MUSIC IN MEDICINE

  by

  SIDNEY LICHT, M.D.

  _Fellow, New York Academy of Medicine_

  NEW ENGLAND CONSERVATORY OF MUSIC
  BOSTON, MASSACHUSETTS




  _Copyright, 1946, By_

  SIDNEY LICHT, M.D.

  All rights reserved, including
  the right to reproduce this book
  or portions thereof in any form.

  _First Edition_

  PRINTED IN THE UNITED STATES OF AMERICA




FOREWORD


In presenting a musician’s point of view on so specific a subject as
“Music in Medicine”, it seems to me necessary at the outset to clarify
the status of music as an independent aesthetic art, and its practical
adaptation for definite utilitarian purposes. We must clearly separate
the active individual process of artistic creation from the elements
of passive perception and from effects such perception may have when
applied for different realistic reasons.

Taken aesthetically, as an art, music is a social “superstructure”,
which, as far as the individual creative act is concerned, remains
an abstract manifestation of the human mind and imagination.
Its existence as a creative art is possible only as long as the
practical “possibilities” and potentialities of its effects in the
phase of passive perception, do not intrude into and interfere
with its character as an absolute non-utilitarian phenomenon in
the processes of the creative art. Art, by its very nature is a
product of individuality. As opposed to the anonymous craft, the
main requirement of an aesthetically artistic product assuming the
presence of professional skill and knowledge is that it be the work
of a human organism, which possesses acceptable qualifications of
vocation and expression. To this attribute we have given such names
as talent, genius, imagination, and many others. This phenomenon of
specific predestination must also be accompanied by a characteristic
property which has received such names as personality, individuality or
originality. It is obvious that these fundamentals of artistic creation
prevent any general or universal approach to the creative processes
which, with the exception of purely technical and formal elements of
craftsmanship and common expression of specific style, exclude the
pattern and definite utilitarian aims. All these factors are obviously
concerned only with the living moment of the musical art in the essence
and genesis of the individual creation.

Although music as a creative manifestation of the human mind does not
aim at social or utilitarian function, its materialized results may yet
find wide application in the manifold use of this aspect of passive
perception. This passive perception stimulates an active participation
by the listener in whom it may provoke definite emotional reactions
and mental modulations. If we think of music as the completed creation
of one mind, we can understand how its perception may have a genuine
influence on the listener’s mood and that it may be channeled into
desired directions which takes the forms of adaptation and adjustment.
This, in spite of the variety of tastes and reactions, can certainly be
generalized within limits by scientific methods.

Although I do not believe that music should be written for purely
utilitarian reasons (and I am speaking not of the material advantages
it may bring the artist, but of the aesthetics of creative art) I see
no reason for not using any composition to such practical advantage as
its application may offer. Music as an _art appliqué_ has been known
since ancient times in many different roles, not all as laudable and
noble as its use in healing. Its property of melodical expansion,
propulsive character, rhythmical vitality, nervous insistence, harmonic
intricacy, development in time rather than space, its wealth of moods
(which extend from static calmness to wild exuberance with an enormous
range of intermediary impressions, even in its abstract character
of pure organized sound) provokes in listeners a response which is
primarily psychological and emotional, but which frequently influences
physiology and the nervous system.

The use of music for work, marches, the stimulation of mass sentiment
or emotional impact (patriotism, war, etc.), for entertainment,
oblivion, mood change, mood creation, and background music for motion
pictures, evokes realistic responses, where music is applied for
its effect, rather than for its intrinsic value. It is therefore no
surprise that the applied use of music (which has nothing to do with
the active process of artistic creation) should be used in the care
and treatment of the sick mind and body. I do not know what subjective
responses result from such purely physical phenomena as vibration
and harmonics but I am convinced that listeners are physiologically
and psychically effected by such musical characteristics as mood,
intensity, pitch and rhythmical outline. It seems to me that the
right music should provoke remembrance and association of thoughts
and situations more easily in a mental patient than methods using
factual persuasion. Music can avoid the realistic approach and by its
absolute progression abstractly recreate a familiarity of situation
which may prove most useful in handling mental patients. By eliciting
a desired mood it may offer the physician a method of handling disease
as important as shock, and a result obtainable in no other way. To a
musician, completely unfamiliar with medicine and pathology this use
seems obvious and undeniable. Dr. Licht has made a thorough study
of this subject and has indicated some of the many uses of music
in mental and physical pathology. The work which has been based on
scientific research and clinical experience is most impressive and
encouraging. If we, as musicians, can bring our contribution to such a
wonderful purpose as healing, it would certainly be our most glorious
accomplishment for mankind, and the noblest use of our art.

But, as I have said, aesthetically it should not be the aim but the
effect of art which should be considered. If _applied use_ rather
than creation were to assume greater importance, art would lose its
essential characteristics and would become a social manifestation of
mass production instead of an abstract phenomenon. It might work out
usefully, perhaps for a time, but in losing those primordial elements
which condition its own existence, it would also lose the _effects_
which its use provoke not only in medicine but in other important
directions. The effects of music will progress satisfactorily to
the advantage of mankind only as long as it is permitted its normal
development regardless of motivations and their justifications. In
the long run it will find a greater and better use in the practical
sense, if its creation continues along traditional lines, and is not
diverted into the fallacious channel of anonymous mass production with
consequent loss of proper utility and aesthetic _raison d’etre_.

It is likely that scientific research and clinical experience will
motivate the production of musical compositions which are designed
for certain classes of patients. This will require much skill,
craftsmanship, gift of adaptation and assimilation of established
patterns as well as disciplined imagination, but the creation of
such planned utilitarian works would not be possible without the
continuation of music as a self sufficient art activated by its own
emotional and spiritual reaction and enjoyment. No derivative may
exist and progress by suppression of the source which must aliment it
continuously by its own growth and through the conservation of its
individual characteristics.

Music as an art has its own internal laws of creation and traditional
development. These laws are not casual but organic and they can not
be violated without self destruction. Consequently, the beneficial
effects of music can be applied for utilitarian purposes only if its
integrity is safe from external intervention, even if only temporarily,
and if the element of social usefulness does not influence the creative
process.

The criteria of artistic and practical values do not necessarily
coincide. Artistic value is defined only by time, the practical value
is a matter of present usefulness. Works of great artistic value may be
useful, whereas facile “hits” which fall into oblivion within a brief
period may prove extremely useful, and that is why the two conceptions
must be differentiated. Michelangelo’s _Medici Tomb_, or a Bach _Mass_
are completely useless in the practical sense of the work, and most
successful “hit-songs” are completely devoid of any artistic value
or originality. Yet both kinds supply the specific wants of those
who would lament the absence of either of them. This resolves itself
into a question of taste, educational background, musical culture and
other factors which I presume are of importance in the clinical use of
music. Patients will show preferential response to the music they like
regardless of the elements of mood, tempo, rhythm and pitch.

But classifications are always dangerous. Good music is not necessarily
useless, and useful music is not necessarily bad music. The eternal
principal of _suum cuique_ is the principle of individual human
taste which can be placed into approximate categories, but cannot be
standardized without the artificial interference of external factors.
The same principle certainly applies to music as a weapon of healing,
where selection should be determined by science but at the same time
we must strive to adapt the results of research of the individual
preferences of normal subjects.

  Alexandre Tansman
  Los Angeles, January 1946




  CONTENTS


  _Introduction_                                                      ix


  Chapter I

  _History of Music in Medicine_                                       1

  Primitive use and the medicine man. Ancient
  civilizations. Music against animal bites and mental
  disease. Magic and the Middle Ages. The magic
  flute. Recent developments.


  Chapter II

  _Philosophy and Psychology of Music_                                15

  Physiology of musical elements--pitch, intensity,
  timbre, duration, rhythm, melody, mode, key. Color
  in sound. Music interpretation. Live music and the
  human voice. Listening and appreciation. Musical
  taste and appetite.


  Chapter III

  _Music as Occupational Therapy_                                     44

  Origins of occupational therapy. Advantages of
  music as a modality. Analysis of motion in piano
  playing. Analysis of string, plectrum, foot, wind
  and percussion instruments. Use of voice as exercise.


  Chapter IV

  _Psychiatry and Music_                                              59

  Criteria of therapeutics. Classification of mental
  diseases. Description of diseases and indications for
  music.


  Chapter V

  _Background Music_                                                  73

  Counter-irritation. Music in the operating room.
  Effect on physical exercise. Use with calisthenics.
  Eurhythmics. Remedial exercise. Industrial music.


  Chapter VI

  _Mealtime Music_                                                    82

  Criteria for mealtime music. Examples of orchestras
  and songs most suitable. List of suggested
  recordings.


  Chapter VII

  _Music in Bed_                                                      89

  Needs of children. Slumber music. Bedside
  radio. Program distribution systems. Head phones
  versus loud speakers. Personalized music. Instruction
  in bed. Toneless instruments.


  Chapter VIII

  _Diversion and Entertainment_                                       98

  Need for entertainment in hospitals. Programming
  for patient groups. Amateur show. Group
  singing. Music instruction.


  Chapter IX

  _Public Address System_                                            105

  Basic equipment and personnel. Programming.


  Chapter X

  _Equipment and Library_                                            110

  Patient band. Instruments and rooms. Record
  library. Holiday music.


  Chapter XI

  _Direction_                                                        118

  Medical direction. Qualifications and duties of
  the hospital musician. Training program and curriculum
  for music aides.


  _Bibliography_                                                     125


  _Index_                                                            129




INTRODUCTION


In the middle of the eighteenth century there were two prominent men
in Paris whose conflict was typical of the controversial nature of the
subject known as Musical Therapy. The Abbé Nollet was not only one
of the most prominent clerics in France during his time but was in
addition the most famous of its physicists. He had constructed some
excellent models of machines which produced static electricity, but
he had had no medical training. At about this time throughout western
Europe, the subject of static electricity had become very popular.
Several physicians claimed that it was of great use in the treatment
of many diseases. Particularly did they say that it cured paralysis.
The Abbé Nollet wrote a book about static electricity and in it told
of the cases he had cured with it. The most prominent physician in
Paris was Doctor Louis, who was the chief physician at the Salpêtrière
Hospital, the largest and best known hospital in France. Dr. Louis
tried to repeat the cures promised by Nollet but was unable to secure
success in any of the patients whom he exposed to static electricity.
He published the story of his failure to do so, which so excited Abbé
Nollet that he wrote an entire volume condemning Dr. Louis. Instead of
refuting the ability of Dr. Louis to diagnose paralysis and evaluate a
cure, he climaxed his remarks with the classical question addressed to
the doctor, “Is electricity your field?”[61]

For many centuries philosophers and musicians have claimed the ability
to cure mental illness through the use of music, and have at times
called this procedure Musical Therapy. Although the physicians might
well say to these musicians that therapeutics is definitely not within
the province of musicians, it is unlikely that a musician would at this
time have the courage to ask physicians, “Is this your field?”

A thorough search of the history of medicine will show that almost all
phenomena and substances have at one time or another been tried in an
attempt to combat disease. Many of these agents were abandoned when
they became unfashionable to a more sophisticated civilization, or were
recognized as unwholesome by a more educated generation. The fact that
few were given up merely because of their ineffectiveness can be seen
in the great number of quack nostrums which still enjoy an active sale
among the ignorant, and by the impossible claims of highly organized
cults which continue to gain in numbers and followers in this country.
Healing schemes based upon the use of herbs because they are delivered
right from nature’s womb, or the fanciful notion that all diseases
arise from the imaginary displacements of the spinal bones, are still
in their ascendency. The liberal system we call democracy has not only
permitted their growth but has rewarded their ingenuous and ingenious
development. Exposure of the fraudulent methods involved serves little
purpose because the mentality which is so susceptible to warped
reasoning responds poorly or even antagonistically to enlightening
guidance.

