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Tulp on cancer

DANIEL DROIXHE

In his Histoire du cancer du sein en Occident, Prof. J. Rouëssé has mentioned at length Nicolaes Tulp (1593-1674), famous for the Anatomy Lesson painted in 1632 by  Rembrandt [1].  We reconsider here the three chapters devoted to the disease in Tulp’s Observationum medicarum libri tres, first published in Amsterdam by LodewijkElzevier in 1641 [2]. The “three books” work will have soon several editions. The 1652 edition announces in the subtitle that it is augmented by a fourth book, with many improvements. We follow the order of the chapters adopted by Tulp.

The chapter 47 of the first book relates the case of a Cancer which stayed harmless during fifty years [2, pp. 90-91). “An occult cancer may often remain innocuous for a long time, but irritated, it consumes the skin”. “When it happens, either spontaneously or due to a bad medical treatment, then no barrier could contain it”. The criticism of “irritation” and “bad medical treatment” in oncogenesis is a traditional argument going back to Hippocrates’s statement according which “it is better no to treat the occult cancer”, as repeated by Guilelmus Fabricius Hildanus, the “father of German surgery”, who surely influenced Tulp [3]. Tulp tells this story. “The daughter of Geropius Becanus, physician of Antwerp in the old days, was affected during more than fifty years, in those somber times, by a hard and unequal carcinoma”. Jan van Gorp (1519-1572), also known as Goropius Becanus from his birthday village, Beek in the Netherlands, was not only a distinguished physician working at the court of the emperor Charles V, but also one of the forerunners of the theory of the common Oriental origins of the European peoples [4, 5]. The word inaequale refers to the traditional conception still illustrated by authors like Antoine Furetière in his 1690 French dictionary or Jean Astruc in the French Treatise on tumors and ulcers of 1759. The first wrote that the cancer is a “hard, rough, round, still and inégale tumor”; Astruc said that the squirrhe - a potential tumor - changes into a cancer when the mass becomes “sharp, inégal, angular” [1, p. 7; 6; 7). “But the disease was without any ulceration, any serious harm”, Tulp adds. “It really grew little by little” when a change occurred, “whether because her husband, Caspar Conjetti, underwent a bad fortune; whether because the atrabile became more abundant”. The Dutch surgeon also considers the fact that “something was thoughtlessly administered according to the advice of an empiricist - I do not know with which burning medicament”…

We learn that one of Goropius Becanus’ daughters, that various sources name Isabella, Isabelle, Isabeau and even Beeltje (little Bella, in Dutch), actually experienced bad times, when her husband, Casper Quingetti, was “scammed by an employee” and was left by creditors “like a thief in the night”, abandoned by everybody [5]. After those trials, the disease “quickly degenerated into an ulcerated carcinoma”, with “change of color in the lips, ashen scab, deformed breast, unequal tumor, livid color, deathly sanies, pain, waking states, soul absences, heat, pruritus, and the other signs of a desperate cancer”.  “No medicine” against that.  Thus, Isabella van Gorp became one of the most well-known illustrations of the link between cancer and the psychological factor, especially stress and the “adverse life-events” [8; 1, p. 43 sq; 9; 10]. The chapter 53 of the first book is entitled Cancer mammarum [2, pp. 100-101].  The beginning is direct, in a telegraphic but also rhetoric style.  “Against the moving cancer, there is only one remedy: the early amputation”. What does Tulp mean by mobilis characterizing the tumor? He repeats the prognosis: “Out of this remedy: irreparable mistake”! “Unless the tumor is cut, it cuts the thread of life. But other things than the breast are worthy of attention:  “axillas, glands of the ears, and the major veins”.


Johannes Wierix, Goropius Becanus’s portrait, published in his Opera (Antwerp: C. Plantinus, 1580).
© Eddy Frederickx, Toon van Hal, Johannes Goropius Becanus (1519-1573) (Hilversum: Verloren,2015), 64.

A case of breast cancer is illustrated by “the maid Coymann”. “An enormous tumor grew, from a blow”, “with pain, hot bruise and itches”. If the cause of the cancer seems to be a mental shock in Isabella van Gorp’s case, it is here a contusion which is incriminated, like in some many cases that has been related [9].  “In order to avoid its malignancy, we decided that it was better to destroy it with the scalpel”. The operation was realized by a Leiden surgeon who, “after having cut the flesh until some point, separated with his skillful finger the tubercle, enclosed in its outer layer, from the grease which was around, without removing anything of the muscles involved”. Thus, “he made no less than completely extirpate the harm”. The passage exactly emphasizes the necessity of high technical skill in surgery suggested by the Anatomy Lesson.

