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Botulinum Toxin
PROCEDURES IN COSMETIC
DERMATOLOGY

FOURTH EDITION

Edited by

Jean Carruthers MD, FRCSC, FRC (OPHTH),

FASOPRS
Clinical Professor, Department of Ophthalmology and Visual Science, University of British Columbia,
Vancouver, BC, Canada

Alastair Carruthers MA, BM, BCh, FRCPC,

FRCP(Lon)
Clinical Professor, Department of Dermatology and Skin Science, University of British Columbia, Vancouver,
BC, Canada
Series Editor

Jeffrey S. Dover MD, FRCPC, FRCP

Director, SkinCare Physicians, Chestnut Hill, MA; Associate Clinical Professor of Dermatology, Yale
University School of Medicine; Adjunct Associate Professor of Dermatology, Brown Medical School, Providence,
RI, USA
Associate Editor

Murad Alam MD, MSCI

Professor of Dermatology, Otolaryngology, and Surgery; Chief, Section of Cutaneous and Aesthetic Surgery;
Vice-Chair, Department of Dermatology, Northwestern University, Chicago, IL, USA

2
Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2018

3
Table of Contents
Cover image

Title Page

Series page

Copyright

Video contents

Series preface

Series preface first edition

Preface

List of contributors

Acknowledgments

Dedication

1 Therapeutic uses of the botulinum toxins

Introduction

Hyperfunctional muscular uses

Autonomic nervous system use

Afferent nervous system, pain syndromes, and antiinflammatory

Further reading

2 History of onabotulinumtoxinA therapeutic

Introduction

Identification, isolation, and characterization

Exploration of clinical potential

4
 Developed indications for onabotulinumtoxinA

Commentary

Acknowledgment

Further reading

3 History of cosmetic botulinum toxin

Introduction

Serendipitous discovery

Patient zero and the first clinical trials

FDA approval

The face of BoNT

Further reading

4 Basic science of BOTOX® Cosmetic

Introduction

Serotypes and structure

Role of neurotoxin-associated proteins

Manufacturing

Formulation

Mechanism of action

Immunogenicity

Clinical pharmacology of onabotulinumtoxinA in aesthetics

Approvals

Exploration of potential new uses in dermatology

Unique dosing of neuromodulators

Summary and conclusions

Acknowledgment

References

Further reading

5 AbobotulinumtoxinA

Clinical studies performed for abobotulinumtoxinA

References

Further reading

6 Basic science
Introduction

Properties of incobotulinumtoxinA

5
 Clinical performance of incobotulinumtoxinA

Clinical experience with incobotulinumtoxinA

Conclusion

References

Further reading

7 Basic science

Introduction

Mechanism of action

Myobloc formulation and dosage

Immunogenicity of Myobloc

Clinical studies in aesthetic medicine

Side effects

Conclusion—future outlook

References

8 Neuronox® and Innotox®

Introduction

Microbiological, physicochemical, and biochemical profiles of Neuronox®

Innotox®: novel liquid botulinum toxin type A product

Use of Neuronox® and Innotox® in Asians

Further reading

9 Injectable daxibotulinumtoxinA (RT002)

References

10 Comparison of botulinum toxins

Introduction

Types of botulinum toxin A

Mechanism of action

Compositional differences

Dosing

Efficacy

Duration of action

Diffusion and field of effect

Safety

Resistance

6
 Storage

Conclusion

Further reading

11 Topical daxibotulinumtoxinA (RT001)

The need for topical delivery

Topical daxibotulinumtoxinA

Topical daxibotulinumtoxinA for lateral canthal lines

Topical daxibotulinumtoxinA for hyperhidrosis

Topical daxibotulinumtoxinA for migraine

Further reading

12 Topical botulinum toxin type A

Introduction

Barriers to transdermal permeation

Nanoemulsion delivery systems

Allergan botulinum toxin type A topical nanoparticle delivery system

Conclusions

Further reading

13 Reconstitution and dilution

Introduction

Reconstitution diluents

Foam, shaking, and stirring

After reconstitution: storage, use, and sterility

Fresh or frozen? Does it matter?

What concentration is adequate for cosmetic and noncosmetic indication?

Conclusion

Further reading

14 Benzyl alcohol

Introduction

Saline with benzyl alcohol: early evidence of anesthetic efficacy and historical concerns

Saline with benzyl alcohol: RCTs with botulinum toxin

Saline with benzyl alcohol: use in combination with lidocaine infiltration

Saline with benzyl alcohol: use in comparison with lidocaine infiltration

Safety of saline with benzyl alcohol

Summary of key concepts

7
 References

15 Glabella

Introduction

Anatomy

Injection technique (see Video 15.1 “Botulinum Toxin Glabella”)

Dosing

Novel botulinum neurotoxins

Special considerations

Potential adverse events

Conclusion

Further reading

16 Modulation of eyebrow position and shape by treatment with Neuromodulators and fillers
Introduction

The consultation

Treatment

Fillers

References

17 Frontalis and horizontal forehead line

Introduction

Side effects

Injection techniques

Types of botox

Botox dosing

Treatment of scars

Conclusion

Further reading

18 Treatment of crow's feet

Introduction

Anatomy of crow's feet lateral orbital rhytides

The youthful eye

The aging eye

Preoperative assessment

Treatment

Adjunctive treatments

8
 Complications

Conclusion

Further reading

19 Infraorbital/upper and lower eyelids

Introduction

Anatomy of the eye

Periorbital aging

Patient assessment and selection

Indications and techniques

General considerations

Adjunctive treatments for the lid

Adverse events

Conclusion

Further reading

20 Treatment of the midface with botulinum toxin

Introduction

“Bunny” and nasal sidewall scrunch lines

Levator labii superioris alaeque nasi

Zygomaticus complex

Risorius

Conclusion

Further reading

21 Orbicularis oris, mentalis, and depressor anguli oris

Introduction

Anatomy

Perioral and chin aging

Differences in the use of botulinum toxin for the upper and lower face

Patient selection for botulinum toxin perioral and chin rejuvenation

Target muscle

Dosage and injection technique

Conclusion

Further reading

22 Platysma, Nefertiti lift, and beyond

Introduction

9
 Anatomy

Treatment techniques

Technical variations for lower face contour with neuromodulators

References

23 The masseters and their treatment with botulinum toxin

Introduction

History

Anatomy

Raison d’être for botulinum injection to the masseters

Bruxism

Treatment method

Complications

Conclusion

References

Further reading

24 Darker skin types

Introduction

Racial and ethnic differences in photoaging

Safety and efficacy of botulinum toxins in darker skin types

Ethnic specific applications of botulinum toxin

Conclusion

Further reading

25 Combination noninvasive facial aesthetic treatments with botulinum toxin type A

Anatomy related to multiple therapeutic modalities

Combination therapy in the upper face

Brow ptosis

Combination therapy in the lower face

Neocollagenesis

Injectables

Skin tightening

Vascular lesions and pigmentation

Topical agents

Sequence and timing of a multimodal approach

Summary

10
 References

Further reading

26 Focal axillary hyperhidrosis

Introduction

Epidemiology

Quality of life

Clinical assessment of hyperhidrosis

Botulinum toxin therapy

Axillary hyperhidrosis

Use of botulinum toxin type B for hyperhidrosis

Techniques for nonaxillary hyperhidrosis

Future directions

Further reading

27 Palmoplantar hyperhidrosis
Introduction

Patient evaluation

General considerations

Marking the treatment areas

Anesthesia

Dilution and injection

Injection technique

Results and follow-up

Complications

Conclusion

Further reading

28 The future of neuromodulators in aesthetic medicine

Introduction

Expansion of current uses

Changes to the molecule and formulation

New areas and new uses

Conclusions

References

Further reading

Index

11
Series page
Procedures in Cosmetic Dermatology
Series Editor: Jeffrey S. Dover MD, FRCPC, FRCP
Associate Editor: Murad Alam MD, MSCI

Chemical Peels

Second edition

Rebecca C. Tung MD and Mark G. Rubin MD

ISBN 978-1-4377-1924-6

Treatment of Leg Veins

Second edition

Murad Alam MD, MSCI and Sirunya Silapunt MD

ISBN 978-1-4377-0739-7

Body Contouring

Bruce E. Katz MD and Neil S. Sadick MD, FAAD, FAACS, FACP, FACPh

ISBN 978-1-4377-0739-7

Non-Surgical Skin Tightening and Lifting

Murad Alam MD, MSCI and Jeffrey S. Dover MD, FRCPC, FRCP

ISBN 978-1-4160-5960-8

Botulinum Toxin

Fourth edition

Alastair Carruthers MA, BM, BCh, FRCPC, FRCP(Lon) and Jean Carruthers MD, FRCSC, FRC(Ophth),
FASOPRS

ISBN 978-0-323-47659-1

Soft Tissue Augmentation

Fourth edition

Jean Carruthers MD, FRCSC, FRC(Ophth), FASOPRS and Alastair Carruthers MA, BM, BCh, FRCPC,
FRCP(Lon)

ISBN 978-0-323-47658-4

12
Body Shaping: Skin Fat Cellulite

Jeffrey Orringer MD, Jeffrey S. Dover MD, FRCPC, FRCP and Murad Alam MD, MSCI

ISBN 978-0323321976

Cosmeceuticals

Third edition

Zoe Diana Draelos MD, Murad Alam MD, MSCI and Jeffrey S. Dover MD, FRCPC, FRCP

ISBN 978-0-323-29869-8

Lasers and Lights

Fourth edition

George Hruza MD and Elizabeth Tanzi MD

ISBN 978-0-323-48006-2

Photodynamic Therapy

Second edition

Mitchel P. Goldman MD

ISBN 978-1-4160-4211-2

Liposuction

C. William Hanke MD, MPH, FACP and Gerhard Sattler MD

ISBN 978-1-4160-2208-4

Scar Revision

Kenneth A. Arndt MD

ISBN 978-1-4160-3131-4

Hair Transplantation

Robert S. Haber MD and Dowling B. Stough MD

ISBN 978-1-4160-3104-8

Blepharoplasty

Ronald L. Moy MD and Edgar F. Fincher MD

ISBN 978-1-4160-2996-0

For Elsevier
Content Strategist: Belinda Kuhn
Content Development Specialist: Humayra Rahman Khan
Project Manager: Srividhya Vidhyashankar
Design: Miles Hitchen
Illustration Manager: Nichole Beard

13
Copyright

© 2018, Elsevier Inc. All rights reserved.

First edition 2005

Second edition 2008
Third edition 2013

No part of this publication may be reproduced or transmitted in any form or by any means, electronic
or mechanical, including photocopying, recording, or any information storage and retrieval system,
without permission in writing from the publisher. Details on how to seek permission, further
information about the Publisher's permissions policies and our arrangements with organizations such
as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website:
www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the
Publisher (other than as may be noted herein).

Notices
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical treatment
may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds, or experiments described herein. In using such
information or methods they should be mindful of their own safety and the safety of others, including
parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to
be administered, to verify the recommended dose or formula, the method and duration of
administration, and contraindications. It is the responsibility of practitioners, relying on their own
experience and knowledge of their patients, to make diagnoses, to determine dosages and the best
treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume
any liability for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.

