The Eyes Have It: On Eugene M. Helveston’s “Death to Beauty”

FROM 1803 TO 1815, the Napoleonic Wars ravaged large parts of Europe, creating food shortages that forced peasants to rely increasingly on blood sausages for sustenance. Made of meat, vegetables, spices, and blood stuffed into animal intestines, the sausages were often allowed to stand at room temperature for prolonged periods and undercooked to avoid bursting their casings.

These conditions allowed a bacteria, Clostridium botulinum, as well as its toxin, botulinum, to proliferate in the sausages and, once consumed, in the peasantry. Thus poisoned, the peasants experienced a paralysis that began with their eyelids and extended down as far as their lungs, killing them via asphyxiation.

It took Justinus Kerner, a local health officer, years of study to establish those fundamentals of botulism. In 1822, as his research concluded, he placed a dab of contaminated sausage fat on his tongue, temporarily numbing it. From the experience, Kerner deduced that botulinum might one day be transformed into a medicine.

As Eugene M. Helveston recounts in his recently published book, Death to Beauty: The Transformative History of Botox, it took more than 150 years for Kerner’s prediction to come true, in the form of Botox. Now a billion-dollar-a-year industry, Botox got its inadvertent start in the self-financed research laboratory of Alan Scott, an ophthalmologist from California who was treating patients with strabismus, or crossed eyes.

Helveston, also an ophthalmologist, joined Scott’s research team in 1982, when clinical trials of the drug that would become Botox were already underway. Nevertheless, Death to Beauty covers the entire journey, from the guts of German peasants to the faces of celebrities, with curious detours along the way, including Cold War–era CIA ops.

Botulinum, the toxin that causes botulism, is the world’s deadliest poison. It has no odor, color, or taste and can be lethal in doses as small as billionths of a gram. According to Helveston, as little as eight grams, the weight of a pencil, would be enough to kill every person on Earth.

The bacteria that produces botulinum is ubiquitous and can be consumed without issue, as it is by many people on a daily basis. However, if Clostridium botulinum is allowed to reproduce in an environment that lacks oxygen, salt, and acid, it produces botulinum. The toxin can be destroyed by exposing it to temperatures above 185 degrees Fahrenheit for five minutes, but consuming tainted food that is cooked to a lower temperature for less time may result in the poisoning known as botulism.

The relatively undetectable nature of botulinum has enticed would-be poisoners. Shamans suggested it to Indian maharajas to kill their enemies, and Winston Churchill feared that the Nazis would use it to taint the British water supply. Although the United States Office of Strategic Services determined it unlikely that botulinum could be used as a chemical weapon of mass destruction, the CIA later believed it was ideal for targeted assassinations of political opponents, like Fidel Castro.

In 1972, Scott obtained some samples for more benign purposes. Scott had worked on strabismus at the San Francisco Eye Research Institute and hypothesized that if he could weaken overactive eye muscles, the patient’s eyes would align. Could botulinum be the key? he wondered.

Pharmaceutical development is typically undertaken by dedicated teams at research universities, not independent practitioners in the lab before and after work hours. But Scott was able to establish that botulinum delivered via injection could indeed temporarily paralyze ocular muscles at doses well below the lethal limit and without adverse side effects.

In 1973, Scott published his findings and then applied for further research approval from the Food and Drug Administration. During phase one of the clinical trial, Scott himself successfully treated strabismus with botulinum in a small number of patients. Phase two saw Helveston, future author of Death to Beauty, join the clinical team as a researcher for much wider trials.

Throughout this process, Scott’s application of botulinum was proven safe and effective enough that he felt confident rebranding it as “Oculinum,” a reference to “ocular alignment.” But injecting the world’s deadliest toxin into one’s eye was always going to be a hard sell. The FDA categorized Oculinum as an “orphan drug,” signifying that it would serve a limited market and therefore yield limited financial gain, making it an even harder sell. Scott spent five years trying, and failing, to sell Oculinum to the pharmaceutical industry.

Instead, Scott mortgaged his family home and used the proceeds to establish a manufacturing operation at a facility in Albuquerque in 1983. Treatment remained free to patients, until Scott’s FDA sponsors pulled the plug. The story of Oculinum would have ended there had the clinical trials not already generated enough successful results for the FDA to issue its approval, leading to a $9 million sale of Oculinum to the pharmaceutical company Allergan. A decade later, one of the researchers who had received Oculinum from Scott during the clinical trials secured approval for its “off-label” use in dermatology. This is the Botox that we know today.

While Helveston’s academic background sometimes cramps the narrative—each chapter reads as if it could be a stand-alone paper, retreading material from previous chapters—the story itself is captivating enough to draw a layperson through. As he mentions in the introduction, his motivation was to capture the history of Botox’s development firsthand, from Scott and the other researchers themselves, before their retirement from the lab advanced to retirement from life altogether. His timing was not far off, as Scott died in 2021, cutting their interviews short. Nevertheless, Helveston got the whole story, and then some.