The Long History of Botulinum Toxin

1793 was an eventful year by any standards. It started with the French King Louis XVI being guillotined in front of a cheering crowd in Paris and ended with the execution of his wife, Marie Antoinette. The fact that Louis had tried to escape and was captured while trying to make a purchase at a store, where the clerk recognised his face on the coinage, only added to the drama.

 

Across the Rhine, in Southern Germany, a food poisoning epidemic caused by eating uncooked blood sausages claimed the death of over half of those patients who fell ill. The symptoms of the disease included malaise, nausea, vomiting, diarrhoea, double vision, dilated pupils, fatigue, unsteady gait, difficulty swallowing, thirst and, when fatal, unconsciousness, rigour and ultimately death. The disease and the remnants of the century passed, but in 1817, the dreaded sausage food poisoning returned to the town of Baden-Wurttemberg. 

 

All this mention of disease and food poisoning in the days before antibiotics would have passed idly into history except for the actions of a meticulous medical doctor called Justinus Kerner. Justinus, who later became one of Germany’s greatest romantic poets, studied medicine at the University of Tübingen. In 1815, he obtained the official appointment of district medical officer in Gaildorf and, three years later, was transferred to Weisberg. The local townspeople gave him a house at the foot of the historical Schloss Weibertreu, and within these walls, he dedicated all his spare time to discovering the cause of the food poisoning, which was killing half of his patients. 

 

In the space of five years, Kerner investigated 155 cases, treated 12 patients and performed autopsies. He also gave extracts from sausages that had been confiscated by the police to different animals and observed their reaction before dissecting the remains. In 1822, he published the first systemic description of the clinical picture of botulism, a lethal type of food poisoning known since the era of the Roman Empire. At the end of his publication, he concluded that there was no cure for sausage poisoning. He recommended that ‘all blood sausage and liverwurst still on the fireplace by February should be thrown out by the chimney sweep with the other rubbish’. 

 

With great foresight, in the dying throes of his sentinel paper, the poetic doctor also noted that small amounts of the sausage poison might be useful for neurological conditions such as St Vitus’ dance. 

 

Without knowing it, Justinus Kerner laid the opening shots in the greatest contribution of biology to the world of cosmetic medicine. He was describing the neurological action of botulinum toxin, later to be known in another century as Botox®. Kerner could isolate the toxin and use it to kill other animals, but he was lacking the biggest piece of the jigsaw – what was it and how was it formed?  

 

The next part of the botulinum toxin journey takes us back across the Rhine to meet one of the greatest scientists that the world has ever known, Louis Pasteur.

 

 

Louis Pasteur’s sentinel work from the late 1850s proved that milk became sour because of yet unknown living organisms; by verifying the ‘germ theory’. This sentinel work would change the whole outdated post-Aristotelian pathology and surgery forever. Of course, this great thesis led to the discovery that the bacteria van Leeuwenhoek found in his microscope slides in 1668 could cause disease and illness. Pasteur died in 1895, and in that year, the dreaded disease struck again, this time in the exalted company of the salted pork dish at the annual gathering of the Music Society in the town of Ellezelles in Belgium.

 

Three people eventually died from the resultant food poisoning, among them a close friend of one of society’s eminent members – the microbiologist, Professor Emile P. Van Ermengem. The professor took the death of his friend personally and, armed with the twin technologies of van Leeuwenhoek’s microscope and Pasteur’s closed flasks, he became the first person to isolate the microbe Clostridium Botulinum from both the food and the post-mortem tissue of victims who had died. He also knew that the disease process was caused by a toxin produced by this bacterium.

 

But this knowledge remained unheralded within the dusty pages of science books because, at the end of the nineteenth century, the sexy end of microbiology was tropical disease, increasingly important with the ever-expanding colonial empires, thrusting young soldiers into evermore unfamiliar climates. 

 

 

The new century came and, with it, more effective ways for the soldiers to kill their enemies. Overall, about 113,000 tons of chemical weapons were used in World War I, killing around 92,000 soldiers and creating a total of 1.3 million casualties. But the biggest problem with chemical attacks during this time was that their effective ability could change rapidly if the winds shifted, and they often did. 

 

And so, it came to pass that these scientists and others began to try and harness the power of the botulinum bacterium in the use of warfare. In 1916, the British set up a chemical warfare complex in 7,000 acres of scrubland at Porton Down in Wiltshire and research into the ability of botulinum toxin as an agent went underground.

 

In many ways, botulinum toxin would appear to be an ideal agent for this type of warfare as it is an anaerobic organism. This means that it effectively dies after initial exposure to oxygen in the air, meaning its use is short-lived, and the bombed area can clean itself within a short period, allowing friendly troops to enter the area. But this apparent benefit also made it impractical as an easy agent for British and American armies to use as aerosol disposal. It was also known that vast quantities of botulinum bacteria would have to be produced for it to become effective. 

