William Cullen (1710 - 1790) excelled as a physician and professor, standing out among his contemporaries and gaining recognition as the most renowned among them (Passmore, 2010). Indeed, his influence has endured as the most lasting of all. Shortly after his death, documents about his life and works began to emerge, leading to an extensive literature that continues to grow. Throughout his life, he enjoyed good health and maintained his energy without ceasing. Even at the age of 79, he published his "Treatise on the Materia Medica" in two volumes, which became a work used in both Europe and America, remaining a standard reference for forty years. In fact, the library of the Royal College of Physicians of Edinburgh holds a copy corrected by Cullen the year before its publication. According to Passmore (2010), only in the last year of his life, when he died at the age of 80, did his energy begin to decline.
Biography
William Cullen, born on April 15, 1710, in Hamilton, Lanarkshire, Scotland, was the second of seven children in his family (Passmore, 2010; The Editors of Encyclopedia Britannica, 2024). His father, a lawyer who managed the estate of a duke in the Clyde Valley, owned a small estate near Hamilton, a town located about 10 miles southeast of Glasgow (Passmore, 2010). He received his early education at the Hamilton Grammar School, the same town where he was born and where his father worked as a lawyer for the Duke of Hamilton (The Editors of Encyclopedia Britannica, 2024). In 1726, he went to the University of Glasgow, where he became an apprentice to British surgeon John Paisley (The Editors of Encyclopedia Britannica, 2024). According to Passmore (2010), Paisley was a liberal man who owned an extensive medical library and encouraged his apprentices to make the most of it.
After completing his apprenticeship at the age of 19, he moved to London to expand his medical experience (Passmore, 2010). By then, he had developed a habit of broad reading that he would maintain throughout his life, encompassing not only medical literature but also philosophy, history, and sciences, with a particular interest in chemistry and botany. His published writings and the manuscripts of his lectures testify to his knowledge. Students appreciated his culture and education, which likely contributed to his success as a professor. Similarly, according to Passmore (2010), patients valued a learned physician, which undoubtedly was an important factor in his professional success.
In 1729, he was hired as a surgeon on a merchant ship sailing from London to the West Indies (The Editors of Encyclopedia Britannica, 2024). After a year of travel, he returned to London, where he worked in an apothecary's shop, continued his reading habit, and attended public lectures (Passmore, 2010). He remained in London until 1732, when he decided to return to Scotland and established his own medical practice near the village of Shotts in Lanarkshire, which is now in North Lanarkshire (The Editors of Encyclopedia Britannica, 2024). After the death of his older brother and with his father already deceased, he was forced to return to Scotland to take charge of the education of his younger siblings (Passmore, 2010). There, he reunited with a friend who lived near the family estate and offered him lodging in his home to care for his son, who suffered from a chronic illness. Additionally, according to Passmore (2010), he maintained a small medical practice.
After nearly two years, he received an inheritance and decided to continue his education before settling in Hamilton to practice medicine (Passmore, 2010). He attended the winter sessions of the 1734-35 and 1735-36 classes in Edinburgh, including anatomy lectures given by Monro Primus. During the summer months, he resided with a clergyman in Northumberland, where he devoted his time to reading general literature and philosophy, an unusual preliminary approach to medical practice today. In early 1736, he returned to Hamilton and established a practice there, nominally as a surgeon. Although his formal training had concluded, his tireless energy and efficient use of time ensured that his education continued until the end of his life (Passmore, 2010). According to The Editors of Encyclopedia Britannica (2024), he dedicated eight years to private clinical practice, during which he treated those who could not afford his services for free.
In 1740, he received the title of Doctor of Medicine from the University of Glasgow, and several years later, he obtained the necessary authorization to deliver a series of independent lectures on chemistry and medicine, which represented the first offering of its kind in all of Great Britain (The Editors of Encyclopedia Britannica, 2024). In 1741, he married Anna Johnstone, the daughter of a clergyman residing in the western region of Scotland (Passmore, 2010). Anna, over the course of 46 years, provided a home for Cullen and their eleven children, passing away three years before her husband. In 1751, he was elected to occupy the chair of medicine at the University of Glasgow (Passmore, 2010). According to The Editors of Encyclopedia Britannica (2024), in 1755, he returned to the University of Edinburgh, where he was appointed president of the institutes of medicine, a position he held until shortly before his death.
