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Salt-poor human albumin (25 g/dl) is a safe and effective colloid for increasing intravascular volume. It is usually given together with saline solutions at a final concentration of 5 g albumin per 100 ml infusion volume. Although relatively nontoxic, albumin costs about $120 per liter, more than ten times the cost of artificial macromolecular colloids used as "plasma substitutes". Hydroxyethyl starch (6 g/dl NaCl) is a new polysaccharide volemic colloid similar in effect to dextran-70; 70% of an infused volume remains intravascular at 3 hours and 30% at 24 hours. It is nonallergenic, causes no anaphylactoid reactions, and interferes with coagulation less than dextran-70 or dextran-40. Bleeding may be observed when doses of more than 1500 ml are given without blood replacement, especially in thrombocytopenic patients. The effects of dextran-70 and dextran-40 on inhibiting thrombogenesis and facilitating blood flow in small vessels are due largely to hemodilution; the relative efficacy of hydroxyethyl starch for these purposes has not yet been established. Hydroxyethyl starch is a safe and effective colloidal solution for replacement of lost blood and augmentation of blood volume.

Clinical features, pathophysiology, pathology and therapy of secondary drowning are described. This is a little-known complication of drowning accidents which needs intensive therapy, since it is often lethal.

Substitutes for whole blood include blood fractions such as plasma, serum albumin and other fluids of various kinds which are not derived from blood but are used as plasma volume expanders; these, include the usual crystaloid intravenous solutions. Since in comparison to blood far more of these later solutions are given intravenously, a thorough knowledge of plasma volume expanders is essential. The first use of such expanders in human patients was by Hogan in 1915. He used colloidal gelatin and noted an improvement in blood pressure in shock. In 1945, Gronwall and Ingelman advocated the use of dextran in shock. The reguirements for an acceptable plasma substitute are: a satisfactory colloidal osmotic pressure, constand composition at reasonable cost, a viscosity suitable for intravenous administration, stability in prolonged storage at variable temperatures, and sterilization by autoclaving. Such substances must be either fully excreted or metabolized, and must cause no early or late tissue damage. They must be non-antigenic and pyrogen free. They must cause no change in the blood such as haemolysis, R.B.C. agglutination, increased sedimentation rate and no impairment of haemostasis. The presently available plasma expanders include blood derivatives (plasma, albumin), modified protein (gelatin, oxypolygelatin), polymerized carbohydrates (dextran) and plastics (polyvinyl pyrrolidone-PVP). All these substances expand plasma volume, decrease haematocrit and plasma proteins, increase sedimentation rate and blood pressure. Dextran, PVP and geletin do not alter hepatic function. Dextran and gelatin have no deleterious effects on renal function. Features of the clinically used plasma expanders are: 1. Fresh Frozen Plasma Fresh frozen plasma contains all clotting factors except platelets. The risk of the transmission of hepatitis is present as it is with whole blood. 2. Plasma Protein Fractions Plasma protein fractions are free of hepatitis virus, but may cause arteriolar dilatation and hypotension. 3. Serum Albumin Serum albumin is a concentrated blood protein fraction. It is salt poor, stable and does not transmit the virus of hepatitis. Since it has a high oncotic pressure it is necessary to give significant quantities of clear fluids with it. It is expensive, scarce, and dilutes the clotting factors. It is, however, a first choice for emergency treatment of shock; 4. Dextran The dextrans may be of medium or low molecular weight. They are inexpensive and readily available, and do not transmit the virus of hepatitis. In large amounts they cause a coagulation defect and may be antigenic. Continued.

To determine the effect of fragmentation on potency of immune globulin preparations, two comparisons were carried out. In one study, the immune globulin was derived from American plasma; in the other, the source was Israeli plasma. In each of the two studies, three materials were given to household contacts of icteric hepatitis: (1) human albumin as a placebo; (2) immune globulin with the IgG intact; and (3) immune globulin of the same lot with the IgG deliberately fragmented by added fibrinolysin. Comparable reductions in secondary attack rates were achieved with fragmented and unfragmented materials from both lots. Fragmentation, therefore, had no deleterious effect. In addition, it was found that American globulin is comparable to Israeli globulin for protection against strains of Type A hepatitis prevalent in Israel. Administration in the second half (last 15 days) of the incubation period did not reduce the frequency of icteric disease.

Hyperstimulation appeared in one case on the 10th 11th day after ovulation, allowing by its presence the very precocious diagnosis of successful fecondation. The study of blood coagulation revealed that hypercoagulability was mainly related to hyperactivity of the thrombocytes and of the coagulation proteins. The pathogenesis of the syndrome is discussed. Increase in the permeability of the capillary vessels and hypovolemia seem to be responsible for the main accidents. Unfortunately as we have no real mean of decreasing the permeability of the capillary vessels, the treatment can be directed only against hypovolemia and its results. The infusion of macromolecular fluids, the restriction of sodium and water intake, together with the prescription of spironolactone have been successfully employed in those three cases.

Utilization of packed red blood cells (PRBC) and plasma components individually or in combination allows replacement of the precise blood element needed, while avoiding some of the potential hazards of whole blood transfusions. Transfusion of PRBC, rather than whole blood, reduces the risk of circulatory overload and nonhemolytic transfusion reactions. Frozen PRBC essentially eliminate leukocyte or platelet sensitization and transmission of hepatitis is extremely rare.

1. During thoracic duct drainage a significant decrease of serum beta- and gammaglobulins can be found. 2. The withdrawn lymphprotein can be sufficiently substituted by human serum albumin. 3. The number of small lymphocytes decreases significantly during thoracic duct drainage, while the number of large lymphocytes and lymphoid cells increases. 4. The drainage of thoracic duct in humans is a highly immuno-suppressive procedure without major risks.