ISBN: 978-0-323-47659-1

E-ISBN: 978-0-323-48007-9

Printed in China

Last digit is the print number: 9 8 7 6 5 4 3 2 1

14
15
Video contents
Video 6 Bocouture Injection
Jürgen Frevert, MD, Gerhard Sattler, MD
Video 8 Neuronox
Kyle Koo-II Seo, MD
Video 15 Glabella
Derek H. Jones, MD
Video 16 Brow Shaping
Alastair Carruthers, MD
Video 17 Frontalis and HFL
Joel L. Cohen, MD
Video 18.1 Crow's Feet
Jean Carruthers, MD
Video 18.2 Lower Eyelid
Alastair Carruthers, MD
Video 19 Technique Demonstrating Pretarsal Injection to Widen Vertical Palpebral Aperture
Shannon Humphrey, MD, Steven Fagien, MD
Video 20.1 Bunny Lines
Jean Carruthers, MD
Video 20.2 Gummy Smile
Jean Carruthers, MD
Video 21.1 Depressor Anguli Oris and Mentalis (1)
Alastair Carruthers, MD
Video 21.2 Depressor Anguli Oris and Mentalis (2)
Jean Carruthers, MD
Video 21.3 Depressor Anguli Oris and Mentalis (3)
Jean Carruthers, MD
Video 26.1 Hyperhidrosis: Palmar Injection Technique
Dee Anna Glaser, MD, Adam R. Mattox, MD
Video 26.2 Hyperhidrosis: Axillary HH Treatment and Starch Iodine Test
Dee Anna Glaser, MD, Adam R. Mattox, MD

16
Series preface
Much has changed since the first edition of this series. Non-invasive and minimally invasive cosmetic
procedures, as pioneered by dermatologists, have become increasingly adopted by physicians and well-
accepted by patients. Cosmetic dermatologic surgery procedures have been refined and improved.
Interventions have become more effective, and also safer and more tolerable with increasing benefit:
risk ratios. Combination cosmetic regimens that include multiple procedure types have been shown to
achieve results comparable to those with more invasive procedures. And new devices and technologies
continue to be introduced.
And how best to keep up with these advances and to ensure your offerings are state of the art and at
the cutting edge? The newest edition of the Procedures in Cosmetic Dermatology series keeps you
there, and for those starting out in the field these texts quickly introduce you and bring you to the state
of the art. Each book in this series is designed to quickly impart basic skills as well as advanced
concepts in an easy-to-understand manner. We focus not on theory but on how-to. Our expert book
editors and chapter authors will guide you through the learning process efficiently, so you can soon get
back to treating patients.
The authors are leading dermatologists in the field. Dermatologists' role in cosmetic medicine has
continued to expand. Research has revealed that primary care physicians and the general public view
dermatologists as the experts in less invasive cosmetic procedures. A nationwide advanced fellowship
program in cosmetic dermatologic surgery has been initiated to train the next generation of
dermatologists to the highest standards.
What has not changed is physicians' need for clear, concise, and current direction on procedure
techniques. Physicians need to be proficient in the latest methods for enhancing appearance and
concealing the visible signs of aging.
To that end, we hope that you, our reader, find the books enjoyable and educational.
We thank our many contributors and wish you well on your journey of discovery.
Jeffrey S. Dover MD, FRCPC, FRCP, Murad Alam MD, MSCI

17
Series preface first edition
Although dermatologists have been procedurally inclined since the beginning of the specialty,
particularly rapid change has occurred in the past quarter century. The advent of frozen section
technique and the golden age of Mohs skin cancer surgery have led to the formal incorporation of
surgery within the dermatology curriculum. More recently technological breakthroughs in minimally
invasive procedural dermatology have offered an aging population new options for improving the
appearance of damaged skin.
Procedures for rejuvenating the skin and adjacent regions are actively sought by our patients.
Significantly, dermatologists have pioneered devices, technologies, and medications, which have
continued to evolve at a startling pace. Numerous major advances, including virtually all cutaneous
lasers and light-source-based procedures, botulinum exotoxin, soft tissue augmentation, dilute
anesthesia liposuction, leg vein treatments, chemical peels, and hair transplants, have been invented or
developed and enhanced by dermatologists. Dermatologists understand procedures, and we have
special insight into the structure, function, and working of skin. Cosmetic dermatologists have made
rejuvenation accessible to risk-averse patients by emphasizing safety and reducing operative trauma.
No specialty is better positioned than dermatology to lead the field of cutaneous surgery while meeting
patient needs.
As dermatology grows as a specialty, an ever-increasing proportion of dermatologists will become
proficient in the delivery of different procedures. Not all dermatologists will perform all procedures,
and some will perform very few, but even the less procedurally directed among us must be well versed
in the details to be able to guide and educate our patients. Whether you are a skilled dermatologic
surgeon interested in further expanding your surgical repertoire, a complete surgical novice wishing to
learn a few simple procedures, or somewhere in between, this book and this series are for you.
The volume you are holding is one of a series entitled Procedures in Cosmetic Dermatology. The
purpose of each book is to serve as a practical primer on a major topic area in procedural dermatology.
If you want to make sure you find the right book for your needs, you may wish to know what this
book is and what it is not. It is not a comprehensive text grounded in theoretical underpinnings. It is
not exhaustively referenced. It is not designed to be a completely unbiased review of the world's
literature on the subject. At the same time, it is not an overview of cosmetic procedures that describes
these in generalities without providing enough specific information to actually permit someone to
perform the procedures. Importantly, it is not so heavy that it can serve as a doorstop or a shelf filler.
What this book and this series offer is a step-by-step, practical guide to performing cutaneous
surgical procedures. Each volume in the series has been edited by a known authority in that subfield.
Each editor has recruited other equally practical-minded, technically skilled, hands-on clinicians to
write the constituent chapters. Most chapters have two authors to ensure that different approaches and
a broad range of opinions are incorporated. On the other hand, the two authors and the editors also
collectively provide a consistency of tone. A uniform template has been used within each chapter so
that the reader will be easily able to navigate all the books in the series. Within every chapter, the
authors succinctly tell it like they do it. The emphasis is on therapeutic technique; treatment methods
are discussed with an eye to appropriate indications, adverse events, and unusual cases. Finally, this
book is short and can be read in its entirety on a long plane ride. We believe that brevity paradoxically
results in greater information transfer because cover-to-cover mastery is practicable.
We hope you enjoy this book and the rest of the books in the series and that you benefit from the
many hours of clinical wisdom that have been distilled to produce it. Please keep it nearby, where you
can reach for it when you need it.

18
Jeffrey S. Dover MD, FRCPC, FRCP, Murad Alam MD, MSCI

19
Preface
So why should we expect you to be interested in a new volume on the cosmetic use of
neuromodulators? Well, right there is a reason. Earlier editions talked about botulinum toxin, whereas
now we are discussing neuromodulators—referring to the use of these materials to modulate the
subject rather than to achieve the result by controlled paralysis. Partly this is due to our better
understanding of the method of action of the botulinum toxins, but also it reflects the way we are using
the neurotoxins now.
Since the third edition in 2012 there have been major advances in the use of neuromodulators, and
we have attempted to incorporate these into this volume without being too biased. We have continued
the policy begun in volume 3 of asking each of the companies involved in the commercial production of
neuromodulators to write a chapter on their product(s), avoiding comparisons as much as possible.
These chapters contain much useful information to be discovered, and we hope you will enjoy them as
well as the other chapters in this volume. We think that we have avoided too much of a commercial
bias.
The chapter on the newer Revance products (RT002) shows a significant change from the third
edition, when we thought they would be producing a commercial topical toxin, whereas now they
appear to be focusing on extending the duration of effect of the toxin. We advise you not to give up on
the topical toxin, which we believe to have a future in both the cosmetic and therapeutic worlds, and we
expect that the other companies with expertise in this area will be producing neuromodulators with
unique properties.
Similarly, the cosmetic use has continued to change, and we hope you will appreciate the new
chapters. New authors are giving you their expertise and their new knowledge. It is fascinating to see
how something that we thought was settled (the use of botulinum neurotoxin type A in the brow) has
changed so much! In addition, the use has expanded into new areas, as well as the new methods of
using the botulinum neurotoxin (BoNT).
Overall, our understanding of the clinical use of BoNT, as well as the products themselves, has really
changed this area. We hope that you will agree with us after reading this well-produced volume. Enjoy!
Alastair Carruthers MA, BM, BCh, FRCPC, FRCP(Lon), Jean Carruthers MD, FRCSC, FRC (OPHTH), FASOPRS

20
List of contributors
The editor(s) acknowledge and offer grateful thanks for the input of all previous editions' contributors,
without whom this new edition would not have been possible.

Murad Alam MD, MSCI, Professor of Dermatology, Otolaryngology, and Surgery; Chief, Section of
Cutaneous and Aesthetic Surgery, Northwestern University, Chicago, IL, USA

Andrew F. Alexis MD, MPH

Chairman, Department of Dermatology, Mount Sinai St. Luke's and Mount Sinai West;
Associate Clinical Professor, Icahn School of Medicine at Mount Sinai, New York, NY, USA

GeeYoung Bae MD, Director of Rose Clinic, Clinical Professor in the Department of Dermatology of
Ulsan University, College of Medicine, University of Ulsan, Seoul, Korea

Katie Beleznay MD, FRCPC, FAAD, Clinical Instructor, Department of Dermatology and Skin
Science, University of British Columbia, Vancouver, BC, Canada

Jeanette M. Black MD, Dermatologist, Skin Care and Laser Physicians of Beverly Hills, Los Angeles,
CA, USA

Andrew Blitzer MD, DDS, Professor Emeritus of Otolaryngology/Head and Neck Surgery, Columbia
University, College of Physicians and Surgeons; Adjunct Professor of Neurology, Icahn School of
Medicine at Mt. Sinai; Director, NY Center for Voice and Swallowing Disorders; Co-Founder and
Director of Research, ADN International, New York, NY, USA

Jennifer B. Mancuso MD, Dermatology Resident, Henry Ford Hospital, Detroit, MI, USA

Mitchell F. Brin MD
Senior Vice President, Global Drug Development,
Chief Scientific Officer, BOTOX®, Allergan, Inc., Irvine, CA;
Professor of Neurology, University of California, Irvine, CA, USA

Letícia Cardoso Secco MD, Volunteer Dermatologist, Hospital do Servidor Público Municipal de São
Paulo, Brazil

Alastair Carruthers MA, BM, BCh, FRCPC, FRCP(Lon), Clinical Professor, Department of
Dermatology and Skin Science, University of British Columbia, Vancouver, BC, Canada

Jean Carruthers MD, FRCSC, FRC (OPHTH), FASOPRS, Clinical Professor, Department of
Ophthalmology and Visual Science, University of British Columbia, Vancouver, BC, Canada

Joel L. Cohen MD
Director, AboutSkin Dermatology and DermSurgery, Englewood;
Associate Clinical Professor, Department of Dermatology, University of Colorado, Denver, CO, USA

Jeffrey S. Dover MD, FRCPC, FRCP

Director, SkinCare Physicians,
Chestnut Hill, MA;
Associate Clinical Professor of Dermatology,
Yale University School of Medicine;

21
Adjunct Associate Professor of Dermatology
Brown Medical School, Providence, RI, USA

Steven Fagien MD, FACS, Private Practice, Aesthetic Eyelid Plastic Surgery, Boca Raton, FL, USA

Timothy C. Flynn MD
Clinical Professor, Department of Dermatology, University of North Carolina, Chapel Hill, NC;
Medical Director, Cary Skin Center, Cary, NC, USA

Jürgen Frevert PhD, Head of Botulinum Toxin Research, Merz Pharmaceuticals GmbH, Potsdam,
Germany

Conor J. Gallagher PhD, Senior Medical Director, Facial Aesthetics, Medical Affairs, Allergan, Plc,
Irvine, CA, USA

Dee Anna Glaser MD, Professor and Vice Chairman; Director Cosmetic and Laser Surgery,
Department of Dermatology, Saint Louis University School of Medicine, Saint Louis, MO, USA

Richard G. Glogau MD, Clinical Professor of Dermatology, University of California San Francisco,
San Francisco, CA, USA

Greg J. Goodman MBBS, FACD, MD, Associate Professor, Monash University; Chief of Surgery, Skin
and Cancer Foundation Inc., Carlton, VIC, Australia

Pearl E. Grimes MD, Director, Vitiligo and Pigmentation Institute of Southern California; Clinical
Professor, Division of Dermatology, David Geffan School of Medicine, University of California, Los
Angeles, CA, USA

Bhushan Hardas MD, MBA, US Head of Research & Development and Vice President, Merz
Pharmaceuticals, LLC, Greensboro, NC, USA

Shannon Humphrey MD, FRCPC, FAAD, Clinical Assistant Professor, Director of CME, Department
of Dermatology and Skin Science, University of British Columbia, Vancouver, BC, Canada

Matthias Imhof MD, Dermatologist, Aesthetic Dermatology Department, Medico Palais, Bad Soden,
Germany

Derek H. Jones MD, Associate Clinical Professor, Dermatology, David Geffen School of Medicine,
University of California, Los Angeles; Dermatologist, Skin Care and Laser Physicians of Beverly Hills,
Los Angeles, CA, USA

Dr. Michael Z. Lerner, Assistant Professor of Otolaryngology, Albert Einstein College of Medicine,
Bronx, NY, USA