However, if “some remains of the cancer persist inside”, one must always “remove them until the root”, for example with a “precipitate of mercury” [3, Cent. VI, obs. 22, p. 522]. The surgeon or physician has also to be sure that “the sick person is not developing a dangerous salivation - and that the medicine is not led into an inerasable disgrace”. Astruc, in his Treatise already quoted, explains the precaution pointed by Tulp. “In the salivation obtained by mercury, the humor that flows from the salivary glands inflames and ulcerates the extremities of their excretory canals in the mouth, without acting upon the glands themselves” [6, p. 296]. A third observation was and remains the most famous (11; 12; 1, p. 61; 13;  14). It was published as the chapter 7 in the fourth book of Observations, which appeared only in 1652. It is entitled Cancri contagium, “The contagion of cancer” (2, pp. 307-309). Tulp urges the “idle physicians” to consider whether the “virus” of an ulcerated cancer “is not more propagating by proximity than at a distance”. “What ascertain the limit of its exhalation? what fixes the fences between which this volatile spirit may be contained?”.  

Thus, he relates this other case. “Adriana Lamberta, late in life, eaten up with sorrow during some years, suffered from an ulcerated carcinoma that reached a degree of putrefaction to the point that she infected, by her breath, her maid, who continually took care of her”. The disease finally acted as “a huge fire” disseminating “sparks of the scourge”, so that “it invaded the maid no less than her Mistress”: it “spread to her breast and her axillas, with a hideous and uneven ulcer, in a way that I interrogated myself for some time about which one of them would be more tormented”.

But this was not the only bad effect of Miss Adriana Lamberta’s cancer. Tulp, having closely examined that ”stinking carcinoma”, suffered himself from a ulceration of the throat, against which “not only the precipitate of mercury, but even the everyday use of pliers did not remove the scabs aroused by the venom feeding on in the throat (depascente in faucibus). The episode proves that “an ulcerated cancer not only disseminate its contagion up close (cominus) but remotely (eminus)”. “Accordingly, it is better to trust indisputable experiments than not to care about an unwise youth with futile arguments and imaginary subtleties “. “In the Arts (Seneca told), you must search for what is more useful than subtle”. Let us keep a “youth lacking in foresight” from “the appeal of words”.

By a curious coincidence, Tulp’s lesson could have been applied to the couple Rembrandt and Hendrickje Stoffels, the painter’s lover, if, as it has been supposed, the latter suffered from a breast cancer. Prof. Rouëssé has written that such a disease is “clearly visible” on the famous Bathsheba at Her Bath finished by Rembrandt in 1654, with Hendrickje as a supposed model [1, pp. xxii, 7]. “An adherence to the deep planes, without necessarily a cutaneous or mammillary retraction, constitutes a relatively rare, but possible situation”. Let us remind that Tulp’s warning about the risk of contagion appeared in the 1652 edition.  In 1656, Rembrandt went bankrupt, like Isabella van Gorp’s husband. Hendrickje died in 1663 and Tulp in 1674. If the warning of contagion was addressed to everybody - and not especially to Rembrandt  - Tulp had much time for meditating on another possible example of a breast cancer caused by an “adverse life-event”.

I acknowledge Prof. J. Rouëssé and T. van Hal for informations.

Bibliography

  1. Rouëssé J. Une histoire du cancer du sein en Occident. Enseignements et réflexions. Paris : Springer, 2011, p. 61.
  2. Tulp N. Observationum medicarum libri tres. Amsterdam: Apud Ludovicum Elzevirium, 1641. - Editio nova, libro quarto auctior, et sparsim multis locis emendatior. Amsterdam: Apud Daniele  Elzevirium, 1652.
  3. Fabricius Hildanus G. Opera quae extant omnia. Frankfurt : Beyer, 1646. Cent. III, obs. 77, pp. 267-68 (“De cancri occulti periculosa curatione”). 
  4. Droixhe D. La linguistique et l'appel de l'histoire (1600-1800). Rationalisme et révolutions positivistes. Genève : Droz, 1987.
  5. Frederickx E. and van Hal T. Johannes Goropius Becanus (1519-1573). Brabants arts en taalfanaat. Hilversum: Verloren, 2015.
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  8. Petticrew M, Fraser J M, Regan M F Adverse life-events and risk of breast cancer: A meta-analysis. British Journal of Health Psychology 1999; 4 /1: 1–17.
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  10. Droixhe D.  Soigner le cancer au XVIIIe siècle. Triomphe et déclin de la thérapie de la ciguë dans le Journal de médecine. Paris : Hermann, 2015, pp. 205 sq.
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