In 1777, he was elected a member of the Royal Society of London (The Editors of Encyclopedia Britannica, 2024). He was a pioneer in demonstrating the effects of cooling by evaporation, a topic he addressed in his work titled "On the Cold Produced by Evaporation of Fluids and Some Other Means of Producing Cold." In medicine, he taught that life was a function of nervous energy, and he believed that muscle was an extension of the nerve. Additionally, he organized a classification of diseases known as nosology, which was divided into four categories: pyrexias, or febrile diseases; neuroses, or nervous diseases; cachexias, diseases resulting from bad bodily habits; and local diseases. According to The Editors of Encyclopedia Britannica (2024), this classification system, which he described in his work "Synopsis Nosologiae Methodicae," was based on the observation of the symptoms manifested by the diseases, which were used for diagnosis.
He gained greater recognition for his innovative teaching methods and for his inspiring and direct lectures, which attracted medical students from all over the English-speaking world to the University of Edinburgh (The Editors of Encyclopedia Britannica, 2024). He was one of the first to deliver his classes in English rather than in Latin, and his clinical lectures were conducted directly in the infirmary, using his own notes rather than relying on established texts. According to The Editors of Encyclopedia Britannica (2024), his work "The First Lines of the Practice of Physic," published in 1777, was widely used as a textbook in Great Britain and the United States.
Several of his students made significant contributions to science and medicine (The Editors of Encyclopedia Britannica, 2024). According to The Editors of Encyclopedia Britannica (2024), among the most prominent students were Joseph Black, a British chemist and physicist known for the rediscovery of carbon dioxide, known as "fixed air"; William Withering, an English physician celebrated for his discoveries on the use of extracts from the plant Digitalis purpurea, commonly known as foxglove; John Brown, a British physician who advocated the theory of "excitability" in medicine; and Benjamin Rush, an American physician and political leader, member of the Continental Congress and signer of the Declaration of Independence, also known for his advocacy for the humane treatment of people with mental illnesses.
"Placebo" in the Lectures of William Cullen
Until the end of the 18th century, the term "placebo" was used in a religious rather than medical context. This stems from an early Latin translation of the Hebrew Bible, specifically Psalm 116:9, which was interpreted as "Placebo Domine," meaning "I will please the Lord" (Kerr et al., 2010). In medieval Catholic Church, "placebo" referred to a funeral rite known as the Vespers for the Dead, which utilized Psalm 116. By the 13th century, the term acquired a derogatory and secular meaning, as mourners who were paid to attend funerals to "appease" the dead were said to be "singing placebos" in the form of insincere and easy praises. According to Kerr et al. (2010), it is noteworthy that in the 14th century, Chaucer, in the Canterbury Tales, named his obsequious and flattering courtier "Placebo."
How did the word "placebo" come to signify a medical treatment intended to please a patient? The term "placebo" seems to have entered common medical use in the late 18th century (Kerr et al., 2010). While the 1775 edition of George Motherby’s New Medical Dictionary contained no reference to the term, the 1785 edition defines it as "a common method or medicine." The transition from the religious to the medical meaning of the word "placebo" can be understood through an analysis of William Cullen’s writings. He used regular medications as placebos, albeit in lower doses. According to Kerr et al. (2010), his lectures also reveal the medical and social context of placebo use in medical practice at the end of the 18th century.
He used the term "placebo" at least twice in a series of lectures delivered in 1772 (Kerr et al., 2010). First, he described administering a placebo treatment to a patient named Mr. Gilchrist, whom he considered "absolutely incurable" and who was "awaiting his fate." In fact, his motivation for taking the case was more scientific than clinical, as he hoped to make observations and learn something from the patient’s death. Since he had no hope that the treatment could cure Mr. Gilchrist, he decided to use a placebo treatment to console him. In particular, according to Kerr et al. (2010), he chose to use what would now be called an "active placebo," as opposed to an "inactive" substance that he knew was physiologically inert, such as a bread pill.