Austin Liu MD, Dermatology & Mohs Surgery Center, Doylestown and Sellersville, PA, USA

Ian A. Maher MD, FAAD, Assistant Professor, Department of Dermatology, Saint Louis University,
St. Louis, MO, USA

Kavita Mariwalla MD, Assistant Clinical Professor, Department of Dermatology, Columbia

University, New York, NY, USA

Adam R. Mattox DO, MS, Physician Research Fellow, Department of Dermatology, Saint Louis
University School of Medicine, Saint Louis, MO, USA

Gary D. Monheit MD, FAAD, FACS, Private Practice, Total Skin and Beauty Dermatology Center, PC;
Associate Clinical Professor, Departments of Dermatology and Ophthalmology, University of Alabama
at Birmingham, Birmingham, AL, USA

Jasmine O. Obioha MD, Resident, Department of Dermatology, Icahn School of Medicine at Mount
Sinai, New York, NY, USA

22
David M. Ozog MD, FAAD, Director of Cosmetic Dermatology; Vice-Chair of Operations, Division
of Mohs and Dermatological Surgery, Henry Ford Hospital, Detroit, MI, USA

Amit A. Patel MD, Otolaryngologist, ENT Allergy Group, Shrewsbury, NJ, USA

Andrew Pickett BSc, PhD

Director and Founder, Toxin Research Limited, Wrexham, UK;
Adjunct Professor, Botulinum Research Center, UMASS Dartmouth, MA, USA

Roman G. Rubio MD, MBA, Senior Vice President of Clinical Development, Revance Therapeutics,
Inc., Newark, CA, USA

Thomas E. Rohrer MD
Clinical Associate Professor of Dermatology, The Warren Alpert Medical School of Brown University,
Providence, RI;
Director of Mohs Fellowship, SkinCare Physicians, Chestnut Hill, MA, USA

Neil S. Sadick MD, FAAD, FAACS, FACP, FACPh, Clinical Professor, Weill Cornell Medical College,
Cornell University; Sadick Dermatology and Research Group, New York, NY, USA

Nazanin Saedi, Director, Laser Surgery and Cosmetic Dermatology, Thomas Jefferson University
Hospitals, Philadelphia, PA, USA

Gerhard Sattler MD, Fellow of Dermatology; Clinical Director of Rosenparkklinik, Darmstadt,

Germany

Kyle Koo-II Seo MD, PhD, Clinical Associate Professor, Dermatology, Seoul National University
College of Medicine; Director, Dermatology, Modelo Clinic, Seoul, Korea

Kevin C. Smith MD, FRCPC [Derm], Private Practice, Niagara Falls, ON, Canada

Nowell Solish MD, FRCPC, Assistant Professor of Dermatology, University of Toronto, ON, Canada

Ada R. Trindade de Almeida MD, Dermatologist, Dermatologic Clinic, Hospital do Servidor Público
Municipal de São Paulo and private office, São Paulo, Brazil

Jacob M. Waugh MD, Illustris Pharmaceuticals, Inc., Palo Alto, CA, USA

Mara Weinstein Velez MD, Dermatologist, SkinCare Physicians of Chestnut Hill, Chestnut Hill, MA,
USA

Naissan O. Wesley MD
Clinical Instructor, Medicine, Division of Dermatology, David Geffen School of Medicine, University of
California, Los Angeles, CA, USA;
Dermatologist and Dermatologic Surgeon, Skin Care and Laser Physicians of Beverly Hills, Los
Angeles, CA, USA

23
Acknowledgments
Looking back over the past 30 years of our involvement in the clinical use of botulinum toxin there are
very many people who have supported and encouraged us. The first to be mentioned, of course, is Alan
Scott, MD, who has been consistently generous with his educational efforts, his clinical information, his
research results and, with his wife Ruth, hospitality. Sitting on their deck above Mill Valley looking
towards the Golden Gate Bridge we have learned more about botulinum toxin than in any lecture hall.
From the early days of oculinum and then botox we have had fascinating and enlightening
discussions with Mitchell Brin, MD, and Andrew Blitzer, MD, both from Columbia. The early group of
us who formed a core set of advisers for Allergan (our advice was not always well received and usually
was ahead of its time) consisted of Andrew Blitzer, MD, Richard Glogau, MD, Nicholas Lowe, MD,
Arnold Klein, MD, and the two of us. These sessions and teleconferences set the stage for the future
education and development of the cosmetic use of botulinum toxin and were a major learning
experience for us all. The basic science which Roger Aoki, PhD, of Allergan Inc., provided to us gave a
solid basis for our understanding of how the toxin works and the meaning of both basic and clinical
studies.
In more recent years we have had valuable assistance from many individuals, many of whom are
coauthors in this book. We have greatly appreciated the contributions of many of our international
colleagues such as Ada Trindade de Almeida, MD, Francisco Perez Atamoros, MD, and Koenraad de
Boulle, MD. To all of the authors of this text, we salute you! We are so grateful for the hard work you
have put into this volume and the tolerance you have shown when faced with yet more unreasonable
editorial demands. The proof of your labors and dedication is easily seen between the covers of this
book.
Any list of acknowledgments would not be complete without recognizing the people who actually do
the work to make it all work: our staff and our patients. Our patients have been so very tolerant,
especially in the beginning when we did not fully understand the potential benefits as well as the
pitfalls of the cosmetic use of botulinum toxin. Our staff have been consistently supportive and helpful
(finding photographs from the vaguest descriptions, following up results good and bad, keeping things
running smoothly so we could go off and deliver another lecture). We could not have done it without
you!
Finally, our friends and family have accepted the fact that we might or might not be in a given place
at a given time, that we spend more time thinking about them in airports than actually talking to them,
that our crazy idea has generated a crazy life. Many thanks to you all!
Alastair Carruthers MA, BM, BCh, FRCPC, FRCP(Lon), Jean Carruthers MD, FRCSC, FRC (OPHTH), FASOPRS

24
Dedication

Firstly, and most importantly, we dedicate this volume to our sons and their families. Our
sons were young when the botulinum toxin story began and they have regarded the efforts
of their parents to cope with this accidental discovery with tolerance and increasing pride
over the years. We have appreciated the support and encouragement they have given us.
The love they have given us means we are indeed fortunate.

We have been fortunate to have an amazing series of mentors during our careers, Alan
Scott and Barrie Jay for Jean and Ted Tromovitch, Sam Stegman, Rick Glogau and Stuart
Maddin for us both. The interest and imagination stirred by these individuals has been
crucial.

Finally we have been fortunate to work with outstanding people over the years in our
various offices as well as at the American Society for Dermatologic Surgery. They have all
been a part of our story and have helped to create our careers and hence the volume
which you are holding. Thanks to all of them!
Alastair Carruthers MA, BM, BCh, FRCPC, FRCP(Lon), Jean Carruthers MD, FRCSC, FRC (OPHTH), FASOPRS

25
1

Therapeutic uses of the

botulinum toxins
Andrew Blitzer, Am it A. Patel, Michael Lerner

Sum m ary and Key Features

• Botulinum toxins enzymatically affect the soluble N-ethylmaleimide-sensitive factor attachment
protein receptor (SNARE) proteins in neural endings.

• Botulinum toxins will reduce and prevent the release of substances exocytosed by SNARE proteins.

• Reduction of SNARE function may have therapeutic implications for autonomic, sensory, and motor
parts of the nervous system.

• Reduction of acetylcholine neurotransmitter can reduce the hyperfunction of muscles in various

dystonias.

• Reduction of acetylcholine neurotransmitter can reduce autonomic nervous system hyperfunction,

such as hyperhidrosis and sialorrhea.

• Reduction of SNARE function can also reduce the release of inflammatory mediators, such as
substance P, calcitonin gene-related peptide, and glutamate.

• Reduction of inflammatory mediators can have an effect on pain syndromes.

• Pain syndromes, such as postherpetic neuralgia, migraine headaches, and temporomandibular

disorders, can be improved with botulinum toxin.

• Inflammatory conditions, such as rheumatoid arthritis, may be improved with intraarticular

injections of botulinum toxin.

• Bioengineered toxins may allow precise localization and decrease of exocytosed proteins, such as
hormones.

Introduction
Since the 1970s, when Alan Scott introduced botulinum neurotoxin A as a therapeutic agent, the
number of different uses for this drug has increased exponentially. In the 1950s Arnold Burgen and
Vernon Brooks, at McGill, discovered that botulinum toxin presynaptically blocked the release of
acetylcholine from motor nerve terminals, thus weakening muscle strength by chemical denervation.
Brooks also reported that botulinum toxin could possibly be used therapeutically. The observation that
tetanus and botulinum toxins blocked the exocytosis of acetylcholine was further refined with the
discovery that these toxins enzymatically degraded different portions of the soluble N-ethylmaleimide-
sensitive factor attachment protein receptor (SNARE) proteins. Alan Scott's original work using
botulinum toxin to weaken muscle for the correction of strabismus and then blepharospasm led others
to begin to investigate the toxins for use with other dystonias and hyperfunctional muscular disorders.

26
 The original observations of Kerner that patients with botulism had dry mouth and eyes suggested
that the toxin might be used to control hypersecretory states. With the knowledge that the autonomic
nervous system also depended on acetylcholine as the neurotransmitter, it seemed even more likely
that botulinum toxin could be used to control disorders of this system. Clinical trials have shown
efficacy in autonomic disorders, such as hyperhidrosis, sialorrhea, and Frey syndrome.
A number of trials for hyperfunctional muscular disorders, such as cervical dystonia and spasticity,
showed a dramatic reduction of pain, even greater than the reduction of muscle function. Our trials of
toxin use for cosmetic indications revealed a number of individuals whose migraine headaches
disappeared. These and other studies revealed a pattern that seemed to indicate that the toxin had a
role in pain syndromes. Other studies then showed that, even in cases of postherpetic neuralgia, pain
could be decreased or eliminated. This clinical information led to the discovery that inflammatory
mediators, such as calcitonin gene-related peptide (CGRP), substance P, and glutamate, are also
released by SNARE proteins. The toxin will reduce or eliminate the release locally of inflammatory
mediators that have the effect of lowering central nervous system pain thresholds and thereby causing
central sensitization. Toxin treatment of chronic migraine headaches was recently European Union (EU)
and US Food and Drug Administration (FDA) approved after extensive clinical trials.
The newest change to potential toxin treatment has been the ability to change the molecule. The
binding site of the molecule has been altered chemically to add specific ligands. This allows a toxin to
be created that has an affinity for sensory but not motor neurons, autonomic neurons, and even certain
excretory glands. Keith Foster, of Syntaxin, has described making a specific ligand for growth hormone
secretory cells in the pituitary gland. Growth hormone is also secreted with a SNARE-related exocytosis
and therefore can be modulated with targeted specific botulinum toxin. This treatment could be used
for patients with acromegaly. Other glandular secretions should be studied in this new paradigm for
hypersecretory control.
Given the already wide range of clinical applications of botulinum toxin, it is not surprising that
other avenues are being pursued. Intraarticular injections of botulinum toxin are also under study as a
way of relieving joint pain from osteoarthritis and chronic pain after joint replacement among others.
The utility of toxin in temporomandibular myofascial and joint pain is also being investigated.
Both crocodile tear syndrome and first bite syndrome, both consequences of aberrant nerve
regeneration similar to Frey syndrome, have been successfully treated with botulinum toxin injection.
One interesting avenue of research involves botulinum toxin in the treatment of cancer and the side
effects of current treatments of cancer. Botox has been shown to reduce vesicle transport in breast
cancer cell lines; further research is ongoing to see if this has an effect on cancer growth. Research in a
mouse model has shown that preradiation treatment of the salivary glands with botulinum toxin
conferred protection. A phase I trial is ongoing to see if this carries over to humans.
Further work continues on elucidating the clinical efficacies of the different subtypes of botulinum
toxin. Currently all the type A toxin used clinically is subtype A1. Kaji et al. described the clinical
efficacy of the A2 subtype and found it was 1.5 times that of onabotulinumtoxinA (subtype A1) with
similar time course and less spread of its action to a neighboring muscle. Further studies into this
subtype and other subtypes are currently underway.
In addition to its use for neurogenic overactive bladder, studies have also suggested a role for
botulinum toxin in the treatment of interstitial cystitis and chronic bladder pain, as well as chronic
prostatitis. Studies suggest that intravesical botulinum injection reduces bladder pain and increases
bladder capacity and can reduce inflammation.
The following material will in greater depth describe the use of botulinum toxins for the
management of disorders of efferent nerves and muscular hyperfunction; afferent nerves, pain
disorders, and inflammatory conditions; autonomic nervous system disorders; and glandular
hypersecretion (Box 1.1).