There are, however, certain valuable features in herb and spinal
doctrines which have been partially ignored by reputable physicians
because of the intimate relation of these ideas to cult practice.

In spite of a spirited rebirth of the movement towards the
establishment of a system of healing based on music, there are many
valuable uses of music in medicine which might suffer a like fate
unless a critical analysis of the worth of music as a therapeutic agent
is effected before Musical Therapy reaches the dubious distinction of
classification as a healing cult.

This book has been written with a view to preserving for medicine that
which is good for patients, and in an attempt to aid musicians under
medical guidance in using music to help the sick.

Primitive peoples throughout the world still use music in association
with the healing arts. This of course is an indication that they have
probably used it for more centuries than are recorded in the pages of
written history. Ancient civilizations frequently associated music
with the divine, but placed diminished emphasis upon its association
with healing. Even so, the Hebrews accredited to music curative and
inspirational powers[7], as can be seen by the reference in Scripture:
“And it came to pass when the evil spirit from God was upon Saul that
David took a harp and played with his hand; so Saul was refreshed and
was well and the evil spirit departed from him.”[63]

For the Greeks to whom we owe the origin of the word music, Apollo
served as the God of both medicine and music, and there were some among
them who suggested its use for both mental and physical disease. “Plato
and Aristotle claimed that the Dorian mode was regarded as virile,
energetic, and proper for the perfect citizen; the Phrygian made them
headstrong and the Lydian included effeminacy and slack morals. The
modes of Asiatic origin were considered suitable for banquets.” Five
hundred years before the birth of Christ, Pythagoras[I.] founded a
brotherhood “based on music as a means of life and moral uplift.”[70]
The influence of music was so great among the Greeks that it is not
surprising that they used it in all walks of life, including medical
treatment. The extent to which they and the peoples who followed them,
used music in this manner will be more fully discussed in the first
chapter.

Nicholas Murray Butler once stated that “An expert is one who knows
more and more about less and less.” There is much truth in this
facetious definition. In ancient civilization the known facts were
so few that it was possible for some scholars to acquire all the
knowledge available. The professional thinkers or philosophers had a
comparatively complete familiarity with biology, law, music, medicine,
government and theology, and could easily write authoritatively about
most of them. Some of the important discoveries in the arts and
sciences were made by men equally well known in entirely unrelated
fields. As late as the Roman Era, Celsus wrote a series of books
on different subjects, each of which was so complete that it was
considered an authority in its field. To cite one example, the ten
volumes on medicine were accepted for the next thousand years as its
gospel text. Although specialization was known to ancient society, its
foundation was one of individual will rather than basic training in
facts. With the passage of time more and more knowledge developed till
the single volume could no longer hold all the known facts of a science
and what had been titles of chapters became the titles of books.
Knowledge may really be said to have progressed when books are written
on subjects about which only one sentence could have been written
previously, but knowledge progressed very slowly until the fifteenth
century. The Renaissance in art and science developed simultaneously
in a relatively small area. The Renaissance of both medicine and
music, was in Italy during the fifteenth and sixteenth centuries.
Here, instrumental music was asserting its importance over vocal
music, and accurate descriptions of human anatomy finally replaced
the old erroneous conceptions. Both of these changes were necessary
for progress in these fields, but progress was slow in each because
there is always a reluctance on the part of the people to accept new
concepts. Individuals may be intellectually progressive, but the people
find security and comfort in established folkways, whether it be of
music or medicine. Fortunately, individuals continued to write of new
discoveries and in new idioms, and that which was good was accepted by
a few in the same generation and by more in succeeding generations.
But each successive step was tedious and it was just as difficult to
influence the new generation as it had been the old.

With the growth of knowledge came an increase in specialization and
men understood less of subjects unrelated to their own. As the rolling
mass of education grew, it threw off tangential bodies of information
which moved farther apart from each other, and it is only comparatively
recently that these diverging lines have begun to approach one another
and offer mutual assistance. Music, the art, found the need for
acoustics, the science. Industry has come to accept the importance of
color and form, and government has been forced to employ mathematics.
There was a time when such combinations would have been considered
fanciful; now they are indispensable.

Music and medicine have had casual contacts through the ages, but
neither has cried out to the other for help. Musicians and physicians
are independent people, brooking no outside interference. There are
those on both sides who would protest their marriage, not so much
from a concern over connubial bliss as over the possible offspring
and undesirable relatives. Medicine has never refused to try anything
that might alleviate suffering or cure disease, but it has and
will continue to ignore unfounded claims or secret remedies. To be
acceptable, therapeutic measures must be applicable to all who suffer,
and the ingredients must be available to all qualified practitioners of
medicine. Physicians insist that therapeutic modalities be given under
their guidance and reserve for themselves the right to evaluate their
results. Very few physicians object to the use of music for and by
their patients, but many object to calling that use musical therapy.
If the musician is aflame with the desire to make music for patients
there is no need for insisting that it be labelled anything but music,
providing of course that it is music. Physicians do not discourage acts
of kindness or personal attention to their patients. They want them to
have clean bedding and fluffed pillows, but insist that such procedures
be called nursing care and not therapy, regardless of the amount of joy
it brings the patient. There are many uses to which music may be put
in medicine and especially in hospitals. When one considers the number
and variety of hospitals in this country, it is difficult to imagine a
kind of music which can not find a place in at least one of them, but,
for reasons which seem more obvious to musicians than physicians, music
has been used in the past almost exclusively for patients suffering
from mental illness. During the past few decades, hospitals have given
increasing attention to music, and in some instances have developed
impressive programs.

In 1944 the National Music Council sent questionnaires to more than
three hundred hospitals which treated psychiatric disorders, and
received replies from two hundred of them. A summary of the survey was
published by them under the title of “The Use of Music in Hospitals for
Mental and Nervous Diseases,” and some of the information contained in
this pamphlet will be of interest to those who are considering this
aspect of music as a career. Almost all mental hospitals use music in
some form. In half of them, patients participate in music vocally or
instrumentally. In many hospitals the use of music is increasing and
in a few it is extensive. About one-quarter of the hospitals have some
budgetary appropriation for music, such appropriations are not great at
present.

Most hospitals look for musical workers among the members of their
regular staff; but a few have consulted musical organizations. Trained
musicians might think that hospitals would turn more uniformly to
musical schools for this sort of assistance, but for the most part, few
schools of music have openly encouraged the study of this subject,--in
spite of the fact that one-half of all the hospitals questioned stated
that they could use additional qualified workers.

Of greater interest perhaps to those who would like to become hospital
music aides are the opinions expressed by the hospital authorities on
the principal qualifications which they believed musical workers in
mental hospitals should have. It must be remembered, however, that
questionnaires submitted to hospitals are not answered in a uniform
manner, and any survey of this type must be interpreted with caution.
When questionnaires are sent to hospitals they usually pass first
through the hands of the director or superintendent, who reacts as
an individual and not according to a set pattern. One will turn the
paper over to his secretary for reply; another will pass it on to a
physician, nurse or occupational therapist. In many instances the
answers will be filled out by the hospital music worker, and sometimes,
if the superintendent is sufficiently interested, he may answer it
himself. Each person to whom the questionnaire is submitted may
transfer the burden of answering to a subordinate, if he is too busy
to fill it out himself. The signature which appears at the bottom of
the returned questionnaire is usually one of approval rather than of
authorship. Surveys should list the titles of respondents. This one
did not. Even if it did, the foregoing possibilities would have to
be considered. In spite of this, the qualifications listed will be
reviewed for the help they may offer the prospective hospital musician.

A majority agreed that a knowledge of music was necessary, and not only
were all phases of music specified, but the ability to make intelligent
selections of music and to operate commercial sound equipment was
recommended by some. Experience in teaching music, particularly the
piano, was high on the list of desired accomplishments, and the faculty
of directing singing was even higher.

Many hospitals stressed the importance of a “wholesome personality”,
but this is a term which defies suitable definition. However, the
following qualifications were named: emotional stability, patience,
refinement, congeniality, quietness, and a sense of humor. There are
further recommendations that the worker should possess: imagination,
tactfulness, consideration, energy, perseverance, sincerity,
co-operation, adaptability and understanding of human nature. In the
final chapter of this work a more realistic approach to this subject
will be offered.

One final qualification is mentioned which is to be taken most
seriously, and that is that the musician who would work with mental
patients should have “a definite urge to help the mentally ill.” As a
supplement to this he should have or be given a working knowledge of
hospital procedure and the handling of the psychiatric patient.

From these comments by hospital authorities and the recent trends in
institutions throughout the country, it is reasonable to assume that
the demand for adequately trained hospital music aides will increase.
Some hospitals will want one or more full-time workers, and others will
want a part-time worker. This means that some musicians may be able to
supplement their earnings by securing partial pay from hospitals in
their communities, the remuneration offered varying with the size of
the hospital, its endowment and income. It will never be a source of
wealth to a musician, but it can be a stop-gap in the hard early years
or a continuous position for those who seek the security of regular
employment.

Some people fill positions for which their only qualification has been
influence; but in the majority of cases the people who have spent the
greatest effort in securing superior training will be the recipients of
the best positions. The student of hospital music should prepare for
his job as seriously as for any other aspect of music. Regardless of
his other qualifications, he must of course be a musician, and a degree
in music is valuable; in fact almost essential. The ability to play a
second instrument even moderately well is useful. The universal appeal
and advantages of the piano make a working knowledge of it important.
The music aide should be able either to play the piano at sight or
he should study one of the rapid systems of piano instruction for he
will be called upon not only to accompany group singing but to assist
visiting artists or talented patients.

Although a foundation in classical music is part of any good musical
training, a musician who refuses to recognize the importance of popular
music in American life is not suited to this work. If he has a positive
dislike for popular music, he should look to other fields. It is not
necessary that he be able to play all the types of modern jazz, but
he should be familiar with the common jargon of jazz and should learn
the distinctions which exist between these so-called musical forms.
His musical tastes need not be catholic, but his attitude towards the
tastes of others must be broadminded.

Advances in mechanical reproduction of music are progressing at a very
rapid rate, so the technological aspects of music should be cursorily
reviewed. A working knowledge of record players, record cutters,
needles, tone control and amplification is not difficult to acquire.
It may be part of the duties of a music aide to supervise record
cuttings and a public address system. In some hospitals the library
of musical recordings and literature may be large. A study of musical
librarianship will save much time, and the study of classification
systems and filing will become an additional part of the work of a
music aide.

More often than not a musician approaches a problem with more emotion
than analysis, and this becomes of great importance when the problem is
a patient. There have always been and will continue to be physicians
who with honest conviction or for greater glory will anxiously ally
themselves with anything new or sensational, therefore musicians
impassioned with the belief that music is necessary to health will have
little difficulty in finding collaborators in the ranks of medicine.
Musicians must be cautioned to consider the fact that their sincere
efforts may result only in discrediting music, as a therapeutic agent.
As a result its acceptance as the basis of such merits as it may
possess may be undeservedly delayed because of antagonism aroused by
extravagant claims made in its behalf.