Thus, his definition of placebo treatment was not so much related to the substance itself, but to the intention with which it was prescribed (Kerr et al., 2010). He considered a "placebo" treatment to be one administered to please the patient, but without any curative intent or hope. For Cullen, whether mustard, an external treatment, or Dover's powder, an internal treatment composed of Ipecac and opium, it could be prescribed when circumstances made it "necessary," even when the clinician himself "did not have much faith" in the curative activity of the offered medicine. In this context, according to Kerr et al. (2010), Cullen illustrates his general principle of prescribing placebos that could be "useful" to the patient, using his knowledge of botany and materia medica to offer active compounds that might "tend" to be beneficial, even if they were offered without a specific hope of cure.
Neurosis
The term "neurosis" was formally introduced into Western medical literature by William Cullen in 1769, with the aim of referring to diseases that affected the senses and movement, without presenting idiopathic fever or local affliction (Sarudiansky, 2012). Thus, in line with Sarudiansky (2012), Cullen differentiated these diseases from other types of pathologies grouped under the categories of "fevers" or "pyrexias," which included pneumonia, gastroenteritis, hepatitis, nephritis, rheumatisms, chickenpox, malaria, and hives; "cachexias," a category that covered diseases such as syphilis, scurvy, and trachoma; and "locales," where conditions such as bulimia, polydipsia, pica, nymphomania, anorexia, nostalgia, aphonia, strabismus, contracture, and gonorrhea were grouped.
William Cullen based his disease taxonomy on the methodology proposed by Thomas Sydenham (1624 - 1689), and justified the introduction of the category of "neurosis" on the need to overcome the inaccuracy of the concept of "nervous disease" (Sarudiansky, 2012). Sarudiansky (2012) mentions that, according to Cullen, almost all morbid alterations of the body depended, to some extent, on the motions of the nervous system, so almost all diseases could, in that sense, be called "nervous."
According to Sarudiansky (2010), within the group of neuroses, Cullen identified four main categories: "comatas," which involved a decrease in voluntary movements, accompanied by sleep or suspension of the senses, including here apoplexy and paralysis; "adynamiae," which involved a decrease in voluntary movements, with examples such as syncope, dyspepsia, hypochondriasis, and chlorosis; "spasmi" or spasms, characterized by irregular muscle movements, including tetanus, convulsions, chorea, raphania, epilepsy, palpitations, asthma, dyspnea, pertussis, pyrosis, colics, cholera, diarrhea, diabetes, hysteria, and hydrophobia; and finally "vesaniae," a disorder of the mental faculties of judgment, without fever or sleepiness, which covered conditions such as amentia, melancholy, mania, and onirodynia.
From this classification, under the denomination of neurosis, a great diversity of clinical pictures was grouped, some of which, today, would be questionable to label under that term (Sarudiansky, 2012). Despite this, the distinction had a significant impact on the medicine of the time, even influencing one of the most prominent physicians in the development of psychological and psychiatric disciplines, such as Philippe Pinel (1745 - 1826). However, this definition of the term neurosis did not remain intact over the centuries. For example, Étienne Georget (1795 - 1828) redefined them as chronic and intermittent diseases that did not present post-mortem anatomical lesions and were not necessarily dangerous, but caused excessive suffering in those who suffered from them. Sarudiansky (2012) mentions that, for Georget, neuroses could include frequent headaches, madness, hypochondria, catalepsy, chorea, hysteria, nervous palpitations, asthma, gastralgia, and neuralgias.
References
Kerr, C. E., Milne, I., & Kaptchuk, T. J. (2010, mayo 26). William Cullen and a Missing Mind - Body Link in the Early History of Placebos. The James Lind Library. https://www.jameslindlibrary.org/articles/william-cullen-and-a-missing-mind-body-link-in-the-early-history-of-placebos/
Passmore, R. (2010, mayo 26). William Cullen (1710-1790). The James Lind Library. https://www.jameslindlibrary.org/articles/william-cullen-1710-1790/
Sarudiansky, M. (2012). Neurosis y Ansiedad: Antecedentes Conceptuales de una Categoría Actual. Aacademica.org. https://www.aacademica.org/000-072/63.pdf
The Editors of Encyclopedia Britannica. (2024). William Cullen. In Encyclopedia Britannica. Britannica. https://www.britannica.com/biography/William-Cullen
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