Box 1.1
Therapeutic uses of botulinum toxins
I. Hyperfunctional muscular use

1. Dystonia

27
a. Cervical dystonia

b. Blepharospasm

c. Oromandibular dystonia

d. Spasmodic dysphonia

e. Occupational writer's cramp

f. Foot dystonia

g. Musician's dystonia

h. Facial dystonia

i. Meige syndrome

j. Tic disorders and stuttering

2. Hyperfunctional facial lines (cosmetic)

3. Hemifacial spasm/facial synkinesis

4. Strabismus

5. Esotropia/exotropia

6. Nystagmus

7. Poststroke and cerebral palsy spasticity

8. Tremor disorders: limb, neck, vocal

9. Myoclonus

10. Other laryngeal disorders: puberphonia, vocalis process granulomas

II. Autonomic nervous system use

1. Hyperhidrosis: axillary, palmar, plantar, and facial

2. Benign prostatic hypertrophy

3. Sialorrhea/sialocele/drooling

4. Rhinitis

5. UES/LES achalasia

28
6. Neurogenic hyperactive bladder

7. Frey syndrome

8. Anal fissures

9. Vaginismus/anismus

III. Afferent nervous system, pain syndromes, antiinflammatory

1. Tension headaches

2. Migraine headaches

3. Temporomandibular disorders/bruxism

4. Myofascial pain

5. Postherpetic neuralgia

6. Arthritis

7. Trigeminal neuralgia

8. Low back pain

IV. Glandular and secretory cell modulation

1. Growth hormone/acromegaly
LES, Lower esophageal sphincter; UES, upper esophageal sphincter.

Hyperfunctional muscular uses

Cervical dystonia (spasmodic torticollis)
Dystonia is a group of neurologic disorders characterized by muscular hyperfunction with abnormal
movements and/or postures often accompanied by pain. Cervical dystonia, the most common of the
dystonias (most often lateral colli, but also retrocollis and anterocollis) comprises disorders with
abnormal neck postures and pain. Results of injecting the hyperfunctioning and painful muscles with
botulinum toxin in several randomized, placebo-controlled or open-label studies have shown that 50%
to 90% of patients receive benefit (improved function and/or reduced pain). The results may vary with
dose and choice of muscles to be injected. The dosage range for Cervical Dystonia (CD) is 200 to 400
units of Botox®. Xeomin®, botulinum toxin A (Merz Pharm.) has also been approved by the FDA for CD.
Myobloc®, botulinum toxin B (Solstice), has been FDA approved for CD, particularly in patients who
have a resistance to type A toxin.
Blepharospasm is a focal dystonia affecting the orbicularis oculi muscle, producing excessive
blinking or eye closure. This was one of Alan Scott's original studies and led to toxin use in other
dystonias. Using botulinum toxin A for management of blepharospasm has been shown in several
studies to produce significant improvement in 70% to 100% of patients. Toxin injections have become
the treatment of choice for this disorder. Scott's original work comprised studies of toxin use for eye
muscle balancing in cases of strabismus and later esotropia, exotropia, and nystagmus.
Scott extended the use of toxin to patients with hemifacial spasm. This is a condition in which the
anterior inferior cerebellar artery beats on and compresses the facial nerve (VII), causing irritability

29
and facial twitching. The treatment can be a neurosurgical decompression of the nerve or injections of
botulinum toxin into orbicularis oculi and may include the zygomaticus and levator labii muscles to
diminish the twitching and hyperfunctional activity. The same approach may be used for patients with
posttraumatic or post-Bell palsy facial synkinesis. Aside from treating the synkinetic side of the face,
often toxin is given to the contralateral face to balance the weakness for symmetry. These facial studies
led to a number of investigators realizing the cosmetic benefit for functional facial lines and opened
the door for injections of toxin for cosmesis.

Pearl 1
Botulinum toxins may be used for management of lines and wrinkles of the face that are related to
pleating of the skin overlying the facial muscles of expression.

Pearl 2
Botulinum toxin may be used to control hyperfunctional muscular conditions, such as dystonia,
tremor, spasticity, and synkinesis.

Oromandibular dystonia (OMD) is a focal dystonia affecting the muscles of the jaw and may present
most commonly with closing spasms, making opening of the mouth for eating and chewing very
difficult. It may also present with opening spasms, making closing of the mouth difficult, or with
lateral or protrusive spasms of the jaw. Some patients may have writhing movements of the jaw, making
speaking and eating difficult. In a number of cases the tongue is also involved, producing not only a
jaw opening but also uncontrolled tongue protrusion. When this is combined with other cranial
dystonias (usually blepharospasm) it has been termed “Meige syndrome.”
Our group successfully treated the first OMD with botulinum toxin in 1983. We reported our series in
a publication in 1989. Treatment of the tongue with toxin is often ill advised in many of these patients
because the production of a hypofunctional tongue causes dysarthria and significant dysphagia. The
successful treatment of OMD led to the management of other hyperfunctional disorders of the jaw,
including temporomandibular disorders (TMDs) and bruxism. The usual muscles injected are the
masseter, temporalis, and external pterygoids.
Spasmodic dysphonia is a focal dystonia of the larynx. Most patients have the adductor or closing
type, producing a strain-strangled voice type. We performed the first injection of botulinum toxin
injections of the larynx for this condition in 1984. The other types are the abductor or opening type that
produces a whispering voice or voice with breathy breaks. There are also patients with adductor
respiratory spasms and a singer's dystonia. All of these can be managed with botulinum toxin
injections, and this has become the standard treatment for these disorders. Laryngeal injections were
extended to include management of vocal tremor, vocalis process granulomas, puberphonia, stuttering
with glottal block, and other hyperfunctional vocal disorders.
Occupational writer's cramp (focal dystonia of the hand) was also found to be a disorder in which
toxin can reduce spasm and return normal function. These injections are usually given with
electromyography (EMG) guidance into the muscle causing the abnormal postures or contractures. This
treatment also is for other functionally specific hand dystonias including stenographer's dystonia and
musician's dystonia. This treatment was extended to include dystonias of the feet. In cases of more
generalized dystonia the abnormal limb postures can also be reduced and function increased with toxin
injections of the affected muscles. Treatment has also been extended to patients with poststroke
spasticity and cerebral palsy spasticity. Toxin treatment has reduced the contractures and pain.
Extending the concept of reducing hyperfunctional muscle activity with toxin injections, patients
with tremor disorders and myoclonus have been successfully treated. This includes treatment of the
limbs, neck, palate, and vocal cords. Although the toxin does not prevent the tremulous activity, it can
decrease it, thereby decreasing the patient's symptoms.

Autonomic nervous system use

Based on observations of patients with botulism, many have autonomic symptoms, such as dry eyes
and dry mouth. Because the sweat glands are cholinergic, it became obvious that toxin injections
should be able to decrease their function. Numerous studies have shown this and led to FDA approval
for axillary hyperhidrosis. Studies have also shown efficacy on palmar, facial, and plantar hyperhidrosis.

