Who invented botox?

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Alan B Scott, MD, an ophthalmologist and founder of the Smith-Kettlewell Eye Research Institute in San Francisco, first developed and manufactured Botulinum Type A neurotoxin (BTX-A) for therapeutic use in eye muscles. Originally trade-named "Oculinum", it was rebranded "Botox" when rights were sold to Allergan, which developed it as a cosmetic. Scott first reported that BTX-A could weaken selected eye muscles in monkeys in 1973, and was clinically useful to treat human strabismus in 1980.

Strabismus is misalignment of the eyes caused by imbalances in the actions of muscles that rotate them. Regardless of cause, balance can sometimes be restored by weakening a muscle that pulls too strongly, or pulls against one that has been weakened by disease or trauma. BTX-A prevents neurotransmitter release from neuromuscular junctions, and so at least partially paralyzes injected muscles. The paralytic effect is temporary, and it might seem that injections would always need to be repeated, except that muscles adapt to the lengths at which they are chronically held, so that a muscle paralyzed by BTX-A tends to get stretched-out by its antagonist (if there is one) and grow longer, while the antagonist tends to grow shorter. This can lead to a permanent re-alignment, even when BTX-A-caused paralysis has resolved.

Scott wanted to treat strabismus without surgery or general anesthesia, but the 6 muscles of an intact eye lie deep in the orbit and are hardly visible, so how could the desired muscle alone be injected? Scott solved this problem by developing EMG-guided injection: the hypodermic needle used to inject the toxin would also function as an electrode that recorded the activity (the electromyogram or EMG) of the muscle in which its tip was embedded. Patients would need to be awake during the procedure. The needle would be introduced, and as the patient looked in different directions, the pattern of muscle activity, played through a speaker, would indicate when the belly of the targeted muscle had been entered, and the toxin would be injected.

To appreciate the genius of Scott's work, consider that even a mind capable of working out the medical, pharmacological, and practical aspects of such a non-obvious procedure, and its safe application, would likely flee, early on, from thoughts of pushing a hypodermic needle deep alongside the healthy eye of an awake patient, without visual guidance, for the purpose of injecting the most acutely toxic substance known.
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