Much has been written about music as a therapeutic agent, and recently
there have been entire schools and organizations devoted to Musical
Therapy. In spite of the great temptation to be in on a coming theory
few physicians have associated themselves with these efforts, and what
is more conclusive, no physicians of national repute have come forward
in approval of the term “musical therapy” as applied to the handling of
psychiatric patients.

The use of music should not be limited to mental hospitals, however.
Those who have played music for mental patients are enthusiastic over
the individual responses they have witnessed. The nature of this
response is awakened interest or joy. Joy is a healthful symptom for
all patients to experience and this joy should be available to patients
in all hospitals. Many other phases of music are adaptable for hospital
use and this book is written to outline the many approaches possible
and delineate the scientific basis for some of them.

Of the better known books on musical therapy some, like the work by
Hector Chomet, are built around the effects observed in individual
patients; others, like the writings of Eva Vescelius, are pure phantasy
which stem from unbridled emotion. For science was not applied until
the appearance of psychologic investigations when common sense
began to emerge from a chaos of wishful thinking. One of the first
dependable surveys of the subject was in the _Psychology of Music_
by C. M. Diserens. Since the appearance of this excellent work the
passages stating his views have been often quoted--frequently without
acknowledgment. Its chapter on Musical Therapeutics is recommended for
its scholarly history and sober evaluations of facts and fancies.

This book has been written for the musicians who wish to learn how they
may work with physicians for patients. Technical terminology has been
reduced to simple terms wherever possible for a better understanding,
but co-operation can be secured only if the musician is willing to
forget his preconceived ideas and abide by the decisions of the
physician, who may not be too familiar with music but is familiar with
hospitals and patients.

The unemotional approach to this subject is of recent origin. Little
has been written in that vein, and this book will lay no claim to
originality or perfection. It is hoped that it will act as a guide to
further study and an aid to those who wish to engage in this as yet
uncharted venture.

Realizing that few sources of information are available in this field
to musicians, and that some musicians may one day feel the urge or
experience the need to participate in such work, the New England
Conservatory of Music invited the author to give a series of lectures
to its students on this subject. At the conclusion of the course they
decided to offer this outline to those who might later wish to refer to
its contents.

In preparing this work the author had the good fortune of personal
interviews with some of the leading musicians, musicologists and
musical psychologists in the country. Although no statements which
appear in this volume are to be construed as the opinions of any of
them, an expression of thanks is offered to the following for their
willingness to exchange ideas with the author: Dr. Serge Koussevitsky,
Mr. Igor Stravinsky, Dr. Harold Spivacke, Dr. James Mursell, and Dr.
Carroll Pratt.

The author wishes to express his thanks to Mrs. Margaret E. Gurney
and Miss Ida Evans for their assistance in the preparation of the
manuscript.

The author wishes to express his deep gratitude to Mr. Clifton Joseph
Furness, Director of Academic Subjects at the New England Conservatory
of Music for his supervision in the editing of this book.

  S. L.


FOOTNOTES:

[I.] _Pythagoras passed a black-smith shop one day and was struck
with the beauty of the two sounds he heard coming from it. He entered
the shop, studied the sounds closely and found that the two notes
were an octave apart. This observation stimulated him to a detailed
study of music which led to his musical philosophy. He believed that
all nature and knowledge were contained in harmonic numbers, and that
the world had been made in a musical harmonic accord. He invented a
sacred quartenary of harmonic numbers to explain the phenomena of life.
But Roussier believed that Pythagoras adapted his system from the
Chinese._[70]




_CHAPTER ONE_

HISTORY OF MUSIC IN MEDICINE

  “Music exalts each joy, allays each grief,
  Expels Diseases, softens ev’ry pain,
  Subdues the rage of poison and the plague,
  And hence the wise of ancient days ador’d
  One pow’r of Physic, Melody and Song.”

  “_The Art of Preserving Health_”
  by John Armstrong (1709-1779)


In many fields of endeavor a scholar occasionally appears who not only
makes a personal contribution to the knowledge and advancement of his
subject but summarizes previously gained information so well that
his work becomes at once a milestone and a beacon. In the field of
music, such a man was Charles Burney, who began to publish a _General
History of Music_ in 1776. This book was so thorough and scientifically
critical that his conception is as modern as tomorrow. After listing
all the instances of music as a therapeutic agent, he concludes:

 “Yet men delight in the marvellous; and many bigoted admirers
 of antiquity, forgetting that most of the extraordinary effects
 attributed to the music of the ancients had their origins in poetical
 inventions, and mythological allegories, have given way to credulity
 so far as to believe, or pretend to believe, these fabulous accounts,
 in order to play them off against modern music, which according to
 them, must remain in a state far inferior to the ancient, till it can
 operate all the effects that have been attributed to the music of
 Orpheus, Amphion and such wonder-working bards.”[15]

It is well to begin a study of music in medicine with Burney’s
restrained enthusiasm lest we fall into the error of building
impossible temples of healing on the thin ice of untested claims. We
shall begin with prehistoric times.

The use of music against disease is as old as music itself. In
fact, early history of music is intimately associated with healing.
The wishful thinking of primitive peoples called upon magic for
assistance, and magic is almost universally associated with words,
chanted words, in rhythmic incantation. Chateaubriand believed that
the chant was the offspring of prayers. Among primitive peoples, the
medicine-man combined the offices of priest, physician and magician,
and although all three functions were closely related, their functions
were dissociated on occasion. For instance, there were special songs
for the invocation of natural phenomena, for group activities, and
for accompaniment of healing rituals. “The belief in the efficacy of
musical magic is one of the most important facts in the history of
civilization.”[19]

Although no records exist, it is fair to assume that the truly
primitive peoples of today have not changed markedly from their
ancient customs, and that they resemble to some extent the status of
prehistoric men. The universality of certain folkways among widely
scattered tribes of primitive peoples today lends validity to this
theory.

For such studies we need look no further than our own continent. Even
though certain magical practices have been banned by law, the American
Indians number amongst their tribesmen, those who remember and to some
extent still use music in healing. Several investigators have become
interested in this study, but chief among them is Frances Densmore who
has analyzed and recorded the songs of many Indian tribes. Among the
Teton Sioux she found[21] that the sick appealed to the tribal medicine
man who gave the case some thought and claimed to find the cure in
dreams. “All treatment of the sick was in accordance with dreams.” The
patient was then placed in a dark tent and the medicine man sang his
dream song, as well as songs addressed to the sacred stones. The use of
herbs of the agency of magic might accompany the song. An example of
one of the songs used to cure wounds has the following text:

  “Behold all these things
  something elk-like
  you behold
  you will live”

Words like these have a certain sophistication which we may assume
constitutes a more recent development.

For many centuries primitive peoples have had different concepts of
the exact nature of disease, but for many of them it connotes some
connection between a demoniacal spirit and counter-spirits. There were
a great many methods employed to drive out the evil spirits. The idea
that music was efficacious in these cases persisted for centuries.
Martin Luther said, “The devil is a saturnine spirit and music is
hateful to him and drives him away from it.”

Densmore points out that among the Iriquois[22] the word _orenda_ is
used to designate the universal indwelling spirit. Nothing was regarded
by the Indian as supernatural, in our use of the term, but many Indians
desired an _orenda_ stronger than their own. When a medicine man began
to treat a sick person the result depended upon the power of his
_orenda_. _Orenda_ could be put forth in song. Those who possessed
_orenda_ strong enough to do wonderful things were called medicine men.
They were consecrated to their work, and the safety, success and health
of their people depended on their efforts.

In completing her analysis of Indian medicine songs, Densmore concludes
that they suggest “the confidence which the medicine man felt in his
own power, and which he wished to impress on the mind of his patients.”

Wallaschek[79] lists many examples of the healing use of music among
primitive tribes. Among the Wasambara in East Africa, the doctor
arrives with a small bell in his hand which he rings from time to
time. The patient sits before him on the ground and the doctor begins
speaking in a singing tone: “Dabre, dabre.” He repeats this several
times and the patient sings a simple response. In Australia, Wallaschek
found a tribal doctor shaking a bundle of reeds, an action otherwise
used during a song to mark time. In Borneo, the natives perform
recitatives and songs in order to catch the soul of the patient which
is supposed to have run away before the evil spirit. The Wallawalla
Indians in this country believe that song influences the cure of a
patient, and all the convalescents are directed to sing for several
hours daily. In British Columbia the doctor sings when he visits the
patient, while a chorus of people intones a song outside the house.

With the dawn of civilization, intellectual activity became more
progressive but folkways die hard.

 “The ancient Egyptians called music ‘physic for the soul,’ and had
 faith in its remedial virtues. We may presume that the incantations
 presented in the medical papyri were likewise to be emitted with the
 proper voice and therefore contain an element of music. The Persians
 regarded music as an expression of the good principle Ahura-Mazda
 and are said to have cured various maladies by the sound of the
 lute”[24]. “The Lacedemonians agreed with the Egyptians and confined
 the possessors of music to one family, and their priests like those
 of Egypt were taught medicine and music, and initiated into religious
 mysteries”[28].

The martial and moral values of music were appreciated by most of the
early civilizations. Both Confucius and Plato believed that music
was the most certain means of reforming public mores and sustaining
them at a high level.[25] Although many histories on effects of music
quote the scripture as evidence of the Hebrew use of music in healing,
the passage quoted[63] is subject to various interpretations. It
simply says that after listening to David play on the harp, Saul was
“refreshed and well,” this could refer more to loss of fatigue than
cure of a disease.

The great poets have always sung the praises of their beloved sister
muse. In Homer there is a story relating how the flow of blood from
Ulysses’s wound was stopped, charmed by the use of music.[13] Now it
is very possible that the blood of the famed warrior coagulated in its
wound during a musical interlude, but then, all wounds except those
involving a large artery will cease bleeding in about twenty minutes.
Homer also stressed good music and song as a means of elevating the
spirit and of overcoming depression of the soul or mind, agony,
anguish, anger and sorrow. He gives as an example the story in which
Chiron heals the sick with melody.[57] Cato[13] spoke of luxated
joints which were eased by the harmony of sound. We cannot be sure
of the diagnostic acumen of the observer, but for active people the
most common traumatic joint trouble is a “locked” knee. Most knees
which contain disturbed cartilage will unlock after a relatively short
period of rest. In each of these instances, music was an environmental
coincidence. Such observations would only begin to assume scientific
medical value if they could be repeated many times under identical or
similar conditions. They were not.

We may now return to the episodes related by Burney in his commentary.
Martianus Capella, an ancient author on music, assures us that “I have
often cured disorders of the mind as well as the body with music”[58].
He also claimed that the Aesclepiades, the state-recognized priests
of medicine, cured deafness by the sound of the trumpet. “Wonderful,
indeed!”, says Burney, “that the same noise which would occasion
deafness in some should be a specific for it in another.” In Plutarch’s
book _De Musica_ it is related that Thaletas the Cretan delivered the
Lacedemonians from the pestilence by the sweetness of his lyre.

 “Thaletas, a famous lyric poet, appeared by command of an oracle and
 all the songs he sang were prayers to the Gods. The disease probably
 reached its highest pitch of malignity before he came, and began to
 subside with his coming; but its disappearance was attributed to the
 music of Thaletas.”