30
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wonderful activity, till presently the quarry began to show signs of
fatigue, and the hawk was on the point of securing his prey, when in
cut another hawk, and at a single swoop carried off the game. The
poor snippet’s shrill screams ceased at once, and the hawk, thus
cheated of his rights, quietly sailed away in the opposite direction.
Beyond Julen we passed Zydabad and Nazlabad, and half a dozen
other villages, to the right of the road; and then meeting a few
horsemen who were hurriedly sent out by way of isticbál, were
conducted by them through the covered bazárs of Sabzwár to the
quarters prepared for us in the centre of the town, and adjoining the
residence of the governor. Here we were received by the governor
himself, Muhammad Taki Khán, with pleasing civility and attention.
He is quite European in manner and appearance, and speaks French
like a Frenchman, as do most Persian gentlemen of the modern
school.
Sabzwár, we were told, contained four thousand houses, only half
of which are now tenanted. The district is said to have lost twenty-
four thousand souls by death and emigration during the famine. The
loss of Nishabor district is reckoned at only twenty thousand, which I
think must be under the mark, for its population is naturally much
above that of Sabzwár, which only comprises nine bulúk, some of
which are very sparsely populated. They are Shamkán, along Káli
Shor to the south, Gomesh, Humaon, Kasaba, between Sabzwár and
Záfaráni, Tabbas, Káh, Mazinán, Tagao, to the north of the plain, and
Zamand. Besides these, the bulúk of Júwen and Bám of the
Burdjnurd district have recently been added to Sabzwár by the
Hisámussaltanat.
13th May.—Sabzwár to Mihr, thirty-three miles—route west
through an uninterrupted sheet of corn for two miles, then across an
undulating plain, gradually sloping to a salt desert on our left. At
four miles passed Abári village, and, near it, the Míl Khusro Gard.
This is a lofty minar standing by itself in a ploughed field. It is built
of red bricks arranged in arabesque pattern, and is much decayed.
At a little distance from it stands a domed mausoleum, coated with
plates of tin or similar white metal. From its interior proceeded the
voices of men chanting the Curán. None of our party could tell us
anything about these relics, and there was no stray peasant whom
we could charge down upon and question; so I must be content with
the bare record of their locality.
At five miles on we passed Pírastír and its gardens and corn-fields,
and at another five miles came to an ábambár where the road
branches. That to the left goes W.S.W. by Námen and a succession
of deserted villages on the edge of the salt desert to Mazinán. It is a
fearful road, and how any one could take it, with the option of a
better, is a mystery. Not a particle of vegetation was to be seen; the
whole vista was one of aridity and salt, blinding with a dazzling
glare, and great heaps of drift-sand half buried the little castles
lining the route. Yet the road was a well-trodden track, indicating
frequent use. That to the right went W.N.W. up a rising ground, and
at four miles brought us to Rewand, where we found shelter from
the heat of the midday sun under the shade of some magnificent
plane-trees in the midst of the village. It is delightfully situated
amidst gardens and vineyards, and outwardly has all the
surroundings of prosperity and plenty, but inwardly, within its houses
and courts, who can tell the amount of misery and suffering that
there reigns? We could only guess it from the number of poor men
and women who, through fear of our escort, stealthily crept amongst
the bushes to our resting-place, and in low voices begged a morsel
of bread, whilst gathering up and munching the crumbs and bones
thrown aside from our late repast.
Proceeding hence, we followed a long hill skirt strewed with bits of
trap, and chlorite, and cellular lava, washed down from the hills to
our right, the base of which is set with red clay mounds, in the
hollows between which are spied many little hamlets and
farmsteads. At six miles we passed a roadside pond, and thence
sloping down gradually, at another six miles reached Mihr, where we
camped at 6.20 p.m.—the thermometer 84° Fah.
 14th May.—Mihr to Mazinán, twenty miles—route due west down a
gentle slope skirting the Chaghatay hills, that separate us from
Júwen on the right. The soil is bare and gravelly, and slopes down to
the desert on our left. At four miles we passed through the Súdkar
village, which is the only one on the route. On approaching our
camp at Mazinán, we left a large village at the foot of the hills to the
right. It is called Dawarzan, and is protected by a double row of
outlying Turkman towers.
Mazinán is a small village on the edge of the desert, and adjoins
the ruins of an extensive town, in the midst of which stands a
decayed sarae of the Arab period. There is a post-house here, and
also a good newly-built sarae. The place wears a wretched
inhospitable look, and in summer must be very hot.
15th May.—Mazinán to Abbasabad, twenty-three miles[3]—route at
first north, and then round to the west, along the skirt of the hills
bounding an arm of the desert. Soil gravelly, and surface covered
with saltworts, camel-thorn, mimosa, tamarisk, and similar
vegetation. At half-way we came to the Sadarabad Sarae and halted
for breakfast. It is a recently-built and commodious structure,
erected by the late Sadar Azím, and is furnished with a good
ábambár. Opposite is a small fort for the accommodation of a few
families charged with the care of the sarae. There is no village here,
and the supplies are brought in and stored periodically from
Sabzwár. There are no trees nor cultivation here, and the whole
population consists of three men, as many women and one child,
and a very miserable set they look. They were anxious to leave the
place, as they were in hourly dread of Turkmans, and owing to the
few travellers now frequenting the route, never made any money.
Whilst here, we were overtaken by a courier with our last post from
Peshawar through Afghanistan, with dates to the 10th April. It had
been sent from Mashhad by a Persian courier, and ought to have
reached us at Sabzwár; but the Persian has not the energy of the
Afghan.
 Ahead of us is a dangerous bit of desert, which is always infested
by Turkmans; so, on setting out from Sadarabad, careful
preparations were made for our passage across it. Our baggage and
servants, &c., were all collected together, and massed in a close
column outside the sarae. The gun was placed at their head, and
protected by a score of matchlockmen, whilst the rest ranged
themselves Indian-file on either side the column. The cavalry took
up their posts on the flanks, front, and rear, and threw out advanced
parties, who topped every rising bit of ground to scan the country
ahead.
All the arrangements being completed, our trumpeter brayed out
some hideous sounds, which of themselves were enough to scare
the enemy, if the gun was not, and we proceeded, ourselves
amongst the horsemen in advance of the gun. At a couple of miles,
over a flat bare clay surface, we came to a rivulet crossed by a
crumbling brick-bridge of very ancient appearance. This is Pul
Abresham. Here there was a block in the passage. We had about a
hundred camels, more than half the number of mules, and asses
innumerable, for every matchlockman had his accompanying ulágh
(beast of burden), and there were besides several others who had
taken advantage of the opportunity to join our caravan. The bridge
was narrow, and only a few could pass at a time; presently a few
scattered horsemen were spied far away on the desert to the left.
The news spread like wildfire. “Haste to the front!”—“Keep
together!”—“Cross quickly!”—“Don’t lag behind!”—resounded on all
sides from our escort. The bridge was abandoned to the camels and
mules and asses, and horsemen pushed across the muddy stream
on either side of it, and again formed up on the open ground ahead.
Some horsemen had galloped on in advance to bring intelligence
regarding those we had seen on the desert, and meanwhile the
crowd in the caravan looked around watchfully in every direction, as
if they expected a Turkman to start up from behind every bush that
dotted the plain. The terror these well-cursed marauders inspire in
the Persian breast is laughable, were it not for the reality of the
cause. Men who bounce and brag of their prowess when they have
hundreds of miles between them, pale and shiver in their shoes
when they find themselves in a position where they may meet them
face to face.
After a brief halt here, our horsemen on an eminence some way
ahead were seen to dismount. On this our leader pronounced the
road clear, and we set forward again. This tract has from time
immemorial been infested by Turkmans of the Goklán and Yamút
tribes, whose seat is in the valley of the Atrak. A country better
adapted to their mode of warfare could nowhere else be found. The
hill ranges to the north afford them an unobserved approach to their
hunting-grounds. Arrived on them, they conceal themselves amongst
the inequalities of the surface, finding water in some ravine, and
pasture for their horses in the aromatic herbs and rich grasses that
cover the hollows. Their scouts from the eminence of some
commanding ridge, or the top of some of the innumerable
mameloned mounds and hummocks that form the most striking
feature of the country, watch the roads, and on the approach of a
caravan or small party of travellers, warn their comrades, who
dispose themselves for the attack. If they find the caravan is
marching on the alert and with precaution, they act on the principle
that “Discretion is the better part of valour,” and remain in their
concealment; otherwise they proceed along the hollows to some
spot where the road strikes across a bit of open ground, and so soon
as their prey is fairly out on it, they sweep down upon them, and
generally, I am assured, carry them off without resistance, for
resistance, the Persians have learned, means death.
In conversation with one of our escort, I asked him why the
Government did not make a great effort, and for once and all put an
end to this constant source of trouble and loss? “Pul!” (money), he
said, with a Gallic shrug of the shoulders; “our Government won’t
spend the money. This is an old institution. Nobody put a stop to it
before, and who is to do it now? The present arrangements meet all
requirements. A guard starts twice a month to escort coming and
going caravans between Mazinán and Shahrúd, as we now escort
your party, and that meets all wants.” “Have you ever been attacked
on this duty?” I asked. “Very seldom, and only when the Turkmans
take the field in great force. They mostly attack small parties
travelling without a guard, or sweep off the peasantry at work in
their fields, or surprise a village at day-dawn.” “But are no
arrangements made to protect these people?” “What would you
have?” he replied. “Travellers have no right to move without a guard
in a dangerous country, and the villagers have the protection of their
forts.” “But surely the country would be better off if there were no
Turkmans to harry it,” I said. “Of course it would; but we don’t hope
for such good fortune from our Government. You people might do it,
or the Russians might do it; but we can’t. People say the Russians
are going to rid us of the Turkmans—God grant they may! and if
they clear these pidr sokhta (burnt fathers) off the face of the earth,
they will gain the good-will and esteem of all Persians.” “How,” I
asked, “could the Russians rid you of the Turkmans?” “Russia is a
great country, and very wealthy, and has a large army. What are the
Turkmans to them? If they will only spend their money, they can do
anything. People say they are going to conquer Khiva, and are
making preparations for the campaign. So soon as they take Khiva,
the Turkmans of Marv will also disappear.”
I further learned from my informant, that the Turkmans of the
Atrak valley raid all the country from Shahrúd and Samnán to
Sabzwár and Nishabor, where they meet their brethren of Marv, the
Takka, Sarúc, and Sálor Turkmans, who raid all the country between
Mashhad and Herat up to Sabzwár, thus cutting off from Persia all
that portion of the country to the north and west of the great salt
desert of Káshán and Yazd, so far as security of life, liberty, and
property is concerned.
But to return to our route. Pul Abresham, or the stream it bridges,
marks the boundary between the districts of Sabzwár and Shahrúd.
There is another bridge of the same name about thirty miles higher
up the stream, on the direct road from Shahrúd to Mashhad, by
Jájarm and Júwen; but being more dangerous, it is less frequented
than this route.
 The Pul Abresham river also marks the extreme north-west limit of
the Afghan kingdom founded by Sháh Ahmad, Durrani. It flows
south-east, and joining the Káli Shor, or Nishabor, and Sabzwár, is
ultimately lost in the salt desert between Yazd and Káshán. Beyond
the Káli Abresham, we crossed some low slaty ridges where they
