of volumetric overload in relation to the TURP syndrome”. British Journal of Urology 66 (1990): 71-78.
  27. Essayed Yasmina Saad., et al. “Volumetric Overload Shocks (VOS) Resolving the Puzzle of the Transurethral Resection of the Prostate (TURP) Syndrome, Dilution Hyponatraemia (HN) and the Acute Respiratory Distress Syndrome (ARDS): The Minority Report!”. EC Cardiology2 (2019): 109-122.
  28. Ghanem AN. “Complication of Fluid Therapy Causing the Acute Respiratory Distress Syndrome: Facts and Comments. The Role of Volumetric Overload Shocks in Patho-aetiology”. Archives of Urology1 (2019): 21-31.
  29. Ashbaugh DG., et al. “Acute respiratory distress in adults”. Lancet (1967): 319-323.
  30. Schrier RW. “Fluid administration in critically ill patients with acute kidney injury”. Clinical Journal of the American Society of Nephrology 4 (2010): 733-739.
  31. Jones DG., et al. “Crystalloid resuscitation in trauma patients: deleterious effect of 5L or more in the first 24h”. BMC Surgery 1 (2018): 93.
  32. Ghanem AN. “Does Raising the Central Venous Pressure (CVP) in Treating Shock with Fluids Induce Volumetric Overload Shocks (VOS)?”. Advanced Card Research5 (2019).
  33. Ghanem AN. “Volumetric Overload Shocks: Book. Resolving the puzzles of the transurethral resection of the prostate (TURP) syndrome, acute dilution hyponatraemia (HN) and the acute respiratory distress syndrome (ARDS)”. Scholars Press USA (2018).
  34. Volumetric overload shocks (VOS) cause ARDS: The plenary evidence on patho-aetiology and therapy. Constructing the BRIDGE between physics, physiology, biochemistry and clinical medicine (2020).
Citation: Ahmed N Ghanem. “Goodbye Starling's Law, Hello G Tube”. EC Clinical and Experimental Anatomy 3.5 (2020): 41-44.

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