Many other cures are cited. Xenocrates employed the sound of
instruments in the cure of maniacs; and Appolonius Dyscolos claimed
that music was a sovereign remedy for dejection of the spirits and a
disordered mind, and that the sound of a flute would cure epilepsy and
sciatic gout. Athenaeus rendered the cure for gout more certain by
playing music in the Phrygian mode, while Aulus Gellius insisted that
the music be soft and gentle, the opposite of the furious Phrygian.
Coelius Aurelianus introduced a concept which reappeared at several
widely separated times. He called it _loca dolentia decantare_,
or enchanting the disordered places. He claimed that the pain
was relieved by causing a vibration in the fibres of the affected
part. There is little doubt that music causes a physical vibration
of the air, but the force that such vibrations could have on most
tissues is negligible. Other writers recommended that the instrument
be held against the part to be treated for direct transmission of
the vibrations, but if physical excitement is desired this can be
accomplished more uniformly by applications known as manipulation or
massage. Such manipulations are known to be helpful in some conditions,
but not curative in painful conditions such as sciatica.

Nearchus, who accompanied Alexander the Great in his conquests,
reported that in India the only remedy against the bite of a serpent
was a chant[70]. Galen, one of the soundest physicians of ancient
Rome, recommended music as an antidote to the bite of vipers and
scorpions[7], and for centuries music was recommended for the bite of
a tarantula. In the seventeenth century three physicians named Mead,
Burette and Baglivi explained this use of music. They said that it
threw the patient into a violent fit of dancing which brought out a
plentiful perspiration, and with it the poison. Since perspiration
consists of water and a few simple salts, such activity would increase
the concentration of the poison in the circulating blood, and neither
the explanation nor the treatment is acceptable[28]. Music was
recommended not only for the bites of the reptiles and insects; Desault
recommended it in the treatment of hydrophobia[23]. Not all bites
are poisonous, and it is likely that in the case of the two patients
mentioned the cure was more for fright than bite.

The effects of music on the mind were too obvious to escape the
ancients. When the armies of Greece took the field, they were
accompanied by the best musicians, who by their martial strains
inspired the soldiers with a kind of mechanical courage never
experienced by their enemies.

The distinction between mental health and disease was not advanced
among the ancients, but they did recognize varieties of insanity such
as delirium, melancholy and mania. Many physicians recommended music in
the treatment of mental disease, and Quarin spoke of a single case of
epilepsy cured by music. With the exception of severe epilepsy, many
patients who suffer from the symptoms which bear this name have only
occasional attacks and these disappear spontaneously, making the music
simply another coincidence.

       *       *       *       *       *

Celsus, who was a great medical authority not only in his own time
but in subsequent centuries wrote of the mentally ill, “We must quiet
their demoniacal laughter ... and sooth their sadness by harmony, the
sound of cymbals and other noisy instruments”[16]. Areteus, another
great physician of ancient Rome, prescribed music for “corybantism,
a disease of the imagination”[24]. The great Dutch physician,
Boerhaave[11], said, “I do not know if all that one tells us of the
charms and enchantments could not be attributed to the effects of
music, in which the ancient physicians were well versed.” References
continued to appear concerning the magical relationship between music
and healing. Robert Grosseteste (1175-1253 A.D.) said that disease and
even wounds and deafness could be cured by music based upon a knowledge
of astrology and mathematics[75].

       *       *       *       *       *

During the early part of the Christian Era, most of the arts were
sustained by the Church, and as a result the finest works in painting
and music were available to the average man only within places of
worship. Not until the Renaissance did serious music take on a secular
character. Music until then was largely identified with religion, and
as such was considered to have an influence on the soul. Bacon advanced
as a rule of health that people “recreate their spirits every day
with a piece of good music.”[13] He went a step further in his _Sylva
Sylvarum_.

 “Seeing then the mind is so powerful an agent in particular disease,
 I see no reason why the efficacy of music should not be tried in many
 disorders which arise in the animal constitution; for music composes
 the irregular motion of the animal spirits and more especially allays
 the inordinate passion of grief and sorrow.”[7]

The restful and joyful qualities of music were praised by Shakespeare:

  “But sweet music can minister to minds diseased
  Pluck from the memory a rooted sorrow
  Raze out the written troubles of the brain
  And with its sweet oblivious antidote
  Cleanses the full bosom of all perilous stuff
  Which weighs upon the heart.”

Henry Beacham wrote in his “_The Compleat Gentleman_” in 1634 that

 “the exercise of music is a great lengthner of life, by stirring and
 reviving the spirits, holding a secret sympathy with them; besides
 the exercise of singing opens the breast and pipes; it is an enemy
 to melancholy and dejection of the mind, which St. Chrysostome
 truly called ‘Devil’s Bath’. Besides the aforementioned benefit of
 singing, it is a most ready help for a bad pronunciation, and distinct
 speaking, which I have heard confirmed by many great Divines; yea, in
 myself have known many children to have been aided in their stammering
 in speech by it alone.”

In the dark ages there was very little added to the knowledge of
medicine, but during the Renaissance physicians became more progressive
and articulate. Among these was the famous Willis who said that

 “Music not only is a delightful phantasy, but dispels sadness from
 the grieving heart; and it also allays fevered passions and excessive
 commotion of the breast.”[81]

Characteristic of the use of music as an aid to healing is an anecdote
quoted by Burney. Farinelli was one of the great operatic singers of
his day and his fame was equally great in all of western Europe and
England. One of the countries he visited was Spain. “It has often been
related, and generally believed, that Philip V. King of Spain, being
seized with a total _dejection_ of spirits which made him refuse to be
shaved, and rendered him incapable of attending council or transacting
affairs of state; the Queen who had in vain tried every common remedy
that was likely to contribute to his recovery, determined that an
experiment should be made of the effects of music upon the King, who
was extremely sensible to its charms. Farinelli was summoned and on his
arrival her Majesty contrived that there should be a concert in the
room adjoining the King’s apartment, in which the singer performed one
of his most captivating songs. Philip appeared at first surprised, then
moved; and at the end of the second air, made the virtuoso enter the
royal apartment. He plied him with compliments and caresses and asked
him how he could sufficiently reward such talents, assuring him that
he could refuse him nothing. Farinelli, previously instructed, only
begged that his majesty would permit his attendants to shave and dress
him, and that he would endeavor to appear in council as usual. From
this time the King’s disease gave way to _medicine_, and the singer
had all the honor of the cure. “The King,” according to the _London
Daily Post_ of September 26, 1736, “settled a pension of 3,150 pounds
sterling, per annum, on Signor Farinelli, to engage him to stay at
court.”

A great number of references during the sixteenth and seventeenth
centuries attests to the wondrous workings of music against mental
disturbances. Wilhelm Albrecht[1] reported a patient who was suffering
from melancholia. Many remedies had been tried, when as a last resort
the physician requested that a certain _ritournello_ be played. As
soon as the patient heard it, he began to laugh with all his might
and hopped out of his bed completely cured. More interesting is the
observation of Champlain[17] who wrote on his return from America, “It
is the custom in America when one is sick, to divert them with loud
music, to prevent brooding about the condition and thus help restore
health.”

Mozart was not the first to call the flute “magic.” To Democritus was
attributed the story of abolishing plague with its music. Jean-Baptiste
Porta claimed that one could cure all disease with music, provided
that one used a flute made of the wood of the plant which was a known
specific for the disease to be treated. Thus one could cure mental
disease with flutes made of hellebore stems. One could return some
vigor to the impotent with flutes made of orchid stems, and fainting
could be cured by playing on a flute made of cinnamon wood.[67]

Philippe Pinel, the physician credited with being the first to accord
the mentally ill humane treatment reported at least one instance of the
use of music in the treatment of epilepsy.

 “During the attacks, the sense of hearing, far from being deadened,
 seemed to have acquired more keenness. A skilful musician played on
 the violin at the patient’s side during her paroxysm. Although she
 then appeared insensible to the charm of music, she was so strongly
 effected by it, that she admitted after having recovered entire
 consciousness, that the music had thrown her into a state of rapturous
 delight.”

Literature abounds with many accounts of the use of music by lesser
medical lights. Sauvages[18] mentioned a young man who had attacks of
intermittent fever accompanied by violent headaches which could be
soothed only by the sound of a drum played loudly. This same patient
did not like music when in good health. Instances of this nature may be
explained on the basis of counter-irritation, wherein a new disturbance
superimposed upon an old one may counteract it.

In the eighteenth century, Brocklesby[13] summarized the known
literature of music in relation to health and disease and, considering
the status of medicine in his day, made a fair appraisal of its value.

During the last century Hector Chomet[18], a Parisian physician, became
interested in music and its application to disease. He wrote a short
article setting forth his views, which he was to deliver to a group of
medical men in Paris, but was put off time and again by his colleagues
and by political upheavals. Each time, before replacing his paper on
the shelf, Chomet made additions. This work grew to be the important
thing in his life, and when he could contain himself no longer, he
published a book on the subject which showed considerable research
but which unfortunately contained as much invention as fact. Not
content with the known and proved existence of blood and lymph as the
chief body fluids, he added another--the “sonorous fluid,” which was
influenced for the good or bad by the vibrations of musical sounds.

At about the turn of the century Eva Vescelius, a woman of great charm,
beauty and perseverance, reintroduced the use of music for mental
disease under the guidance of a physician. There is little doubt that
she gave great joy to many patients, but a differentiation must be made
between personal attention and therapeutics. In her works[78] on the
subject one can read enthusiastic accounts of past performances, but
unfortunately her explanations and claims are pure phantasy, to wit:

 “For fever, high pulse, hysteria, arrest the attention, play softly
 and rhythmically to bring pulse and respiration to normal. Tests
 with instruments will prove that music will do this. Do not change
 too abruptly from one key to another; modulate and pause and let the
 musical impression be absorbed. Select songs that depict green fields
 and pastures new, the cool running brook, the flight of birds, the
 blue sky, the sea.

 “Fear is dissipated by music awakening in the listener the
 consciousness of the all enveloping Good. A high nervous tension is
 relieved and nerves are relaxed under the spell of a composition that
 swings the body into normal rhythmic movement. Sluggish conditions
 of body and mind are eliminated by the rhythmic waltz, polka or
 mazurka--music affecting the motor system. Insomnia is cured by the
 slumber-song, the nocturne, or the spiritual song that assures one of
 the Divine protection.”

The use of music in hospitals is by no means limited to the application
to mental disease. Recreation is needed to avoid boredom, for as
Shakespeare said:

  “Sweet recreation barr’d, what doth ensue
  But moody moping and dull melancholy
  Akin to grim and comfortless despair
  And at her heels a huge infection troops
  Of pale distemperatures and foes to life.”

The use of music as a diversion in hospitals received a great impetus
in the First World War but made its greatest leap forward with the
introduction of the portable bedside radio.

The use of music as an exercise for poorly moving joints and weakened
muscles is recent and may be said to have received its great impetus in
the Second World War (described in the Boston Sunday Post, February 11,
1945; A-5).




_CHAPTER TWO_

PHILOSOPHY AND PSYCHOLOGY OF MUSIC


I

In the realm of thought, opinions and theories sometimes find credence
long after they have been proved incorrect. In the field of the arts,
opinions may become so strongly rooted that there is occasional
resistance to any analytical attempts designed to disprove them, and
even after they have been exposed, there will be a significant number
of people who will continue to believe in them. The artist who would
make music for patients must approach such an endeavor with a full
knowledge of the elements involved, and should be willing to recognize
those prejudices, customs and thoughts concerning the effects of
music on the human body which have been fostered by well-meaning, but
misguided, enthusiasts. We must differentiate between the philosophy of
esthetics and the proved psychology of music. Musicians who refuse to
accept those results of scientific research which disagree with their
personal views will fall into the same difficulties which have beset so
many musicians in the past who have desired to help patients.