terminate on the desert, and traversing a gravelly plain thinly dotted
with tamarisk bushes, rose up to the ridge on which the Abbasabad
Sarae stands, and camped on some mounds under its walls, our
escort filling the sarae.
Our next stage was twenty-two miles to Myándasht—route
westerly, over a broken country thrown into little mameloned
mounds, with hills on our right. At six miles we came to the Dahna
Alhác, an easy defile winding between bare rugged hills of coarse
brown trap. On our way through it, we met a caravan of pilgrims on
their way to Mashhad, escorted by a military guard similar to our
own. It was a curious spectacle, from the variety of costume and
nationality and conveyance, all jumbled together in jostling
confusion. We passed each other with mutual stares of wonderment,
and I did not appreciate the novelty of the scene till it was gone
from my sight. There were great shaggy camels bearing huge
panniers, in which were cooped three or four veiled bundles of
female beauty, rolling from side to side like a ship in a heavy swell.
There were others mounted by wiry Arabs in their thin rope-turbans,
or by thick-set Tátárs in their shaggy sheepskin caps, swaying to and
fro with an energy that led one to suppose that the speed of the
camel depended on the activity of their movements. There were
pannier-mules bearing veiled ladies and their negress slaves,
accompanied by their Persian lords, gay in dress and proud, on their
handsome little steeds. There were quiet calculating merchants, with
flowing beards and flowing robes, borne along by humble ponies as
absorbed in thought as their riders; and there were sleekly attired
priests, serene in their conscious dignity, comfortably flowing with
the tide on their well-groomed and neatly caparisoned mules. There
were others too, a mixed crowd of footmen and women, all dusty
and hot, struggling on to keep pace with their mounted wayfarers.
How many will lag behind and fall to the Turkman’s share? There are
amongst these whole families emigrating in search of food and work:
father and mother each bear an infant on their backs, and two or
three of tender years trot by their side. There are tattered beggars,
reduced by sheer want; and there are other beggars, the impudent,
idle, and dissolute scoundrels who impose on the community by an
ostentatious assumption of the religious character, through no other
claim than that of their bold importunity, backed by noisy appeals to
true believers in the name of God and Ali. Their trade pays, and they
flourish in their rags and dissoluteness.
With this caravan came a courier with despatches from Tehran for
Sir F. Goldsmid. He was a mission servant, and had been sent off
from our camp at Birjand with letters for Mr Alison, the British
Minister at the court of Persia, and was now returning with the
tidings of his death on the 29th April. After a brief pause, during
which “Ismáil,” for such was his name, greeted his old comrades all
round with a kiss each on the mouth, we proceeded, and clearing
the defile, halted for breakfast, and to read our letters and papers,
at the dilapidated sarae of Alhác.
Beyond this our route led over a broken hummocky country, in
crossing which we were overtaken by a thunderstorm and rain, and
gently sloped to the Myándasht Sarae, situated, as its name implies,
in the midst of a desert plain girt by hills. The soil is a firm gravel,
and not a tree is to be seen, though the surface is covered with the
asafœtida and rhubarb, the latter in flower.
17th May.—Myándasht to Myánmay, twenty-four miles—route
westerly, over a very broken country, similar to that traversed
yesterday, and intersected by numerous ravines draining to the
northward. At about twelve, we crossed a deep gully called Dahna-e-
Zaydár, and pointed out as one of the favourite routes by which
Turkmans come from the Jájarm valley. At six miles farther on,
crossing a wide stony ravine, we halted for breakfast under the
shade of some sinjit (oleagnus) trees on its bank, close to the fort of
Zaydár. This is apparently a recent erection, and is held by a small
garrison of sarbáz who watch the Myánmay valley. On the summit of
a high rock projecting from the neighbouring hills is a look-out tower,
held by a small picquet. Beyond this we skirted the hill range on our
left, and arrived in our camp at Myánmay just in time to escape the
fury of a thunderstorm with hail and rain, and the cold raw blasts of
a north-west wind.
Myánmay is a considerable village at the head of a long valley,
which towards the east is continuous with that of Júwen. To the
northward the valley is separated from Jájarm by a range of bare
hills, through which are several passes. The hill skirt is dotted with
flourishing-looking villages, whilst the valley itself is a wide
uncultivated pasture tract.
There is a very fine sarae here, and some splendid mulberry-trees
around give it a charming appearance. The sinjit trees are now in full
flower here, and quite overload the air with their strong perfume. On
the top of a high hill overlooking the village from the south, there
are, it is said, the ruins of an ancient town, and some reservoirs
excavated from the rock. We could see no traces of them, however,
and as the information was volunteered by a Persian of our escort, it
may be only a myth.
18th May.—Myánmay to Shahrúd, forty-one miles. We set out at
2.45 a.m., before it was light, our camels with the heavy baggage
having preceded us by four hours. Our route was west by north,
over a plain country for twelve miles parallel to a hill range on our
left, and then diverging to the right, led across a very uneven
country overrun by gravelly ridges and intersected by ravines, the
slopes of which are richly covered with pasture herbs; and another
twelve miles brought us to a roadside ábambár, where we halted for
breakfast, and to let the camels with the heavy baggage, here
overtaken by us, get ahead.
Along the foot of the hills, parallel with the first part of our route,
is a succession of picturesque little villages and orchards, that
extend for six farsakhs up to Armyán, half-way on the route from
Myánmay to Shahrúd. They are on the line of road followed by
single travellers or small parties, for the sake of protection afforded
by the villages.
From the ábambár our course led due west across an open and
gently sloping plain, towards Shahrúd, visible in the distance, at the
foot of a bare rocky hill, that separates it from Bostám, at the base
of the great snow-crowned Kháwar mountain, and at the entrance to
the pass of the same name leading to Astrabad. Both towns are
delightfully situated, and their luxuriant gardens present a most
pleasing view to the eye in this waste of desert and hill.
At a few miles short of Shahrúd we alighted at a small canal,
fringed with sinjit trees, and rested under their shade till our jaded
cattle had gone on with our camp. Our whole party was much done
up by the length of the march and the heat of the midday sun. But
strange to say, our escort of matchlockmen, of all our following,
showed the least symptoms of fatigue. As I mentioned before, they
were accompanied by a number of asses carrying their clothing and
stores of food, &c. The patient little brutes moved along with their
owners, who, turn about, strode across their backs, and thus, riding
and walking alternately, escaped the exhaustion of a long march and
the fatigue of the unvaried ride. The Persian infantry soldier, or
sarbáz, as he is called, is noted for his hardihood and endurance of
long marches, but the humble ulágh contributes no small share to
his reputation in these respects. He is cheaply got, easily managed,
and costs little or nothing to feed, being generally left to pick up
what he can off the ground. The ass of the sarbáz, who yet knows
neither a commissariat nor transport corps, is a useful institution—in
fact, he is indispensable, for, under the existing conditions, the
infantry soldier could not march without him. They would certainly
not prove so efficient and ready as they are without him. We no
sooner arrived at Shahrúd than our escort of sarbáz were ordered
off to accompany the governor of Bostám on an expedition against a
party of Turkmans, who, it was said, had come through Jájarm on
the chance of cutting us off on our way across the desert. They were
to proceed with all speed to take up a position in some pass of the
hills, by which alone the Turkmans could leave the valley, and away
they went merrily, with no impedimenta of tents, baggage, and
luxuries.
We halted five days at Shahrúd, where we came into
communication with the civilised world through the line of telegraph
connecting Astrabad with the Persian capital. The town is a
flourishing place, surrounded by vineyards and fruit gardens, now in
full foliage, and must be a delightful residence. Our camp is pitched
on an open bit of ground between some walled gardens in the midst
of the town, and close to a sarae occupied by some Russian and
Armenian merchants. We meet them as we issue for our evening
ramble, and pass with a polite doffing of hats. They have been
settled here for the last twelve or fourteen years, but have not got
their families with them. From one of them we got a supply of very
indifferent wine, prepared on the spot, and picked up some copies of
Russian primers with pictorial alphabets and illustrated anecdotes.
This place is the entrepôt of the trade between Tehran and the
countries to the north and west, and has several commodious
saraes. It is also an important strategic position, situated as it is at
the entrance to the pass leading to the Caspian, and is the place
where the Persian armies concentrated preparatory to their
campaigns in Khorassan. The plain to the south of the town is well
watered from numerous hill streams, and is dotted with several
flourishing villages, the chief of which are Badasht, Bázij, Ardyán,
Mughán Jáfarabad, Husenabad, Ghoryán, &c. The Shahrúd district,
of which this town is the capital, extends between the hills from
Abbasabad on the east to Dih Mullah on the west, and contains
some fifty or sixty villages. The governor, Jahánsoz Mirzá, resides at
Bostám, but has an agent here.
We did not visit Bostám, only four miles off, as the governor
neither called on us nor made any advances towards the interchange
of civilities. Our Afghan companion, however, Saggid Núr
Muhammad Sháh, went over to pay his devotions at the shrine of
the Imám Báezid, which he described as an unpretending pile of
loose stones, raised by the contributions of passing pilgrims. The
saint is held in great veneration, and the simplicity of his tomb is out
of deference to his dying injunction that no mausoleum should be
built over his grave. In an humble grave near the shrine rest the
mortal remains of the late Amir Muhammad Azím Khán, the usurper
of the throne of Kabul. After his final defeat at the hands of the
reigning Amir, Sher Ali Khán, in the beginning of 1869, he fled to
Sistan, and was on his way to the Persian capital, when he was cut
short in his career by cholera at this place, about the 6th July. The
Saggid, being an adherent of the opposite party, suffered severely at
the hands of the usurper, who plundered his property at Kandahar to
the extent, it is said, of fifty thousand rupees. He took this
opportunity, however, to forgive him, and to offer up a prayer for his
soul.
The day before our departure from this, a strange Afghan came to
my tent, and, with looks of pleased recognition, said, “Saggid
Mahmúd sends his salám, and begs you will give him some medicine
to cure fever and dysentery. He is too ill to move, or he would
himself have come to pay his respects.” A few words of explanation
sufficed to inform me that my applicant was no other than our old
friend of Ghazni, whom we so unexpectedly met at Barshori at the
very outset of our journey. We went over to see him in his lodgings
at the sarae, and found him in a truly wretched plight, so emaciated
and weak was he from the combined effects of the hardships he had
endured on his long journey, and the exhausting nature of his
disease. He rose and received us at the door of his cell, with all the
grace of that innate gentility well-bred orientals can so easily display,
and ushering us in with a dignity enhanced by his handsome
features and snow-white beard, motioned us to seats formed of
hastily arranged rugs, with a composure and self-possession quite
charming and wonderful under the circumstances. He ordered his
servant to prepare some tea for our refreshment, and the while gave
us an account of his travels. “Poor Cásim,” he said, the tears
dimming his bright eyes, “tamán shud—he is finished. His remains,”
he added with a consolatory sigh, “rest in the sacred soil of Karbalá.
He was the son in whom my hopes centered, but God gives and God
takes away—His will be done.” The details of his journey through
Kúm were simply harrowing, and the scenes he witnessed appalling.
Dead bodies strewed the roads and poisoned the air with their
putrescence. The saraes were filled with the dying, whose wails and
sufferings produced a scene impossible to describe. The villages,
empty and still as a house of mourning, were invaded by troops of
