Cancer and the arts: Johannes Brahms and the problem of pancreatic carcinoma

‘Pancreatic cancer kills patients—and it still exhausts their doctors’, an oncologists told me once. ‘Pancreatic cancer is associated with a very poor prognosis, highlighted by the close parallel between disease incidence and mortality. Five-year survival in patients with pancreatic cancer remains as low as 6% in the USA’, Terumi Kamisawa et al1 wrote in The Lancet.

Only recently Cancer Research UK announced that its spending on pancreatic cancer research has tripled from £6 million (€7.2 million) in 2013/2014 to £18 million (€21.6 million) in 2015/2016. Only one in every 100 patients with pancreatic cancer in England and Wales survive their disease for more than 10 years and this has stayed the same since the 1970s. Only 21% of the cases are diagnosed at stage I/II.2

Vienna is the city of music. No wonder that members of the Viennese medical school have always paid interest in the medical fate of musicians, composers and directors. One of them was the composer Johannes Brahms (born 7 May 1833, Hamburg; died 3 April 1897, Vienna). He had started his career in Germany where he also came into close contact with Clara Schumann, pianist and wife of composer Robert Schumann. After some time in Detmold in Germany as conductor of a local choir and a piano teacher in Hamburg he moved to Vienna in 1872 where he became famous for his skills as a piano virtuoso, and conductor (‘Wiener Singverein’, a choir which has been critical in Viennese music—in opera and concerts since 1858), for his symphonies, solo concertos (piano, violin), his German requiem, variations of themes by Haydn and Schumann, his sonatas and famous (‘Hungarian’) dances, etc.

Brahms was applauded for further developing the Viennese classical music tradition (especially that after Ludwig van Beethoven). Great works which are unrivalled in many aspects, particularly admired for their interchange between simple and pure melodic lines and grand crescendos: a certain kind of innate breathing in late romanticism. We should not ignore contradictory opinions as well: a critic stated that the musician's works lack the richness of melodies by other composers.

Brahms was a man of society. The names of his friends and companions do speak for a broad spectrum of interests, for example, philosopher Anselm Feuerbach, the famous critic Eduard Hanslick, Hans von Bülow, Count Georg II of Heldberg and—the pioneer of the second school of medicine in Vienna, the surgeon Theodor Billroth.

The composer was also a man who loved life's pleasures. In 1871 his physical appearance was described as ‘of medium height, broad, well built, still with no tendency of overweight’ which he developed over the years. There are pictures and photographs which show how well-being, soupés, dinners and feasting in a society of the exuberant late 19th century among the rich paved the way for Brahms’ risk factor and obesity. One of the pictures shows the virtuoso whose prominent belly seems almost to keep him at distance from the concert piano.

It was a society which spent its time with music, dance and theatre life, at winter time in capitals such as Vienna, and in summer at elegant resorts. There was great pleasure, and composers like Brahms were invited to take part with their works. We do have lots of descriptions about life in summer during those times in the Austrian region ‘Salzkammergut’, an area famous for its mountains and crystal clear lakes. At one of the most beautiful places, in Altaussee, Brahms was the guest of his patron, Laszlo Wagner, professor of agricultural sciences in Budapest who had his glamorous house built at Lake Altaussee. He loved music so much. The composer visited Clara Schumann who then stayed with friends at Altaussee and also got to see Theodor Billroth nearby. She, Brahms and Wagner met for dinner at the lake, eating the delicious local fish called ‘Saibling’.

In 1882 Brahms brought his recently finished ‘Spring Quartet’ (the name had been selected by Clara Schumann) with him to Altaussee on the occasion of the inauguration of Wagner's room for music performances in this elegant residence which today is a hotel.

Anton Neumayr, distinct and renowned representative of Viennese internal medicine in recent decades and piano virtuoso, has written about Brahms’ sad end from pancreatic carcinoma in his ‘Music and Medicine—the Example of the German Romantic’. The composer felt fatigue and illness at the end of May in 1896, lost weight and had developed jaundice by July of that year.

The second Viennese school of medicine was at its heights then and Brahms was seen by the best doctors of that time. One of them was Leopold von Schroetter (Paget–von Schrötter syndrome), another was Hermann Nothnagel, a German-born specialist of internal medicine (Sigmund Freud did practice at his department) who had moved from the University Clinic of Jena (Germany) to Vienna to become head of the first medical department. The patient's situation worsened with interchanging episodes of hunger and nausea, generalised itching, growing immobility and bleeding episodes.

All these are the typical signs of malignant pancreatic disease with worsening chronic liver failure (jaundice, generalised itching, coagulopathy, loss of appetite, nausea). Unclear episodes of ravenous appetite and concomitant loss of weight at the beginning of the symptoms are suggestive of neuroendocrine symptoms of Brahms’ fatal disease. The composer died on 3 April 1897. Liver carcinoma has been mentioned as the musician's cause of death several times. But now it appears that it was neuroendocrine pancreatic cancer with liver metastases and liver failure.

A few years ago at a concert evening at the Vienna Konzerthaus (the second Viennese concert hall besides the Vienna Musikverein) of a well-known chamber ensemble which played late works by Brahms the topic of the innate ‘breathing’ of his melodies was brought up to the audience in introductory remarks by one of the musicians. ‘The last tunes do fade away like dying breath’, he said. A composer's anticipation? It is a sad story about pancreatic cancer still.

Only recently molecular biology—as in many fields of modern medicine—appears to be able to explore the pathology of the disease down to its origins, maybe making effective precision medicine possible in the future. But until now the death toll has not yet been changed.

Johannes Brahms died of pancreatic cancer some 120 years ago. It is only a few days since the Hungarian author Peter Esterhazy has died (14 July of 2016) in Budapest at the age of 66. It was the same disease. Esterhazy, the most popular contemporary Hungarian writer in German-speaking countries, had disclosed his diagnosis in October 2015. His last piece of literature (‘A Bünös’—‘The Culprit’) represents a kind of diary….