Before the advent of laboratory psychology, there was no satisfactory
test for the theories which dealt with music and the mind, and the
number and variety of theories advanced were great. Some of the most
unreasonable were the most attractive, and it is easy to understand
why they were accepted. But if any of these theories is used as a means
of attaining a scientific end it cannot succeed with any dependability
if it is unsound.

The psychologic effects of sound may be physiologic or intellectual.
They may be related to intensity, quality or direction on the one
hand, or to past or present mental associations on the other. To the
primitive man thunder, which seems to come from everywhere and is
louder than anything he can produce, is terrifying and supernatural;
the rustling of leaves is frequently caused by the wind, but from his
past experience may also instil the fear of the approaching enemy.
Sound is often frightening from its qualities or implications.

The psychologic reaction to the type of sound known as music may vary
from the reflex panic produced by the air-raid siren to the soothing
effect of a softly sung lullaby. For some people, certain musical
selections elicit almost no response, while in still others a truly
amazing chain of mental images results. The latter reaction is the
result of centuries of evolution in the development of music and
knowledge, and will be discussed later.

During the modern evolution of musical composition, many new forms
were devised bearing descriptive names. Some of these forms by their
distinctive tempo, dynamics, or title conditioned the informed
listener to a mental attitude consistent with the intention of the
composer. Some selections by the very nature of their execution cause
stimulation or assist repose. Superficially it might seem, therefore,
that the controlled administration of music could evoke desired moods
in listeners at will, and some practitioners declared that music is a
specific treatment for mental disease. It is undoubtedly possible to
influence the mood of healthy, trained musicians by the use of selected
compositions but to assume that all listeners will react in similar
fashion, or that the moods of the mentally deranged can be changed at
will by prescribed music, is to ignore the nature of mental disease and
the scientific finding of psychologists.

Music is many things, but physically it consists of sounds or notes
which have pitch, intensity, timbre and duration. These notes are
combined in patterns which have rhythm, tempo, melody and harmony and
these in turn are related to key, mode and form. Each of these elements
has been the subject of philosophic interpretation, and more recently
of psychologic investigations. Although the effect of music on the
human mind depends upon the reaction to the entire composition, it is
important to review the existing data in order to understand more fully
the effects of music, in spite of the difficulties; for as Ortman[71]
has said “the problem of analyzing and classifying responses of music
into types is at the same time intensely interesting and notoriously
difficult. The history of the problem is rich in unco-ordinated data
and poor in clear-cut conclusion.”


II

ELEMENTS OF MUSIC

_Pitch._ Heinlein[45] found that the same chords which called forth a
happy and bright feeling when played in high pitch were characterized
as gloomy or melancholy when played in low pitch. The voice of youth
and laughter is higher pitched than the grumbling of old age and may
be a conditioning factor. Beaunis[8] felt that the reaction to pitch
is the effect of experience and custom and cited a reversal among
Orientals in whom low pitched sounds effect joyous reactions and the
high, sadness and sorrow.

_Intensity._ Heinlein found that loud chords are rarely soothing, and
soft chords are almost always soothing. Beaunis stresses the fatiguing
quality of great intensity over a long period, and contrasts it with
“Very soft sounds as in Schumann’s ‘Danse des Sylphes’ ... which holds
you under the charm of delightful emotion.”

_Timbre_ is the quality of sound which identifies it with the
instrument of its production. Although many instruments can be
convincingly gay or subdued, most authors are agreed that some
instruments emit prejudicing tones. Chomet[18] considered the bassoon
mournful, the flute tender, and the trombone harrowing. He found that
the clarinet expresses grief, the oboe suggests reverie, but that the
violin “seems suited to express all sentiments common to humanity.”
Mursell[60] finds consistent tactile values in tone. Low tones are dull
and high tones cutting. He speaks of the French horn as smooth, the
piccolo sharp, the oboe as stringent, the cello velvety and the bassoon
rough.

Gundlach[38] believes that the timbre of an instrument is significant
in mood response. He finds the brasses triumphant and grotesque,
never melancholy or tranquil, delicate or sentimental; the woodwinds
mournful, awkward, uneasy, never brilliant or glad. The human voice
also has timbre, and distinctive values. There is the dramatic quality
of Marian Anderson and the syrupy flow of Bing Crosby; the virility of
the basso and the sparkle of the coloratura.

_Duration._ The sounding of a single note will attract attention,
but if the note continues for a sufficient period without changing
its characteristics it will become monotonous, annoying and finally
exasperating. If the sound is interrupted at equal intervals, this
reaction will take longer to develop, but if the intervals between them
are irregular, interest is sustained, especially if these variations
occur periodically; that is, with a certain rhythm.[8]

_Rhythm._ It is possible to have music without rhythm, but as
Rameau[68] pointed out long ago, “Music without rhythm loses all its
grace.” Since percussion instruments probably preceded all others,
rhythm was the first stage in the evolution of music. The proponents of
the motor theory of rhythm feel that muscular response to music with
pronounced rhythm is a physiological reflex. They point out that it is
difficult to walk deliberately out of time to a well accentuated march,
and Dunlap[26] has shown that in reclining subjects “With the utmost
possible relaxation of the entire body, good rhythmic grouping of an
auditory series can be obtained.” With the aid of the electromyograph
Jacobson[50] has shown that in complete relaxation mental activity
results in fleeting but specific muscle contractions invisible to the
eye and unknown to the subject.

Rhythm perception is a mental stimulant. Reade[69] observed that
African negroes when ordered to row a boat always began to sing as an
aid to overcome their natural laziness. Bücher[14] believed that rhythm
as exemplified in working songs facilitates the synchronous expenditure
of energy by individuals engaged in a common task.

Although rhythmic song will not necessarily elicit obvious motor
responses in all subjects, the wide-spread use of work songs among
groups of people engaged at hard work on land or sea throughout the
world is indicative of the value of background rhythm for communal
effort. Mursell[60] believes that “any notion that pure or ‘naked’
rhythm is more effective than rhythm clothed in tone is open to very
serious doubt.” But the chief effect of marked rhythm is the feeling of
excitement and happiness which it can arouse. Rhythm gives us a certain
pleasure because of its orderliness to which the mind is sensible.

_Melody_ as a musical element contributes chiefly to restfulness.[71]
If it is simple and recognizable it will recall other times and rest
the mind from the thoughts of present problems. If it is complex and
new it will distract the more musical but have a less desirable effect
on the uninterested.

_Mode._ The term _mode_ is applied to the arrangement of whole and
half-tones in the musical scale construction. Of the many possible
modes only two are used in our present system of music, the _major_
and the _minor_. There is only one form of the major mode, and it is
the one most people recall when they think of the scale. There are
three forms of the minor mode, but of these the _harmonic_ is the most
frequently used. It is formed by lowering the third and sixth notes by
a half-tone.[80]

When an author pioneers convincingly in a field which has long needed
clarification, it is likely that even his questionable remarks will
be accepted with the same degree of authority as his scientific
statements. In 1722, Rameau[68] published a treatise on harmony which
received wide acceptance because of its excellence and comprehension,
but in that work he prejudiced many of the writers who followed into
believing that the major triad was more pleasing and beautiful than the
minor. This concept was not only adopted but embroidered. Hauptman[44]
likened the minor triad to the branches of the weeping willow and
hence attributed to it a mournful downward drawing power. To the major
triad he assigned the property of an upward driving force. (When this
is taken literally, as it was, and applied to the patient, we can see
clearly why remarkable attributes were claimed for music.)

Now there is little doubt that if the triad of C minor is struck on a
piano after that of C major, most people will describe the sensation
elicited by the sound of the minor chord as melancholy. Helmholtz[46]
attributed the veiled or sad effect of a minor chord to certain notes
foreign to the chord which physical reasoning expects.

 “The foreign element thus introduced is not sufficiently distinct to
 destroy the harmony, but it is enough to give a mysterious obscure
 effect to the musical character and meaning of these chords, an
 effect for which the hearer is unable to account, because the weak
 combinational tones on which it depends are concealed by other louder
 tones, and are audible only to a practiced ear.”

But Gurney[40] refuses to admit to a sense of melancholy in this slight
dissonance, for as he points out

 “the same slight degree of dissonance as exists in the minor triad
 may be made to supervene on a major triad, by adding to it a certain
 extremely faint amount of discordant elements: it would seem then
 that the major triad thus slightly dimmed or confused ought to sound
 melancholy, but it does not in the least. Another argument may be
 found in the following fact. The minor triads of D and A are of
 perpetual occurrence among the harmonies of C major; and yet they do
 not seem then to convey the distinctly pathetic impression, instantly
 produced by the appearance of the C minor triad.

 “Music in a major key may be profoundly mournful; and it would
 often be impossible for any description to touch the musically felt
 difference between such music and mournful minor music. The minor mode
 has a somewhat more constant range of effect.”

Such discussions continued until Valentine[76] decided to test the
mood effect of the modes on a group of listeners. He found that
“major intervals are described as sad or plaintive twice as often
as the minor.” Heinlein[45] not only substantiated this but found
that intensity was the dominant modifier of feeling. He reviewed
more than twenty-five hundred compositions for beginners and among
them found only seven per cent written in the minor mode. “It is a
difficult matter to obtain a composition in the minor mode written
for children that does not have a title which relates to the weird,
the mysterious, the sad and the gloomy. Apparently composers in their
attempts to differentiate the modes for children fall victim to the
method of introducing titles opposite to feeling content. To children,
the title of a composition is a very outstanding feature. It may be,
after all, that reaction to the modes is largely a question of the
extent to which association with descriptive titles of a specific
variety first establishes the affective impressions in the mind of
the beginner.” Thus it can be seen that composers have been nurturing
an old philosophy by titles rather than music. Beaunis has shown that
although among European composers, the major mode has been used for
bright and restful passages and the minor mode has been used for uneasy
and stirring selections, a study of the music of other races will
uncover an entirely opposite use. Hevner[47], in an elaborate series of
controlled studies, concluded that “all of the historically affirmed
characteristics of the two modes have been confirmed” but admits that
“in producing its effect on the listener, the mode is never the sole
factor.”

In a later study Hevner[48] continues to maintain that modality is
effective in the dimensions of sadness and happiness but quite useless
in the dimensions of vigor, excitement and dignity.

The reaction to mode is influenced by what has been heard immediately
previously, and by musical training. The reaction to mode is not
physiologic but offers one key to music for patients in that those who
identify the minor mode with sadness should not be given such music
when gay music is indicated.

_Key._ There was a time when particular keys were credited with
emotional powers. Lest such thoughts still persist, the following
quotation from Gurney[40] is offered.

 “Particular keys are sometimes credited with definite emotional
 powers. That certain faint differences exist between them on certain
 instruments is undeniable, though it is a difference which only
 exceptional ears detect. The relations between the notes of every key
 being identical, every series of relations presenting every sort of
 describable or indescribable character will of course be accepted by
 the ear in any key, or if it is a series which modulates through a set
 of several keys, in any set of similarly related keys. But as it must
 have a highest and a lowest note it will be important, especially in
 writing for a particular instrument, to choose such a key that these
 notes shall not be inconvenient or impossible; and also the mechanical
 difficulties of an instrument may make certain keys preferable for
 certain passages. Subject to corrections from considerations of this
 sort, the composer probably generally chooses the key in which the
 gem of his work first flashes across his mind’s eye: and when the
 music has once been seen and known, written in a certain key, the
 very look of it becomes so associated with itself, that the idea of
 changing the key may produce a certain shock. But the cases are few
 indeed where, had the music been first presented to any one’s ears in
 a key differing by a semitone from that in which it actually stands,
 he would have perceived the slightest necessity for alteration; and
 as a matter of fact when a bit of music is thought over, or hummed
 or whistled, unless by a person of exceptionally gifted ear it is
 naturally far oftener than not in some different key to that in which
 it has been written and heard. Even the difference most commonly
 alleged, between C major as bright and strong and D flat as soft and
 veiled, comes to almost nothing when a bright piece is played in D
 flat or a dreamy one in C.

