Experimental Research on the Hemostyptic Effect: In a series of studies we sought to find the mechanism by which butanol controls hemorrhage. In an investigation carried out in our laboratory, M. Bier and P. Teitel baum (194) showed that individual members of the homologous series of aliphatic alcohols decrease the degree of retraction of clots when added in vitro to blood. (Figs. 141 to 143) By varying the amounts added, this effect was observed to occur only at values above a critical concentration of the alcohol in blood. Bier could show that the critical value, which differs for members of the homologous series, is proportional to the lethal toxic dose in mice.

This non retraction of clots in vitro also can be recognized in cases treated with butanol through the gelatinous aspect of the clots at the moment when the hemorrhage stops. However, it is interesting to note that the amount of butanol injected, considered in terms of the amount of the circulating blood, results in concentrations considerably below the critical values needed to produce this effect in vitro. However, concentration of butanol at the site of the wound may explain this. It is also of interest that the same gelatinous character typifies the clots which remain attached to bleeding lesions in animals treated with butanol. In mice, when a portion of tail was cut and butanol was used, the abnormally long clot remained adherent to the wound, differing from that seen in controls.

In spite of changes in the clot, it seems that the effect upon the blood itself, and its coagulation in a wound, represents only one of the means through which butanol controls hemorrhage. The speed with which butanol acts, often within seconds after intravenous injection, is much greater than blood coagulation time. Consequently, changes in clot formation alone do not appear sufficient to explain the mechanism through which the rapid hemostasis occurs.

M. Bier and H. Lerner in our laboratory studied the influence exerted by butanol upon hemorrhage induced by the highly active proteolytic enzyme, ficine. (195) They were able to induce standardized hemorrhages by injecting ficine solutions under the skin of the abdomen of white mice. (Fig. 151a) (In other animals and with other sites of injection in mice, the individual variations were too great to make the resulting bleeding useful as material for testing the effect of agents upon hemorrhage.) With adequate doses of ficine, severe hemorrhages followed by skin ulcerations were induced. The bleeding, and even the ulcerations, were almost entirely prevented when butanol was administered. Figure 151b shows the results of this experiment, with the manifest differences, following ficine injections, between animals receiving butanol intraperitoneally and controls.

Shows graded extent of hemorrhagic infiltration obtainable with progressive amounts of ficin injected subcutaneously in the abdominal region in mice

Fig. 151a. Shows graded extent of hemorrhagic infiltration obtainable with progressive amounts of ficin injected subcutaneously in the abdominal region in mice.

The influence exerted by butanol upon the hemorrhage induced by ficin injection

Fig. 151b. The influence exerted by butanol upon the hemorrhage induced by ficin injection.

Top Row. Comparative group treated with butanol. Last animal in each row shows the external appearance of the site of the injection while in others, the skin flap was separated. Bottom Row: Ficin injected animals.

The antifibrinolytic activity of butanol (196) could explain its intervention in protracted bleeding, and especially in cases where the effect of butanol appears after hours or days. However, inhibition of fibrinolytic activity cannot be conceived to intervene in an action taking place in less than a few minutes.

In trying to explain butanol's antihemorrhagic effects, we also considered its pharmacological activities. We have noted the action of butanol upon the acid base balance of abnormal tissues, as shown by changes in the pH of the second day wound crust. In abnormal tissues, butanol reduces local pH but it does not do this to any great extent in normal tissues. This led us to investigate the difference in the influence of butanol upon pathological hemorrhages. The immediate bleeding induced by standard cutting of the tail in mice was not constant and, in general, was not markedly influenced by administration of butanol. But there was a marked effect upon hemorrhage induced by the displacement of the clots through mechanical maneuvers one to two hours after cutting of the tail. In controls, the bleeding lasted almost the same length of time as bleeding from fresh lesions, while in animals treated with butanol, it often stopped in a very short time.

These data, although interesting, did not seem to offer a completely satisfactory explanation of the mechanism by which butanol stops bleeding, especially in cases in which it acts within minutes or less. It appeared improbable that the formation of a clot alone would stop the hemorrhage under these conditions. An interesting observation led us to another hypothesis.

In several patients with wide ulcerations, we were able to examine the hemorrhaging vessel after bleeding had been stopped by butanol. Contrary to all expectations, we found that the artery, which usually was severed transversely, was not buried in a clot but remained almost isolated and somehow separated from it. It seemed that blood vessels themselves might have a role in hemostasis. The intervention of a spasm of the smooth muscles of the vessels was considered. This was indirectly confirmed when a patient with severe and prolonged bleeding from the bed of a prostate after ablation, was treated with butanol. An intravenous injection of 40 cc. of butanol was followed by such violent contraction of the bladder as to expel, with great force, the catheter together with clots and urine present in the bladder. At the same moment, bleeding, which had persisted for more than a week, stopped suddenly. We connected this sudden spasmodic contraction of the smooth muscles in the abnormal bladder with the injection of butanol and considered that butanol might produce a spasm of the muscular walls of abnormal blood vessels—abnormal because of the hemorrhagiparous condition itself. This would explain the rapidity of the hemostatic effect and the selective action upon small and medium arteries with important muscular walls. In fact, we saw that, while very severe arterial hemorrhages were completely stopped in less than one minute after an intravenous injection of butanol, the same effect was not obtained in oozing bleeding.

We tried to investigate further this spastic effect upon blood vessels as the mechanism in butanol hemostasis. Experiments with isolated aorta preparations of rabbits and rats showed that a spastic effect cannot be induced by butanol, even if the vessels previously have been harmed by manipulation. This can be explained by the fact that the aorta does not have muscular fibers. The same lack of spastic effect is seen in normal arteries of the hind legs of rats and frogs.

The administration of butanol to an animal after a small branch of the mesenteric artery was first crushed and, after some time, cut, produced a spastic effect which transformed the jet like hemorrhage into an oozing one, greatly reducing the blood loss. The hypothesis of vascular spastic contraction as the mechanism in butanol hemostasis has received further indirect confirmation through the study of the effect of butanol upon hemorrhage induced by single traumatic lesions in various organs. Differences were observed according to organs or tissues affected. While bleeding liver wounds are influenced only to a small degree by intravenous administration of butanol, hemorrhage from a kidney wound stopped rapidly. The fundamental difference between the liver portal circulation with minimum muscularity of the vessels, and that of the kidney, where highly developed artery muscular layers are seen, can explain the unequal response to butanol.

As we can see in these cases, the contraction of a pathological artery can insure rapid hemostasis and accords with the fact that the artery is not buried in a clot. This explains why, especially in clinical application, butanol is more active upon arterial hemorrhage and much less active upon capillary bleeding. This mechanism also would explain the same good effect upon hemorrhage from veins with important walls. Failure of butanol seen in three cases of hemorrhage from varices of the inferior esophageal veins can be explained by the almost complete lack of muscular layers in these varicose veins, which would bar a vasculo muscular contraction.

Parallel to these studies, other possible hemostatic mechanisms have been investigated. We tried to interpret the unusual fact that butanol stopped hemorrhage while agents such as nikethamide, thiamine, isamine blue, sterols and glycerol induced bleeding—yet all have positive polar groups in their molecules, represented by an amine or amide radical for most of them and by hydroxyls for glycerol and sterols. As we have mentioned before, all agents with such positive radicals induce a shift toward less alkaline values for the second day wound crust pH. Therefore, this could not be considered to be the factor that determines the antagonistic effects on bleeding. The aliphatic or cyclic character of the nonpolar group does not seem to be a factor since glycerol and butanol both have aliphatic chains.