 

 

In 1944, more than one million doses of botulinum vaccine were made for Allied troops in preparation for D-Day as intelligence sources indicated that Germany was interested in developing botulinum toxin as a type of cross-channel weapon.  

 

In the United States, research into botulinum toxin began in earnest during the same period in a place called Fort Detrick in a militaristic bid to address the threat to the American nation from biological warfare. It is now known that Special Operations Division members conducted more than 200 biological warfare tests, some on ordinary subjects, from 1943 until the mid-1960s.

 

In 1969, President Richard Nixon banned the offensive research program and instead set up a defensive biological research program under the US Army Medical Research Institute of Infectious Diseases. When the experiments with botulinum bacterium became public knowledge in 1977, American citizens became outraged that their government had exposed them to live organisms without their consent or knowledge.

 

US military authorities during World War II were interested in the use of botulinum as a weapon, and they recruited scientists to help produce it and evaluate its potential. One of the biochemists who gained employment at Fort Detrick during this period was a scientist called Dr Edward J Schantz, who had developed an interest in a highly lethal toxin called saxitoxin, which was found in clams and other shellfish. In 1946, Schantz became chief of chemistry at Fort Detrick with the specific task of producing the different types of botulinum toxin in their pure crystalline forms. 

 

 

In his first year at Fort Detrick, Dr Schantz isolated the first crystalline form of the neurotoxin serotype BTX-A. In 1949, Arnold Burgen discovered that botulinum toxin blocked neuromuscular transmission through decreased acetylcholine release. Indeed, the batch (79-11) originally prepared by Schantz was still used by Allergan until December 1997 and marketed as the miracle anti-ageing drug Botox.

 

During the 1960s, Schantz continued his research into BTX-A while the rest of America decried Bob Dylan for playing an electric guitar. It is known that the CIA used some of his pure batch to saturate some of Fidel Castro’s favourite cigar type and when they were tested many years later, the neurotoxin was still found to be effective. It was during these years, as the Vietnam War waxed and waned, that Schantz became more and more convinced that botulinum toxin would probably never become an effective biological warfare weapon, and instead, he convinced his military leaders to market his discovery for the purpose of scientific research within the wider community.

 

One of the first people to attempt to use botulinum toxin to treat human disease was a scientist called Dr Alan B Scott, who worked at the Smith-Kettlewell Eye Research Institute in San Francisco. Scott was looking for an agent like BTX-A for some time as he was convinced that he could use it to provide a new non-surgical treatment for the disease of strabismus, commonly known as cross-eyes. During the seventies, he injected a sample of the drug into the rectus muscles of cross-eyed monkeys to find a cure for the condition. The procedure was successful, and within a short period, he had progressed to trying the neurotoxin on humans with similar eye conditions, including blepharospasm or eyelid spasm. The experiments were again successful, and his work led the FDA to approve the use of botulinum toxin to treat two eye muscle disorders – uncontrollable blinking (blepharospasm) and misaligned eyes (strabismus). The cosmetic effect of BTX-A on wrinkles was initially documented by a plastic surgeon from Sacramento, California – Richard Clark – and published in the journal, Plastic and Reconstructive Surgery in 1989.

 

 

During the late eighties and early nineties, the Soviet Union and Iraq produced botulinum toxin for weapons use, even though both nations had signed the 1972 Biological and Toxin Weapons Convention, prohibiting offensive research and manufacturing of biological weapons. In 1990, Iraq invaded Kuwait and deployed 13 specially designed missiles with a 370-mile range and 100 bombs filled with the toxin. After the Gulf War, it admitted that it produced 19,000 litres of concentrated botulinum toxin, with about 10,000 litres loaded into weapons. I became a prisoner of Saddam Hussein’s regime in that same year. 

 

Two years later, Canadian husband and wife ophthalmologist and dermatologist physicians Jean and Alistair Carruthers published the first study on BTX-A for the treatment of glabellar frown lines in 1992. Several other independent groups were apparently observing similar effects. 

 

From here, I would like to look at this publication a little closer. It was, after all, the decisive observation in 1987 of Jean Carruthers that frown lines disappeared following treatment of blepharospasm that ignited the explosive cosmetic application of this product today. Without her, I probably would never have penned this article. Jean once told me that she had been using Botox® for five years on eye patients when she was struck with the idea that her patients noticed that it smoothed out their facial lines. She shared this seminal observation with her husband, Alistair, a dermatologist, saying, “My poison will get rid of your patients’ wrinkles”. 

 

Jean Carruthers was familiar with Alan Scott’s laboratory and was aware of the potential cosmetic applications for the product. When she mentioned her findings to Scott, she discovered that he had apparently used the preparation for such purposes in 1985. The first person that Alistair injected was their joint receptionist, Cathy Bickerton Swann, who was only 30 at the time but had always had deep frown lines. All were pleased with the result.