 “That a variety of emotional characters can be definitely attributed
 to various keys is a notion so glaringly absurd that I would not
 mention it, were it not that it is commonly held; and that such
 doctrines are really harmful by making humble and genuine lovers of
 music believe that there are regions of musical feeling absolutely
 beyond their powers of conception.”

In an unnamed manual the following statements occur:

 “C major expresses feeling in a pure, certain and decisive manner.
 It is furthermore expressive of innocence, of a powerful resolve, of
 manly earnestness, and deep religious feeling.

 “G minor expresses sometimes sadness, sometimes, on the other hand,
 quiet and sedate joy--a gentle grace with a slight touch of dreamy
 melancholy--and occasionally it rises to romantic elevation. It
 effectively portrays the sentimental, etc. Another author, quoted by
 Schumann, found in G minor discontent, discomfort, worrying anxiety
 about an unsuccessful plan, ill tempered gnawing at the bit. ‘Now
 compare this idea,’ says Schumann, ‘with Mozart’s Symphony in G minor,
 that floating Grecian Grace.’ He quotes from the same writer that E
 minor is a girl dressed in white with a rose-colored breastknot.

 “These are but abstracts, and a good deal of the humor is lost by
 selection. For the ‘characters’ of several of his keys the author
 gives a list of examples the choice of which, inasmuch as every
 possible character might be exemplified from compositions in every
 single key, cannot have been very difficult. It is something like
 proving that Monday is a day ‘especially full of melancholy,’ on
 the ground that some individual lost a relative on it, or that the
 characteristic of Thursday is ‘confidence and hope,’ on the ground
 that on it an individual came in for a fortune.

 “These thoughts are similar to that of the Chinese philosopher who
 traced the five tones of the old Chinese scale to the five elements,
 water, fire, wood, metal and earth.”

_Tempo._ “The idea of forcing emotional characteristics on tempo is not
less preposterous than those on key. (Gurney quotes further ideas of
the same writer.)

 “The common time expresses the quiet life of the soul, an inward peace
 but also strength, energy and courage.

 “The three-eight time expresses joy and sincere pleasure; but its best
 characteristic is simplicity and innocence.

 “The three-four time is expressive of longing, sincere hope and love.

 “It would be interesting to hear from this writer what happens when
 any one composes a piece in common time, which expresses the quiet
 life of the soul and ‘inward peace’ and in the key of E minor, which
 represents grief, mournfulness, and restlessness of spirit.”

Gundlach[38] found that speed was by far the most important factor in
distinguishing among several pieces played to a group. And Hevner[48]
found that for excitement the most important element was tempo, which
must be swift. “Dreamy sentimental moods follow slow tempo. Sheer
happiness demands a faster tempo.”

Hanson[42] believes that “everything else being equal, the further
the tempo is accelerated above _tempo moderato_ (which is about the
same speed as the human pulse rate) the greater becomes the emotional
tension.” He goes on to state that “as long as the subdivisions of the
metric units are regular and the accents remain in conformity with
the basic pattern, the effect may be exhilarating but not disturbing.
Rhythmic tension is heightened by the extent to which the dynamic
accent is misplaced in terms of metric accent, and the emotional
effect of ‘off-balance’ accents is greatly heightened by an increase
in dynamic power.” He is unduly alarmed by the effect “Boogie-Woogie”
may have on the younger generation because rhythm irregularity finds
its most fertile field in this jazz form characterized by “a repeated
figure in the bass (which) continues indefinitely in regular rhythm.”

_Sonority._ Hanson[41] has traced the development of music from the
highly consonant music of the Roman Catholic Church at about the time
of Palestrina to the dissonant music of certain modern composers. He
describes the early hymns as “calm, serene and in a sense impersonal.”
For him, “the expression of personal feeling in music seems inevitably
to be associated with the use of dissonance. Indeed the expression
of emotion in music seems to be bound up in the contrast between
dissonance and consonance, the former producing a sense of tension and
conflict to be either heightened by progression to a sonority of still
greater tension or resolved by a succeeding consonance.” It may be easy
for a musician to believe that the increased use of dissonance creates
an increase of emotional tension, but to the musically uncultured
listener dissonance may just as often create boredom or annoyance.

_Composition._ Although musical factors such as pitch, intensity and
melody can contribute to mood effect when isolated, the reaction to an
entire composition is quite different from reaction to tones of chords.
It may depend upon environment or association with the situation in
which the selection was first heard or is being heard. It may be
altered by the length of the composition or unanticipated contrasts of
intensity or the use of unusual patterns, rhythm or tempo. In listening
to music, expectation plays an important role. A sudden change or
interruption is apt to excite surprise. “The mere meeting of the
expectation in all its details affords pleasure of a kind. But great
as is the aesthetic pleasure, a far greater degree of enjoyment may at
times be attained by a carefully planned surprise, the appropriateness
and artistic skill of which is recognized and approved”[10].

Much has been written on the images or stories which musical
compositions evoke. Some musicians have tacitly implied that ability
to appreciate these stories results in greater pleasure, but
Gehring[34] wisely insists that “musical enjoyment does not depend on
interpretations, but it may also be reaped by those who abstain from
making them.” There are some people who can interpret any musical
selection, and others who find no story. Between these extremes is a
group who can get more pleasure from music if listening is preceded by
such preparation. As Damon[20] has pointed out, “A musical selection is
thought to be more beautiful and more colorful when the usual program
notes are supplied before hearing it.”

There are those who see specific color in sound. It was Isaac Newton
who first compared the diatonic scale with the seven colors of the
spectrum from red to violet beginning with C as red. Katz[71] reported
on strong color association of two case studies. For the first, C major
was jet black and for the other C major was brilliant white. But this
could be expected inasmuch as the scale of notes presents intervals
and proportions of the most definite kind whereas those of the color
spectrum are confluent and have no mathematic relation. Spectrum
analogy was discredited by de Marian in 1737[70]. “No two people
agree or hardly ever do, as to the color they associate with the same
sound”[30].

But color is only one element in a mental image; what about the others?
Is it possible for two people listening to a new, unnamed musical
selection for the first time to envisage the same story or picture?

T. Kawarski and H. Odbert[52] found no direct relationship between
color and music which held for more than a few individuals but certain
general relationships of photoism to special aspects of music were
found to recur constantly. Thus increase in brightness tends to
accompany rise in pitch or quickening of tempo. Whereas some one factor
like strong visual imagery or cultural influences or suggestions may be
dominant in some individuals and a totally different factor in another,
none of those factors operate in any pure and simple fashion.

Too often musical interpreters will see too much in a given selection.
Some will try to rhapsodize in words the theme as announced by the
title of the selection. Some enthusiasts will grasp at straws of
suggestion from the original source. Gurney cites an amusing instance
in connection with a sonata of Beethoven, of which the three movements
are entitled: _Les Adieux_, _L’Absence_, and _Le Retour_. These titles
were so inviting that some gushing comments were published about the
portrayal of passages from the life of two lovers. However, on the
manuscript, Beethoven wrote: “Farewell on the departure of His Imperial
Highness, the Archduke Rudolph, the 4th of May 1809.” and “Arrival of
his Imperial Highness, the Archduke Rudolph, the 30th of January 1810.”

The insistence by some of the specific images evoked by certain
selections can be disheartening to those lovers of music who accept
such interpretations as fact and are disappointed in their inability to
experience the same reaction as others, especially if the others are
recognized musicians.

 “It is obvious that the power of music to depict objects, situations
 or ideas is extremely indefinite. No matter how specific a pictorial
 or dramatic program the composer may have in mind to present through
 his music, the listener will never get that program from the music
 itself. If the hearer is told what the music is supposed to depict
 he will imagine the incidents and fit them into the music. Or if he
 is given a title it will suggest to him a train of imagery which he
 will read into the composition. And if he is given neither title nor
 program his fancy might take him on a mental journey, the direction
 of which will depend upon his mood, his mental set, his physical
 condition, his past experience, and numerous other subjective factors,
 for which music serves as a stimulus, but all of which lies outside of
 the music itself.”[35]

Thus when Rubinstein read into the “Second Ballade” of Chopin the
story of a wild flower caught by a gust of wind, the struggles of the
flower and its final breaking, he confused the issue by adding a second
interpretation to the music which was inspired by Mickiewicz’s poem,
“Switez Lake,” the story of which is totally different. When Gilman
played this same song for his students there were many interpretations
which ran the gamut from “meaningless” to “creeping assassins.”[35]

       *       *       *       *       *

Beethoven’s complaints of his interpreters and expounders were frequent
and bitter, but we must turn to the writings of the more literary
musicians, Mendelssohn and Schumann, for coherent expressions on the
subject. Mendelssohn wrote,

 “What any music I like expresses for me is not thoughts too indefinite
 to clothe in words, but too definite. If you asked me what I thought
 on the occasion in question, I say, the song itself precisely as it
 stands.”

Schumann’s position as regards verbal readings of music may be gathered
from the following passage:

 “Critics always wish to know what the composer himself cannot tell
 them; and critics sometimes hardly understand the tenth part of what
 they talk about. Good heavens! will the day ever come when people will
 cease to ask us what we mean by our divine compositions? Pick out the
 fifths, but leave us in peace.”[40]

Some musical selections have been written to accompany a subject. Those
who know the story of _The Barber of Seville_ may associate the aria
“Largo al Factotum” with the despair of an over-worked barber, but
the same song might have been written to accompany almost any lively
subject and for people who have never heard the story and who do not
understand Italian, it is just a bright song, possibly humorous. As
Gurney says:

 “The verbal titles which aim at summing up the expression of certain
 compositions, however interesting, are so adventitious that they have
 often been suggested by instead of suggesting the music; and a hundred
 auditors, if left to guess the title for themselves, would originate a
 hundred new ones.”[40]

Music can evoke specific emotions only when people have been
conditioned to it. The “Horst Wessel” song would not stir Americans
to hatred unless they could identify the title with the song and its
significance. Even then, the degree of hatred or contempt for the music
would be variable.

Edwin Franko Goldman’s “On the Farm” can leave little doubt in any
one’s mind as to its subject matter, but with the exception of such
very obvious music, or music to which we have been emotionally
conditioned, music cannot paint blue skies or green pastures.

What then are the feelings most frequently excited by music? According
to Schoen[72]:

 “The data show that rest, sadness, joy, love, longing and reverence
 appear most frequently as the effects produced. Vocal music has a
 tendency to arouse well-defined emotional effects far more often than
 instrumental, the probability being that the specific emotional effect
 is due in the main to the words.”

The conclusions of Schoen on mood changes in a tested group sum up the
relationship between mood changes and enjoyment. Thus for practical
purposes we want to know not only whether a musical composition
produces a mood change in the listener, but also what is of greater
significance, whether the induced mood is also enjoyed, and to what
degree this enjoyment might depend on such factors as the type of
mood induced. The listener’s familiarity with the selection, and his
judgment of the quality of the selection, are also important.

