What Botox Teaches Us About Serendipity in Clinical Encounters

The story of botulinum toxin (Botox) as a medical treatment began with tragedy in December 1895, when 34 members of a Belgian brass band were food poisoned en masse. The group had just wrapped up performing at a funeral in the village of Ellezelles and gathered for their customary meal at “Le Rustic” inn. Hours later, after eating plentiful portions of salted, uncooked ham, they all came down with a curious but alarming constellation of symptoms: vomiting; double vision; difficulty swallowing, speaking, and breathing; and paralysis of their arms and legs. It was as if something had suddenly switched off all the muscles of their bodies, and within a week nearly half of the band members had become gravely ill. Three of them ultimately died.

While some physicians may know this tale, the majority overlook an important lesson in the history of Botox: the power of serendipity in diagnosis and treatment, fostered by a trusting doctor-patient relationship. Today, during a period of declining trust in the medical system and less and less time to interact with patients, recognizing this connection is more important than ever.

So, how does serendipity play into this tragic tale of food-borne illness? Let’s dive deeper into the story to find out.

The syndrome experienced by the unfortunate brass band, what we now know to be botulism, has likely been a part of human life for thousands of years — essentially for as long as people have endeavored to preserve food. Its cause was finally identified when local health officials in Ellezelles, who suspected botulism from the ham at Le Rustic, invited microbiologist Émile van Ermengem from the State University of Ghent to investigate the outbreak. Van Ermengem hypothesized that a bacteria might have been to blame, and, sure enough, he found the same never-before-seen species of bacteria growing in both the culprit ham and the tissues of the deceased victims. Additional experiments proved that this new microbe, which van Ermengem dubbed Bacillus botulinum (and which is now called Clostridium botulinum), produced the paralytic toxin that causes botulism.

As a pharmaceutical treatment, Botox (onabotulinumtoxinA) is a mass-produced version of botulinum toxin. More than 130 years after its discovery, Botox is now ubiquitous, due primarily to its ability to reduce wrinkles. Botox skin injection represents the most commonly performed cosmetic procedure worldwide, with millions of doses given every year as a part of a billion-dollar industry.

Yet, Botox’s pervasive role in modern culture and medical care only happened after serendipity struck for a Canadian ophthalmologist, Jean Carruthers, MD, in 1987. Carruthers had been an early adopter of the use of Botox for muscle spasms around the eyes (its first clinical use). One day, in September 1987, a patient came back to her clinic for a facial injection and happened to relay an astute observation. The woman requested that Carruthers inject the Botox specifically into the skin of her forehead, even though those muscles weren’t spasming. When asked why, as Carruthers later recalled, the woman said that “when you inject my forehead, my wrinkles go away.” The woman’s fortuitous observation, made casually on an otherwise normal day, would reverberate into and help change the future of cosmetic dermatology.

But, just as importantly, Carruthers didn’t ignore or dismiss what her patient told her, and didn’t rush out as quickly as she could to see the next patient. Instead, she slowed down and heeded what the woman had observed, realizing that, similar to its effects on other parts of the body, Botox had smoothed the woman’s wrinkles by paralyzing the muscles of her forehead. And, just like that, a new era in cosmetic dermatology had arrived.

Many landmark medical discoveries, including chemotherapy, X-ray machines, and penicillin, were all made serendipitously. But Botox involved a unique kind of insight, where the serendipitous spark involved the interaction between patient and doctor: Carruthers only thought to use Botox cosmetically after her patient reported an observation about the drug’s effects.

The fundamental connection between doctor and patient — a quasi-sacred interaction that happens every day in clinics across the world — forms the core of the innovation that happened with Botox for wrinkle reduction. For additional insights, I spoke with Rana Awdish, MD — physician, best-selling author of In Shock, and a thought leader in patient-doctor communication — about the Botox story. She emphasized that the potential for serendipity between patients and doctors exists beyond rare and landmark discoveries on a more fundamental level, even for diagnosing diseases (something that happens all the time).

“Serendipity could be making a diagnosis that we weren’t looking for because the patient shared a symptom or something in their history that required a trusting space. Perhaps it felt shameful or embarrassing, but was incredibly relevant.”

Awdish stressed that the core of any serendipitous encounter between doctors and patients requires two crucial ingredients: adequate time and a foundation of deep trust. Unfortunately, both have come under significant threat in modern medicine. In an age of electronic medical records, clinical efficiency metrics, and productivity-based physician compensation, doctors are pushed by administrators to see as many patients as quickly as possible. As a result, physicians spend less and less time with any individual patient, and typically face consequences if they try to buck that trend.

For example, a physician who spends “too much” time with their patients can expect to potentially make less money and run afoul of expectations from hospital leadership. Likewise, the American public’s trust in physicians and hospitals has fallen sharply since the COVID-19 pandemic, a notion supported by the results of a 2024 survey from Massachusetts General Hospital.

Carruthers’s patient trusted her enough to share what happened with the drug, and she took the time to listen and follow up on what she had heard. But unless the American medical system can both rebuild patients’ trust and grant doctors more time to spend with their patients, sparks of serendipity in any form — whether those that lead to landmark innovations like Botox or an unexpected diagnosis for an individual patient — will be hard to come by.

Avraham Z. Cooper, MD, is a pulmonary/critical care physician and associate professor of medicine at The Ohio State University in Columbus. He is co-author of the forthcoming book, Why Doesn’t Your Stomach Digest Itself? (W.W. Norton).

Please enable JavaScript to view the comments powered by Disqus.