dogs, who contested with the survivors the possession of the dead.
Loud were his lamentations for Persia. “The country is gone,” he
said. “There is neither religion, justice, nor mercy to be found in the
land. We (he was a Shia) in Kabul look to Persia as the centre of all
that is good in Islám, but Afghanistan, with all its faults, is a better
country to live in.” Poor old gentleman! he quite brightened up at the
idea of moving on homewards, though he had one foot in the grave
already, and was fully a thousand miles away from his home, and
talked composedly of retiring into private life, and devoting the rest
of his days to the worship of God and meditation on His laws. On
our departure, the General, with characteristic kindliness and
forethought, presented our pilgrim friend with a Kashmir scarf. The
old man’s gratitude was touching, and he blessed us all round. I
wonder if the old man ever did reach his home, though the chances
were greatly against his doing so? But it is astonishing what
distances these pilgrims do travel, and what hardships they endure
on the way. Let us hope that the old man did complete his circle.
When we met him on this second occasion, he had in the course of
six months travelled from Ghazni to Kandahar and Shikárpúr and
Bombay, thence by sea to Baghdad, and thence to Karbalá, and back
to Baghdad, and thence by Kirmánshah and Kúm to Tehran, and on
to this place. He has yet before him the inhospitable route from this
to Mashhad, and thence to Herat and Kandahar, before he can reach
his home at Ghazni. I gave the old man a small supply of medicines,
and some hints for observance on the road; and with all good wishes
for his onward journey, and a small sum to assist him on the road,
we parted.
 CHAPTER XII.
24th May.—Shahrúd to Dih Mullah, sixteen miles. We set out at
5.30 a.m., bidding adieu to Mr Bower of our party, who at the same
time set out for Astrabad en route to London with despatches. If
fortunate in catching the steamer and trains, he hopes to reach his
destination in twenty days, viâ Astrakhan, Czaretzin, Berlin, &c. Were
but Afghanistan an open country, Indian officers proceeding on
furlough might with advantage take this route homewards. But as it
is not an open country, and there is little use in speculating when it
will become so, its peoples and mountains and deserts may yet for
another generation maintain their isolation from the civilised world,
and remain a country of interest to the politician, and a region of
curiosity to the scientific man.
Our route led S.S.W., along a stony hill skirt by a well-beaten
track, following a line of telegraph posts, a promising emblem of
Western civilisation in this yet semi-barbarous land. The hills on our
right belong to the Alburz range, that separates the Caspian basin
from the tableland of Persia. The northern slopes are described as
clothed with dark forests, the southern, however, are precipitous,
and mostly bare, a few juniper-trees only dotting the rocks here and
there, as little black specks on their rugged sides. The range is said
to abound in wild goat and sheep, and the stag or gáwaz, called
bárásinghá in India. The leopard and bear are also found on it, and
on its eastern spurs a small species of lion, but not the tiger.
To the left of our route the land slopes down to a water-worn
ridge of red clay. It separates the Shahrúd valley from the salt desert
to the south. A range of hills rises out of the desert far away to the
south. One of our escort called the range Jandak, and pointed out a
prominent peak as Ahwand. Jandak is twenty farsakhs from this, and
contains ten or twelve villages on the edge of the desert, where
palm-trees grow in plenty, as my informant said. He was a very
communicative man, and after volunteering scraps of information
regarding the country we were traversing, took an early opportunity
to enlarge on his own grievances.
“The present the sardár” (chief), pointing to Sir F. Goldsmid, “gave
us sowars and sarbáz, has been taken from us by the governor,” he
said. “We have been so many days out,” he added, “our horses are
exhausted, and we are famished. Nobody cares for us, and the
villagers have nothing we can take from them.” “It is hard,” I said,
“but it is the custom of your country.” “Yes, it is the custom of the
country,” was the ready reply, “and that is why our country is
ruined.” “With the aid of the famine,” I add. “The famine! no that is a
decree from God, and we must submit. No one can fight against
what God ordains. But our governor is a very hard master. He is
deeply in debt, and screws his subjects to pacify his creditors. Not a
pul-i-siyáh (a copper coin) escapes his grasp; and there are many
like him. Irán tabáh shud—Persia is ruined. Khyle, khyle sakht ast—it
is very hard.”
And so it is really. We found the Afghan troops in every respect
better off than those of Persia. They are physically finer men, are
better clad, better armed, and better provided with shelter, carriage,
and provisions, though there is room for improvement on all points.
At Dih Mullah we were accommodated in a double-storied
summer-house, in an ornamental garden adjoining the village. Its
shelter, such as it was, with doors and windows opening in every
direction, was hardly so efficient as that afforded by our tents
against the chill gusts of wind sweeping down from the hills to the
north. The situation, however, afforded us a wide prospect of the
country, which, from its nature, hardly compensated for the
discomfort. To the south was an unlimited view of a vast salt desert,
as unvaried as the horizon-girt ocean. To the north rose a barrier of
bare rocks, tipped here and there by snow, and dotted above by
black spots, like one with a mild attack of small-pox; and on either
side lay a long gravelly valley, with a string of villages and gardens
running down its central course.
This evening, having reserved a small supply of wine for the
occasion, we observed the Queen’s anniversary, and at dinner raised
our glasses “To the Queen—God bless her!”
25th May.—Dih Mullah to Damghán, twenty-six miles. We set out
at 3.30 a.m., by the light of a full moon—route south-west along the
valley, passing a succession of villages with their gardens and corn-
fields. The gardens are luxuriant in their foliage, but the corn crops
are thin and backward. Nobody is seen moving about; the villages
are half empty, and a painful silence reigns over a scene outwardly
so prosperous. At about half-way we passed the large village of
Mihmándost, near which are the ruins of the ancient city of
Damghán, the scene of the grand battle between Nadír and Mír
Ashraf, Ghilzai, in which the latter received the first of those crushing
defeats that soon after led to his flight from the country, and
ignominious death at the hands of some petty Baloch robbers in
Sistan, and the expulsion of the Afghan invaders from the Persian
soil in 1730. The ruins present nothing worthy of attraction, and but
for the decayed domes and small mounds that rise amongst the low
broken walls, might be easily passed without notice.
Damghán is a decayed little town, full of ruins ancient and recent,
though buried in the midst of most prosperous-looking gardens. It
has suffered frightfully in the famine, its population having fallen, it
is said, from a thousand to two hundred families. There is a
telegraph office here, and a very fair sarae. Our next stage was to
Khoshá Sarae, twenty-three miles—route south-west, over a plain
country skirting a hill range to our right, and passing twenty-five or
thirty villages en route; morning air cold and bracing. Khoshá is
simply a sarae on an uncultivated gravelly plain at the entrance to a
pass in the hills dividing Damghán from Samnán. No supplies are
procurable here, and but a limited supply of water.
Our next stage was twenty-four miles to Ahuán Sarae, or the
sarae of gazelle deer—route south-west, gradually rising over an
undulating pasture country between broken hills. The soil is hard
and gravelly, and the surface is everywhere covered with a thick
growth of saltwort, wild rue, &c., and the ghích, on which we found
a number of camels at graze; but we found no habitation or water
on all the route. The weather was very changeable. The morning air
was sharp and chill, and during the day sunshine and cloud
succeeded each other, producing quite a wintry state of atmosphere
at this altitude, Ahuán being 6500 feet above the sea, 2240 feet
above Khoshá, and 2820 feet above Damghán. Owing to the wind,
the air here felt much colder than the thermometer said it was; and
for about the twentieth time on our march we found ourselves
retrograding back into winter instead of advancing into summer.
These sudden changes of climate and temperature are characteristic
of travelling in Persia. One passes up and down from the hot dry
atmosphere of the desert-bordered plains, to the chill damp air of
the cloud-attracting hills and their elevated tablelands, with such
rapidity that it is always necessary to be provided with warm clothing
as a protection against the ill effects of these sudden alternations of
temperature, and particularly against the cold winds that blow. The
Persian overcoat, with its close folds gathered in across the back, is
a well-suited garment for the protection of the loins, and no doubt
its adoption as a national costume is the result of its proved efficacy
or adaptability to the requirements of the climate.
Ahuán is merely a roadside sarae with a supply of water. There is
no village or cultivation here, nor are supplies procurable. There is a
tradition connected with the name of this place. It is to the effect
that the Imám Razá once halted here on his march to Mashhad.
Some huntsman in the neighbourhood brought in a deer he had
ridden down in the chase for presentation to the saint On seeing the
Imám, the deer appealed to his justice, and begged to be released,
on the plea of having a young one dependent on herself for support,
promising, so soon as the fawn grew up, to return and surrender
herself to her captor. The Imám at once directed the release of the
deer, and himself stood surety for her return at the appointed time.
The deer, however, did not return at the end of a year, and the fact
being reported to the Imám, he at once caused a deer to seek out
the huntsman, and surrender herself to him in his name. From this
time the deer in these hills have been held sacred, and are not
hunted, and are in consequence very numerous here.
28th May.—Ahuán to Samnán, twenty-four miles, and halt a day—
route S.S.W. through a hilly tract on to the plain of Samnán. At two
miles we crossed a watershed running north and south, at an
elevation of 6750 feet above the sea. It marks the boundary
between Damghán and Samnán. This wide tract of hills forms a
barrier between the plain valleys of Damghán and Samnán. It
extends from east to west about thirty miles, and rises 2500 feet
above the general level of the plains on either side. Its hills are an
emanation southwards from the Alburz range, and join a parallel
range on the borders of the salt desert, to the south. Its higher
ridges are perfectly bare, but the lower are richly clothed with
excellent pasture bushes and herbs, saltwort, wormwood, wild rue,
ghích, &c. We left this hill tract by a very narrow ravine, between
banks of conglomerate and ridges of friable slate, and descended a
long stony slope on to the plain of Samnán, and crossing its bare,
parched, stony desert surface, camped at a kárez stream under the
shade of some mulberry-trees to the north of the town. The plain
wears a desolate uninviting look, and is suggestive of unpleasant
heat in summer.
On approaching the town, we were met by an isticbál party of six
or seven horsemen, with a couple of led horses, and a rickety little
carriage drawn by a pair of very unkempt ponies. And on our arrival
in camp, the governor sent us some trays of sweetmeats and many
polite messages. There is a telegraph office here, but owing to a
break in the line ahead, we were unable to communicate with
Tehran. Though we are now only six stages from the capital, we
have received no later intelligence than the 29th April, received on
the 16th instant.
Our next stage was twenty-two miles to Lásjird, where we camped
on stubble-fields, near some ruined huts opposite the town—route
westerly, over a plain undulating and gently rising to the westward,
where it is narrowed by hills. At this place we received a post two
days out from Tehran, with letters dated London, 8th May. Weather
close and sultry, ending at sunset with a dust-storm, and slight rain
from the north-west A disagreeably high wind blew in squally gusts
all night.
Lásjird is a very remarkable little collection of dwellings on the
summit of an artificial mound with scarped sides. They are ranged in
two stories, in the form of a quadrangle, which at the south-east
angle is open, and presents a glimpse of the interior space. The
chambers open on to a balcony, that runs on both sides of each face
of the quadrangle, as shown in this diagrammatic sketch, which will
convey some idea of the general appearance of the place.