The results of a large series of observations show as a rule, that
music produced a mood change in every listener, or that an existing
mood was intensified when it conformed with the mood of the music.
The tendency of the same composition to produce the same mood in
every listener was very marked. The degree of enjoyment derived from
the musical composition was in direct proportion to the intensity of
the mood effect produced, provided this effect was not due to the
conditions of the performance, such as a poor intonation or faulty
interpretation.

 “No greater amount of enjoyment was derived from one type of mood than
 from another type, unless the mood was due to dislike of the specific
 type of music or to a poor performance. But when the mood change was
 from joyful to serious, the enjoyment seemed to be slightly less than
 when the change was from serious to joyful, provided the hearer was
 not hampered by a knowledge of the critical estimate of the music to
 which he was listening or by faulty interpretation. The evaluation of
 the quality of the musical composition was in direct proportion to the
 intensity of enjoyment.”


III

OTHER CONDITIONING FACTORS

In addition to the physical elements of music previously discussed
there are other factors which enter into the type of response of mind
and body to music. Mention has been made above of the value of program
notes. People who hear new music for the first time may or may not
develop a visual or emotional response, but if prepared by descriptive
writing they may “understand” or at least enjoy the music more.

 “Program notes, oral comments, and the general setting of the
 presentation are important because they concentrate and reinforce the
 mood response. Indeed it has been shown that in a verbal introduction
 offered before a composition is presented, what is said does not
 matter much, and that almost any kind of comment will enhance the
 listener’s enjoyment if it serves to cue him into appropriate
 effective states of mind.”[60]

Music aides should take this finding seriously and preface the playing
of musical selections with verbal commentary. Even popular dance music
may be prefaced by remarks about the solo instrument featured or the
personalities involved.

With the exception of the effects of rhythm, all other reactions
thus far cited have been largely psychologic. Before leaving the
discussion of response, one bit of evidence demonstrating possible
physiologic action will be presented. Gundlach[39] studied the songs
of six different American Indian tribes. Now the language, customs
and music of neighboring European countries frequently have something
in common, but the absence of the wheel in transportation made the
scattered people of the Western Hemisphere strangers to each other.
The speech and songs of the different Indian nations are entirely
unrelated, yet the songs representing the same types of ceremonials
show considerable agreement. From this Gundlach concludes that “music
has some conventions grounded on a firm basis of physiologic structure
and behavioral similarity of human beings.”

_A_--_Live Music._ Most people will turn to the source of sound. Even
the most phlegmatic will turn if the sound is sudden and loud enough.
It is a protective mechanism because identification of the source may
prevent personal injury. There is also a sense of satisfaction in the
corroboration of the auditory and visual images. When the sound is
musical the desire to see its production is greatly increased. For
those who cannot make music themselves, it is like watching a conjurer
from behind. For musicians it offers the opportunity of inspection,
improvement or criticism. One of the most important psychologic
components of music is the physical presence of the music maker. About
twenty years ago a manufacturer produced piano-player rolls which
reproduced the manipulation of well known artists so well that experts
could not differentiate between the sounds produced on the piano by a
live pianist and the automatic player. Yet this method of reproduction
was a failure financially; it had every quality of the live musician
except the physical presence.

We demand far less in quality of music from a live band than from a
mechanical reproduction of band music. Groups of people who assemble to
dance will pay relatively high prices for inexperienced players with a
monotonous repertoire for the sake of having live music. The dancers
may complain of the poor musical execution, but will suffer a return
engagement in preference to the playing of recorded music.

There are cinema stars whose singing voices are harsh to most ears,
yet listeners will applaud them into an encore, not so much for the
sake of a beautiful experience, but to prolong the human contact. We
react not only to the sound, but to the motions and very presence of
music-makers. We listen to people as well as their music. Live music
stimulates, sustains and focuses attention. It should be used as often
as possible for patients. The “live” musician can get patients to
listen to musical forms which would be entirely ignored otherwise. If
musicians wish to spread the appreciation of “good” music and music
appreciation, one method is to be found in personal appearances at
hospitals.

_B_--_The Human Voice._ Of all the sounds of given pitch and intensity
the one which best attracts and maintains interest is the human voice.
We habitually turn to the human voice. Sometimes we do it as a matter
of courtesy. Again, we may do it for better understanding, or even out
of curiosity. The spoken language is understood by far more people than
is the so-called language of music. When words are set to music they
command greater attention than when they are spoken. They are usually
compact and in rhyme. We strain to hear each word to gather the full
meaning and humor or cleverness of the lyricist. Yet, we willingly
lower our literary standards when words are put to music. The verses
of many songs sound vacuous and repetitious without accompaniment. But
the words are made interesting by the melody, and melody takes on
additional meaning from words. “Vocal music has greater power to arouse
a definite emotional response than has instrumental music. Rest results
about equally from instrumental and vocal music.”[71]

Songs with words are ideally suited for arousing patient interest.
Community singing is the most valuable form of music for maximum group
response.


LISTENING

Violet Paget[55] sent questionnaires to one hundred and fifty people in
different parts of the world to obtain a global sampling of reactions
to music. From an analysis of their answers she found

 “two different modes of responding to music, each of which was claimed
 to be the only one in those in whom it was habitual. One may be called
 ‘listening’ to music; the other ‘hearing’ ... with lapses into merely
 overhearing it. Listening implied the most active attention....
 Hearing is a lesser degree of the same mental activity where active
 attention occurs in moments like islands continuously washed over by a
 shallow tide of other thoughts.”

This is very similar to Gurney’s classification of musical perception
as “definite” and “indefinite.” Vernon[77] lists the varieties of
response to indefinite listening as:

 a. Reflex or physiological; soothing or stimulating.

 b. General euphoria.

 c. Stimulation of thought and wandering of attention.

 d. Emotional moods of interpretation of the so-called “meaning” of
 music.

 e. Dramatic visual images of day-dreams.

 f. Awareness that sounds are going on, but no further response.

 g. Lapsing of this awareness into the “margin” of consciousness.

He found reactions a. and b. among primitives and infants; and
reactions c. f. and g. among the untrained.

Schoen[71] found that response to music is related to the psychologic
levels at which they occur, and to sensation, perception, and
imagination. The sensorial response is physiologic and possessed by
all. It is the source upon which all other musical development depends.
It requires a minimum amount of mental effort, and its effects are
within the easy reason of the intellectually inferior and superior
alike. As a sensation, music is either pleasant or unpleasant. Training
and experience may lead to higher types of response, depending upon
individual desire and ability to develop musical taste and education.
The next higher response is perceptual and its distribution level adds
excitement or repose. The highest level of response is imaginal.

 “Much of the music we hear we have heard before, and because of this
 fact we have associated it with a host of memories with pleasant or
 unpleasant coloring. The hearer may not recall the exact time or
 occasion on which he heard the selection before and yet he may have a
 group of images which are definitely referred to his own past.”

Meyer[71] summarizes the appeal that music might have for listeners as
1. Emotional response, 2. Suggested associations, 3. Personification of
a subject, 4. Its value as an object.


IV

MUSICAL TASTE

The selection of music for patients can be handled in many ways. The
easiest and least reliable is to use the music best loved by the
musician guiding the program. Such programming will undoubtedly meet
with the approval of some of the patients but it is unlikely that it
will meet with the approval of all. Non-psychiatric patients should be
given the music _they_ want.

Much has been written concerning specific music for certain groups
of patients. There has been considerable prejudice in favor of “good
music”; that is “good” in its relation to intellectual values.
But music in itself can be neither good nor bad. Its execution or
appropriateness for the occasion or the individual may be open to
question, but the answer must come from the patient. We must keep
uppermost in our minds the goal of music for bed-ridden or chronically
hospitalized patients. They look to music as a morale-booster and a
source of enjoyment. Most people have favorite songs, but the degree
of desire for them or for any music will fluctuate with the time of
day, the kind of day, and many other considerations. The taste of
the patient will vary not only with age, training, nationality and
home back-ground, but with such intrinsic and unfathomable things as
personality and thinking habits.

 “Musical taste is a folkway, a convention which behaves exactly as do
 folkways in other realms of activity. Accompanying this taste is the
 conventional ‘conscience’ which dictates what is ‘right’ and what is
 ‘beautiful.’ It is more or less impervious to contradiction and is
 disturbed at the prospect of change”[59].

The music of any given composer does not change but the audience will
change as a result of the appearance of new forms of music and living.
The works of the eighteenth century, with few exceptions, were loved by
its contemporaries but find a small audience to-day.

The musical taste of an individual changes noticeably from childhood
to maturity but the change is gradual, and except for those studying
music intensively, during any one year of life the change is hardly
appreciable. Even established favorites will become less desirable to
the individual.

 “After a certain number of repetitions, varying with both the founded
 experience of the listener and the complexity of the item, the
 enjoyment is diminished. One might here propose the hypothesis that
 the rate of ascent to popularity is directly in proportion to the rate
 of the decline ... as illustrated by the sharp rise to popular acclaim
 of the ephemeral popular hits and their subsequent precipitous decline
 into oblivion.”[59]

Among the many factors which sometimes have a great effect on musical
taste, contemporary events are outstanding. During a war, the people
welcome songs which sing of their prowess, impending victory, or
derision of the enemy. Such songs become popular because of their
literary rather than their musical content, but they affect taste
indirectly, since the only test of taste lies in the songs to which
people will freely listen.

Soldiers pick up foreign songs and marching songs and bring them home
as souvenirs and favorites. It is now well recognized how great and
prolonged such an influence can be.

Whatever the musical taste of the patient may be, and regardless of how
he came by it, it should be satisfied. As soon as an individual attains
the status of being a patient, there is an immediate mental depression
which may continue to increase if not checked. The patient may develop
anxiety, fear, self pity or boredom. There may be sensory depression
from pain, unpleasant sight or disability. In addition to these
saddening factors there may be undesirable response to environment,
personnel, and the monotony of medical or nursing routines. All efforts
should be directed at substituting joyful experiences for saddening
introspection. The formula for joy is very personal. Although most
people will laugh at some comic situations, the response to music
cannot be predicted except upon the basis of individual desire. The
person who becomes a patient may not have a fundamental change in
musical taste but his appetite may be altered by variations in mood,
and this is of prime importance.

 “More people express a wish for music dynamically similar to the
 existing mood than for music of the opposite effect. The amount of
 enjoyment is slightly affected by the kind of mood change taking
 place.”[71]

It is possible for sad music to be more enjoyable to those who are
receptive to it, than gay music. Nevertheless, other things being
equal, gay music is apt to give a greater degree of pleasure to those
who wish to hear it than sad music gives to its devotees.

The enjoyment of music depends not only upon its pleasantness, but also
upon its familiarity. This recognition may be one of identity or of
idiom. Most people like popular music because they are familiar with
its form or tempo; or because they can hum or name it.

The musical taste of the patient can readily be determined by offering
him a check-list with the names of fifty or more selections including
the entire gamut of musical forms. A general idea of the popularity
of classical selections can be determined from the sales records of
recordings and the frequency with which certain pieces are performed
by the better symphonic orchestras. The popularity of contemporary
offerings can be learned from surveys published in such magazines as
_Variety_ and _Down Beat_ or by listening to radio shows such as “The
Hit Parade.”