The sides of the mound are streaked with open drains, that carry
off all the sewage from the interior, and must render the places
above a very unwholesome and disagreeable habitation. The place
seemed pretty crowded, and numbers of its inhabitants looked down
upon us from the balconies running in front of their chambers. The
community thus crowded together must, judging from our single
night’s experience, lead a life of constant wrangling and quarrelling.
The voices of querulous old women and obstreperous children, and
the rebukes of angry husbands, kept us awake all night, with not the
best of wishes bestowed upon the Lásjirdis. This place looks unique
of its kind, but I am told that Yazdikhast is built on a similar plan.
Our next stage was twenty-five miles to Dih Namak. Set out from
Lásjird at 1.30 a.m., and crossing three or four deep ravines by
masonry bridges, passed on to a stony desert hill skirt that falls
quickly to the southward, where it merges into the salt desert, which
glistens in the morning sunlight as white as snow. At half-way we
passed a deserted village and ruined sarae, but on all the route saw
no cultivation or habitation.
The country is very uninteresting, and no incident occurred to
enliven the march or occupy our thoughts, and hence I suppose the
unwonted attention devoted to the peculiarities of our own
surroundings. We were marching in the usual order of procession—
that is to say, the Mirakhor Jáfar Beg, in his handsome Kashmir-
shawl-pattern coat, led the way, with a couple of mounted grooms,
each leading a yadak, or handsomely caparisoned horse, by which,
according to the custom of the country, all men of rank are preceded
when they take the saddle. Next came ourselves, and behind us
followed our personal servants, the Mirzá, and the escort. The last
had now dwindled down to only half-a-dozen horsemen. Our heavy
baggage with the camels generally went ahead overnight, and the
mules with our light tents, &c., followed in rear of our procession.
The Mirakhor, always serious in look, yet strictly deferential in his
bearing, was always ready with a reply to any and every query, and,
as may be conjectured, with no possible reliance on any of them.
“Mirakhor!” “Bale” (“Yes”). “The village of Sarkhrúd lies on our route
to-day. How far may it be from this?” “Yes, I know the place. You
see that hill ahead? Well it is just a farsakh beyond.” We move on,
prepared for another eight miles before we alight for breakfast; but
on cresting a low marly ridge ahead, a village buried in gardens lies
below us. “What village is this, Mirakhor?” “This is Sarkhrúd. Will you
breakfast here?” “Why, you said it was a farsakh beyond that hill.”
Without moving a muscle, or evincing a trace of discomposure, he
merely replies, “This side the hill. This is Sarkhrúd. Will you alight for
breakfast here?”
The way this man ate his own words was surprising, but the way,
under a quiet undemonstrative demeanour, he gathered in his
mudákhil, was more so; for, not content with charging double rates
all round, he charged for larger quantities than were actually
supplied. By the merest accident I gained an insight into the system
of corruption carried on under the specious rights of mudákhil, for
the extent of which I was not at all prepared. Our Afghan
companions kept their expenditure accounts distinct from ours, and
it was from what I heard from them regarding our Mirakhor’s desire
to cater for them too, that I first got an inkling of the liberality of his
views in the matter of perquisites, and his anxiety to prevent the
extent of them becoming known, by an attempt to get the whole
management into his own hands. Rogues sometimes fall out
amongst themselves, and so it happened one day that a quarrel
amongst our stable establishment threatened a disclosure of their
dishonest dealings. The Mirakhor, however, was master of the
situation, and the contumacious groom who demanded a larger
share of the spoil than his chief chose to give him was summarily
dismissed, and turned adrift on the line of march, on the accusation
of selling for his own profit grain given to him for the feed of the
horses under his charge. “Clever man!” whispered the observers, as
their respect for the Mirakhor’s savoir faire increased with his
success. “He deserves to prosper. You see he has got the upper
hand of his enemy. Any complaint he may hereafter prefer against
the Mirakhor will be declared malicious. Was he not deprived of his
post and turned adrift for a fault exposed by him?”
The discharged groom followed our party for several hundred
miles, up to the capital, and, what was more surprising, came out, in
his disgrace and downfall, in a new suit of broadcloth and silks, in
place of the discarded attire of his late mean occupation, and
certainly looked, so far as outward appearances go, the most
respectable of our servants. The Mirakhor after this coup affected a
character for honesty, and was more punctual than ever in the
observance of his religious duties. As the sun lit up the horizon, he,
and he alone, would move off the road, dismount, and, facing the
Cablá, perform his morning prayers, and then galloping up, resume
his position at the head of our party, with self-satisfied pride in his
singular devotion.
Dih Namak is a wretched collection of huts round a dilapidated fort
on the edge of the desert. Close by is a substantial and commodious
sarae. Our camp was at first pitched on the plain to its west, but the
wind blew with such force from the west, and raised such clouds of
dust, that we were obliged to strike the tents and take refuge in the
sarae—a move of very doubtful advantage; for though we escaped
the violence of the wind, we were almost stifled by the whirling
eddies of stable dust and litter, and tormented by myriads of the
voracious little insects bred in its deep layers.
1st June.—We set out from Dih Namak at 1.30 a.m., and marched
twenty-four miles to Kishlác, facing a high north-west wind, sensibly
warm even at this early hour, nearly the whole way. Our route was
westerly, skirting the Ferozkoh range of hills to our right, and having
a bare desert away to the left. The country is generally flat, dotted
by a succession of villages, and crossed by numerous branches of
the Hubla rivulet, which drains to the desert, and irrigates on its way
a wide surface of corn land.
At eight miles we came to the Padih village, and leaving a cluster
of four or five others on the right and left of the road, at two miles
farther came to Arazan, where there is a telegraph-office. Arazan is
the chief town of the Khár bulúk of the Veramín district, and is one
of the granaries of Tehran, and consequently by no means the “very
mean” country, one of our party facetiously styled it.
At nine miles from Arazan, crossing en route ten or twelve little
streams formed by the outspread of the Hubla river over the surface,
we arrived at Kishlác, and took refuge in its little sarae from the
wind, which blew with such force that we could not pitch our tents.
Our next stage was twenty-one miles to Aywáni Kyf—the “portals
of delight” to the traveller approaching the capital from the west—
route W.N.W., across a wide piece of cultivation, and then over a
gravelly pasture tract to the Sardárra defile. This is a winding path
through low clay hills, said to contain rock-salt. Through the defile
flows a small stream, the sides of which are encrusted with salines.
These hills emanate from Ferozkoh, and stretching on to the plain in
a south-west direction, separate Khár from Veramín. Beyond the
defile we went north-west over a wide pasture tract sloping up to
the hills, and camped on rising ground above the village. Aywáni Kyf
is a considerable place, surrounded by fruit gardens, and protected
by a neat fort, all situated on the right bank of a stony ravine that
issues from the hills to the north, amongst which rises aloft the
snowy cone of Damavand, a prominent object in the landscape as
one approaches from the defile.
We halted here a day, and received letters from Tehran in reply to
some sent off from our camp at Shahrúd. Persia has a telegraph line,
but she has no post. The delays and inconveniences resulting from
the absence of this established institution of civilised countries must
be experienced to be appreciated. To us, accustomed as we had
been to the daily receipt of intelligence from our friends, the
hardship was difficult to endure.
At this place we found the midday sun shone with considerable
force, though cool breezes from the hills to the north tempered the
air. The summer sun in Persia is too hot to admit of travelling during
the day, and consequently our marches latterly have commenced an
hour or two after midnight, an arrangement that admitted of our
reaching camp before the cattle could suffer from the heat, which,
however, is nothing in comparison with that of India. We had no
cause to complain on this score, and even where it was hot, always
enjoyed the luxury of ice, of which the Persians are very fond, and
which they use freely. Every village almost has its yakhchál, or ice-
pits, stocked from the winter snows. The luxury is sold at a very
cheap rate, and is at the command of all classes.
From this place we marched twenty-seven miles to Khátúnabad,
where we found shelter in the sarae, a filthy place, swarming with
vermin, and reeking with offensive odours, and crowded with
famished beggars, who sifted the horse litter for the undigested
grains of barley it contained, and rummaged the ground for bones
and fragments left by more fortunate travellers. Our route was
W.N.W. over the Veramín plain, by a good road skirting a hill range
to our right, and in sight of the magnificent peak of Damavand.
At about ten miles we came to a bifurcation of the road. That to
the right follows the hill skirt direct to Tehran. We followed the
branch to the left, and crossing the Jájrúd (jâjárúd = river
everywhere?), which here spreads over the surface in a number of
little streams that water several villages on either side our route,
went down a gentle slope to Khátúnabad.
5th June.—Khátúnabad to Gulahak, eighteen miles. We set out at
one a.m., across the plain towards the Sherabánú hill, skirting the
foot of which we arrived at Takiabad at 4.30 a.m., and alighted at a
garden belonging to Prince Ahmad. It is a delightful spot, with a
comfortable house looking down an avenue of plane-trees, that flank
a long vista of flowering plants. On each side are vineyards and fruit
trees, in the shady foliage of which are hundreds of nightingales,
strong in song. The morning air here was so chill that we were glad
to warm ourselves at a blazing fire raised to cook us some coffee.
Beyond this we passed through the ruins of Re, or Rhages, in the
midst of which stands the town of Abdul Azím, with its rich gardens
overtopped by the dome of its shrine; and then turning north, went
over a rising plain towards Tehran, of which we now first got a view,
its domes, minars, and palaces appearing high above the dead wall
of its fortifications. The appearance of the city is not so fine as I had
expected, but the general view of the landscape, backed as it is by
the snowy range of Alburz, with Damavand’s fleecy peak standing
sentry over it, is very fine; whilst the bright gardens and happy
villages nestling in the inequalities of the slope at the foot of the
range add a charm to the scene delightfully in contrast with the bare
plain that cuts the horizon to the southward.
We entered the city at the Abdul Azím gate, and passed through
its bazárs round by the king’s palace, to the new buildings of the
British Legation, which appear to be the finest in the whole place.
Beyond this we left the city by a gateway in the new line of
fortifications (like that of Abdul Azím, it is decorated with gaudily-
painted tiles of inferior quality), and followed a carriage-road to
Gulahak, the summer residence of the members of the British
Legation. Here we were conducted by our servants to some
unoccupied bungalows, and alighting, found leisure to reflect on the
marked difference in the forms of social sentiment that animate
Englishmen in India and Persia. Here, after a march of upwards of
two thousand miles, through barbarous countries and dangerous
regions, a small party of British officers arrived in the midst of a little
community of their countrymen, without so much as drawing one of
them from their doors for a welcome or greeting.
Gulahak is one of several picturesque little villages on the slope at
the foot of Alburz mountain, and occupied as a summer residence by
the members of the several European Legations at the court of
Persia. It has an agreeable climate and pleasing scenery, and but for
the limited society, would be a delightful residence.
On our way through the city we saw sad evidences of the effects
of the famine. Beggars, squalid and famished, were found in every
street appealing pitifully to the passers for charity, and no less than
three corpses were carried past us on the way to burial, in the great
and densely packed graveyards that occupy much of the intramural
area, and sensibly taint its atmosphere. The condition of the
population is deplorable. The official returns for the past week
represent the daily mortality within the city walls at two hundred
souls, almost wholly victims to starvation and typhoid fever. This
high rate cannot last long, it is to be hoped, though the prospect
ahead is, from all accounts, gloomy in the extreme. Thousands of
families, who have hitherto kept body and soul together by the sale
of their jewellery and property, down to the clothes on their backs,
are now reduced to a state of utter destitution, and have not the
means of purchasing the food the ripening crops will soon render
available. For these the future is indeed dark, unless the Government
at the last moment comes forward to save its people from
destruction. But as it has so far ignored the existence of a calamity
that has well-nigh depopulated the country, there is little reason to
hope that it will at the eleventh hour stultify its conduct, and stretch
out an arm to save the country from ruin.
The Sháh, it is said, is kept in ignorance of the extent of the
sufferings of his people, through the false representations of his
ministers. He was at this time absent from the capital on a hunting
excursion in the Shamrán hills, and as he did not return until after
my departure from the capital, I did not enjoy the honour of being
presented at His Majesty’s court.
At Tehran I made hasty arrangements for my return to India viâ
Baghdad and the Persian Gulf, with our Indian camp establishment
and despatches for Government. Through the kindness of Mr Ronald
Thomson, chargé d’affairs, I was provided with letters to the Persian
and Turkish authorities for my expedition on the road, and one of
the mission ghuláms or couriers, Shukrullah Beg by name, was
appointed to accompany me as guide.
On the 8th June, the camp having been sent ahead in the
morning, I took leave of my chief, Major-General F. R. Pollock C.S.I.
(now Sir Richard Pollock, K.C.S.I.), and of the Afghan commissioner,
Saggid Núr Muhammad Sháh, of Sir Frederick Goldsmid, and the
members of his staff, and at 4.30 p.m. set out from Gulahak
accompanied by Mr Rozario, and one of the mission servants as
guide to our first stage from the capital. Major Ewan B. Smith, Sir F.
Goldsmid’s personal assistant, rode some way out with us, and then
a “Good-bye—God bless you!” and we moved off in opposite
directions.
 On our way down the avenue leading to the city, we met two
carriages-and-four, full of veiled ladies of the Sháh’s andarún, out for
their evening drive. They were driven by postilions, and preceded by
a number of horsemen, who with peremptory gestures motioned the
people off the road, where they stood with their backs towards
royalty till the carriages had passed. Our guide, seeing the carriages
in the distance, tutored us in our conduct, and as they approached,
we turned off the road, and respectfully turned our horse’s tails to
where their heads ought to have been.
Our route through the city traversed its western quarters, and led
out by the Darwaza Nao—“the new gate”—and then across the plain
to Khanabad, where we were accommodated for the night in a
summer-house situated in a very delightful garden belonging to
Prince Ali Culi Mirzá. On our way through the city we passed a
bloated corpse in a horrible state of putrefaction lying in the street,
and by it stood a couple of men about to drag it into concealment
amongst the broken walls and crumbling huts that here and there
separate the occupied houses, and assail the passengers with the
most sickening stinks. The view of Alburz and Damavand from the
south side of the city is very fine, whilst the wide plain of Veramín,
with its numerous villages and gardens, wears an aspect of
prosperity and plenty, cruelly belied by the hard reality of their
misery and poverty.
Khanabad was our nacl mucám or preparatory stage, hardly four
miles from the city. Our servants had had the whole day to run
backwards and forwards for the hundred and one things they had
forgotten, or which the opportunity made them fancy they required
for the journey, and when we arrived at nightfall, half of them were
yet lingering there, taking a last fill of the pleasures it afforded them.
Seeing this, I anticipated trouble and delay, but, to avoid the latter
as much as possible, gave the order to march at midnight, and, as a
first step, had the loads brought out and arranged all ready for
loading, as a plain hint that I expected the absent muleteers to be
present at the appointed hour. The measure proved successful, for
after much running to and fro amongst the servants, our party was
brought together by two o’clock in the morning, and we set out on
our march half an hour later, but without the head muleteer and
three of his men, who, having received their hire in advance, were
indifferent on the score of punctuality.
Our route was W.S.W., by a well-beaten track, over a plain
country, covered with many villages, and traversed towards the
south and west by detached ridges of hill. At about eight miles we
came to Husenabad, and passing through it, halted on apiece of
green turf near the road for the baggage to come up. I had had no
rest during the night owing to the bustle of our people and the noise
made by the nightingales, and was here so overpowered with
fatigue, that I stretched myself on the sward, and was fast asleep in
a minute, dreaming where all the hundreds of mules and asses we
had just passed on their way to the city with loads of green lucerne
could have come from, since our Mirakhor had assured us that not
one was to be procured in the country, and had, simply as a token of
good-will, provided me with twenty of those that had brought us
from Sistan, only at quadruple the former rates, half down in
advance for the whole journey. Clever fellow! he at all events
secured his mudákhil before losing sight of the muleteers.
From this we went on, and crossing the river Kárij by a masonry
bridge, passed over a stony ridge from a hill on the right, and sloped
down to Rabát Karím, where we found quarters in some of the many
empty houses of the village, having come twenty-five miles from
Khanabad. The population of this village was formerly reckoned at a
thousand families. It does not now contain a fourth of that number,
and a very wretched, sickly-looking set they are, with hardly a child
to be found amongst them. And so it was with every place we came
to on all the journey down to Kirmánshah.
We concluded our first march away from Tehran more successfully
than I had hoped for in the face of the troubles lowering ahead at
the first start. My guide, Shukrullah Beg, has been most energetic
and willing, and promises to turn out a good conductor. He is a
blunt, plain-spoken man, with sharp intelligent features, a freckled
complexion, and bristly red beard, and has none of the polish and
love of finery so characteristic of the Persian of Tehran, though he is
equally impressed with the necessity for ceremony and show. To my
amusement he started our procession this morning quite en règle,
with a strict adherence to the form observed by great men on the
march. My spare horse was lead as a yadak in front by the groom
mounted on a mule, whilst he himself, having assumed the title, led
the way as Mirakhor, the two riding camels, servants, and baggage
following us in column close in rear, and gradually dropping behind
as our pace exceeded theirs.
We arrived at our resting-place at the breakfast hour, and now I
missed the cheerful society of those we had parted from, and my
thoughts ran back over the long journey we had done together. The
frosts and snows of Balochistan, the passage of the Khojak, and the
cutting winds of Kandahar recurred to memory; and with them came
recollections of the General’s enduring energy and indomitable pluck,
that overcame all difficulties and inspired a confidence that deprived
hardships of half their sting; his ever-cheerful spirits too, and kindly
thought for all, that made distance wane, and fatigue lose its load.
Recollections of the Afghan welcome and hospitality, and of the
Saggid’s friendly intercourse and sociability, his amusing
conversation, interesting tales, and theologic dogmatism.
Recollections too of our Persian secretary, Mirzá Ahmad (a native of
Peshawar), his cheerful bearing under trials, his modest demeanour,
his honesty and readiness at all times for all things. I thought of
Sistan, and ran over the journey thence to the Persian capital with
those we joined there, and I missed the charming grace of Sir F.
Goldsmid’s manner, his benevolent self-denial, and his instructive
conversation. Our march through Khorassan was gone over again,
with many an agreeable recollection of the benefits derived from
Major Ewan Smith’s excellent arrangements for the road, and
recollections, too, of many a tedious march enlivened by the vivacity
of his humour and sprightly wit. The first of April in our camp at
Birjand was not forgotten, nor the post we all rushed out of our
tents to meet; and if the others have not forgiven Major Beresford
Lovett, I have, out of respect for his talents. Many a race across
country with Mr Bower to bring to bay and question some
astonished shepherd or ploughman came to mind, and the sharp
ring of his “Máli ínjá hastí? Dih chi ism dárad?” (“Do you belong to
this place? What’s the name of the village?”) methought was heard
afresh.
With such thoughts was I occupied when Shukrullah Beg made his
appearance, and, with a serious face, announced that the mulemen
demanded their discharge, as they had no money for the journey,
and the head muleteer, who had received the advance, had not
joined them. They were afraid they would never get their share of
the hire, and did not wish to go on without being paid. This was
rather embarrassing news. However, I sent for the men, explained to
them that the head muleteer would probably soon overtake us, and
that meanwhile I would pay for their food and that of the mules, and
dismissed them to their work, and ordered the march at two in the
morning. At the same time, for safety’s sake, I had the mules
brought over and picketed in the court below our quarters, and at
sunset had the loads packed and ranged out ready for lading.
10th June.—Rabát Karím to Khanabad, thirty-three miles. We set
out at three a.m., following a westerly course over wide pasture
downs, along the line of telegraph between Tehran and Baghdad,
with a range of hills away to the right. At an hour and a half we
came to a roadside sarae, where we alighted for the baggage to
come up. The sarae dates from the time of Sháh Abbas the Great,
and was very substantially built of trap rock and cellular lava. It is
now in a state of ruin. In the interior we found portions of several
human skeletons. To two of them were still adhering the clothes
they wore during life, and they told the tale of the dead—poor
peasants cut short on their way to the capital in search of food. To
one of them the skull was attached uninjured. I took it off, and
carried it away with me for the anthropological museum of a learned
friend.
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