Musical taste is closely allied to performance. If chosen selections
are played improperly or without regard to certain elementary
considerations, the use of music will lose its value to the patient. A
brief consideration must include the effects of arrangement, tempo and
volume with which the selections are played, since these have been seen
to influence the effects of the selection. Many people when asked to
name their favorite music will name a performer or a band rather than
a specific piece because they have come to desire the characteristic
style of the artists preferred, and style in an orchestra is closely
related to these factors. Some listeners prefer loud music, but it must
be remembered that even though sound does not become painful until
the level of 125 decibels is reached, there are some people for whom
the painful level is much lower, and hypersensitivity to sound is an
important source of irritation. Others may be disturbed by music which
is too fast, which must be taken into consideration.

The role of expectation plays an important part in taste. Most people
who have been conditioned to expect the classic use of the scale and
traditional harmony cannot find joy in the unusual tonal structure
of the moderns as exemplified in Schönberg or even Stravinsky.
Hospitalization is not the proper period of life for indoctrination in
the beauties of innovations.

Musical taste is acquired and always relative, and is based as
Diserens[24] has pointed out, on the “habit of hearing.” An historical
illustration of this is the evolution of the consonances. The
Greeks regarded the octave as the only genuine consonance. In the
fifth century, the fifth and fourth intervals were admitted to this
classification. In the eleventh century, the major third was accepted
as such, but the minor third had to wait until the twelfth century. “In
music the habit of hearing is the Law, and through it, the exception of
yesterday becomes the rule of today.”

The best analysis of musical appetite can be found in the statement
of St. Thomas Aquinas, “Bonum est in quod tendit appetitus”--the good
is that toward which the appetite tends. We repeat there is no such
thing as good music or bad music. Music may be played poorly, but the
evaluation of the good in music is personal. “Pleasure, and pleasure
alone, is the proper purpose of art,” said Walter Sickert. Musicians
will do well to remember that since taste results from the gradual
blending of emotion, experience, and education, it is better to enjoy
wholeheartedly “a waltz of Lehar than to be able to make a thematic
analysis of a Beethoven sonata and yet remain unmoved by it.”[36]


V

SUMMARY

For non-psychiatric patients, musical programming should be based upon
patient requests. For stimulation the important factors are rapid
tempo, accentuated rhythm, and elevated volume. For sedation, slow
tempo and reduced volume are indicated, as well as simple recognizable
melodies. Some discussion of the selection to follow is a valuable aid
to the enjoyment of listening. Live musicians should be used as often
as possible.




_CHAPTER THREE_

MUSIC AS OCCUPATIONAL THERAPY


Until the latter part of the eighteenth century the institutional
treatment of mentally diseased people consisted of custodial care.
This meant shelter, food and restraint. The quality of the shelter
varied in most instances from very bad to poor. The quality of the
food was not as varied--it was just bad. The quality of the restraint
was excellent. With few exceptions commitment meant life internment.
Violent patients were chained to the wall, for who could tell when
they might become violent again after a period of calm? The mentally
deranged were not considered as patients with a disease of the mind but
as inmates who had lost communal value and social desirability. Dr.
Philippe Pinel of the Salpêtrière Hospital in Paris thought otherwise
and began to consider these people as still human. Among the reforms he
introduced was the use of activities to keep the mind and body occupied
doing things. This concept grew slowly at first but eventually reached
universal acceptance, was considered of real therapeutic value and
named occupational therapy.

During the first World War many military patients were confined to
hospitals for prolonged periods while awaiting complete recovery.
It was noted that those who busied themselves with such physical
activities as required the use of their wounded extremities regained
the use of these extremities sooner those who remained idle physically.
Thus was born a branch of Occupational Therapy which was known as
_functional_ to differentiate it from previous psychiatric use.

Functional Occupational Therapy is used to increase three functions:
muscle power, joint mobility and co-ordination of movements. It finds
its greatest use in those patients who fall under the care of those
medical specialists known as orthopedic surgeons and neuro-surgeons.
Orthopedic patients are those who have disease or disability of one
or more joints or bones. The most common disease of joints is called
arthritis, of which there are several kinds of varieties. The most
common disability of bone during war-time is fracture. Arthritis
usually prevents complete joint motion. In some instances the joint
is put at rest to hasten healing. Almost all fractured bones are kept
fixed by plaster casts or traction and prevented from movement during
healing. The prolonged rest, necessitated by diseases of bones and
joints, permits muscles to become weakened or atrophied, and also
permits joints to lose some of their range of motion. When the course
of disease has reached that point where rest is no longer required,
the chief aim of medical treatment is to restore former function. This
means the restoration of power and mobility. This is accomplished by
means of physical and occupational therapy. Physical therapy includes
the use of heat, massage and guided exercise. Occupational therapy is
exercise through work--purposeful, productive work with an incentive.
The incentive is twofold--to produce something useful and to hasten
recovery.

Patients who have had destruction or other disease of the nerves which
activate their muscles develop varying degrees of loss of muscle-power
known as palsy or paralysis. When a nerve is pressed or cut, it usually
heals in such fashion as to permit return of muscle-power. During
the period of its impairment, there is not only a loss of power, but
frequently concomitant disturbance in the skin, the joints and still
other functions. As a result of the nerve disturbance or the disuse
which follows, the portion of the body which is paralyzed loses the
ability to use its muscles with facility and maximum economy. There are
almost no motions performed by single muscles. Most activity results
from the contraction of a group of muscles and these are usually in
delicate balance with other groups of muscles which either assist or
prevent overaction. The delicate adjustment of muscle groups, which is
normally present, results in co-ordinated movements. Following nerve
disease or, for that matter, the immobilization of joints and muscles,
co-ordination is usually lost to more or less degree. Muscles must be
re-trained to work together. Such co-ordination can be accomplished by
special exercises, but even more rapidly and efficiently by imitating
the motions of life. This is the aim of functional occupational therapy.

There are other disease conditions which can profit from the use of
occupational therapy. These include other disabilities which are
accompanied by loss of power, motion or co-ordination. When the skin
is burned, healing is usually accompanied by some degree of scarring.
If the scar includes a joint on its flexor surface (i.e. inside the
bend) there will result a deformity known as a flexion contracture.
If nothing is done about this, the crippling process will become
progressive and some day reach a stage beyond correction other than
that offered by plastic surgery. The early stretching of such joints
will not only prevent progressive disability but may result in some
improvement.

Many other indications for the use of occupational exercise will be
met, but since this is not a text on medicine, the preceding types of
disabilities will serve as examples of the conditions commonly seen.

The crafts first used in functional work were carry-overs of those
most beneficial in mental disease, and for the most part were restful
and simple, such as basketry, weaving and the graphic arts. More
recently, almost all the arts and crafts have been used, as well as
motorized tools.

The results of occupational exercise will depend upon the
attractiveness of the objects which can be produced, the energy
required, the skill and patience of the occupational therapy worker and
patient, and the stage and extent of the disability. For those who are
not “handy”, or who have become increasingly clumsy with disability,
there may be impatience, tedium and fatigue. Occupational therapy is
always seeking new activities or modalities as they have become known
in practice. Music can be used as exercise in occupational therapy as
well as for background and interludes of relaxation.

The fingers of professional pianists and violinists are very strong,
for instrumental manipulation requires and develops strength and
co-ordination. Music as an exercise can be used not only for its effect
on most of the joints and muscles of the body, but to increase the
use of the lungs and larynx. It focuses attention through the use of
visual, auditory and tactile senses and stimulates mental activity and
interest.

Many instruments may be employed for the mobilization of joints and
muscles. When a musical instrument is prescribed as the occupational
therapy activity for a patient, there may be some resistance on the
part of the patient because of a lack of general or musical education,
or the fear of studying something new. The success with which this
resistance may be overcome will depend upon the skill of the musical
aide not only as a musician but as a teacher. The musical aide will
have to convince the patient that the fundamentals of music are far
less difficult to learn than is popularly supposed. Much of the
notoriety about music lessons is developed among children who dislike
regimentation, interference with their play periods, and the length of
time it takes the minute hand to circle the clock. The musical aide may
cite that observation and impress the patient with the greater ease of
adults in learning to play. Interest may be aroused by naming the other
patients who have recently learned to play and by demonstrating the
advantages in earlier recovery that music offers.

Regardless of their initial attitude towards music lessons, most
patients will soon be pleased with their progress and ability to master
musical notation. Visits to the craft shop will usually be made on an
appointment basis and the patient will leave as soon as his “time” is
up. The knowledge newly acquired through instrumental instruction will
keep the patient at work longer and the musical aide will find him
returning for further practice without coaxing and for desirably longer
periods.

_Piano._ Before considering the use of the piano in occupational
therapy, the work of Ortmann[64] should be reviewed.

A joint is the point at which two bones connect. In any moveable joint
the essential feature is a sliding of one surface on another. Joined
to the sides of the two bones near their ends are ligaments which are
strong and inelastic and hold the joints within the joint cavity, and
which prevent the joint from exceeding its normal range of motion.
But the function of holding the bones together and keeping them in
different positions belongs to the controlling muscles. Bones are
usually activated by at least two sets of muscles which effect the
movements in opposite directions. Normally muscles are under a slight
but constant tension known as _tonus_, and the simultaneous pull of
muscles on both sides of the joint presses the bone surfaces closer,
and keeps the muscle in a state which makes immediate action possible.

Joints move by virtue of the contractions of the muscles. Most
movements are made not by one muscle alone, but rather by the
co-ordinated contraction of various muscles and the simultaneous
relaxation of their antagonists. As a result of muscle contractions,
a chemical change takes place which produces substances in the muscle
that interfere with good muscle action. Ordinarily these waste
products are carried away by the circulating blood with sufficient
speed to prevent noticeable effects. If, however, the muscle produces
these deleterious chemicals faster than the blood stream can carry
them away, fatigue results. The earliest manifestation of fatigue is
inability to relax, and the second contraction may be initiated before
relaxation is complete. The second effect of fatigue is interference
with rate and quality of contraction. Only relatively brief periods of
relaxation are necessary for complete recovery, but these periods are
important. When normal muscles practice on the piano, the fatigue limit
is rarely reached, but for the weakened muscles of patients, fatigue
must be guarded against by limiting duration of continuous playing
and by proper interludes of rest. Ordinary piano-playing offers short
rest periods because there is a reflex relaxation after the sound is
produced and it requires less muscle energy to keep the key depressed
than to depress it.

Muscles are excited into contraction by minute bio-electrical impulses
which enter through their motor nerves, but the property of contraction
is independent of the nerve and can also be accomplished by artificial
external stimuli of electricity or mechanical force. The quality of
contraction is a function governed by the health and nutrition of the
muscle. The nutrition of the muscle depends upon its blood supply,
which depends in part upon its warmth. Delicate motions are difficult
for cold muscles and artificial warming is advisable before exercise, a
fact which assumes greater importance in cold weather.

From the viewpoint of patient interest and instruction, the piano is
the best instrument. When equipped with pianola fixtures, it is the
one instrument that gives the widest range of activities. Because the
piano is difficult to move, playing is restricted to the room in which
it is housed and there need be no concern about its interference with
other patients if the practice room is sound-proofed, or is situated
some distance from the other patients. The piano offers excellent
opportunity for flexion of the fingers and thumb, extension, abduction
and adduction of the wrist, as well as flexion and abduction of the
shoulders and exercise of the neck and back.

The piano can be adapted for use by patients with extremities in
hanging casts, which can be supported by sling arrangements attached
to the piano or the patient’s neck. It can even be used satisfactorily
with a cumbersome airplane splint if a very low bench is substituted
for the usual piano chair. The height of the bench can be arranged so
that the key-board and hand are on the same level, and the challenge
of this position will make the patient try all the harder to use his
fingers.

For the contractures resulting from burns of the hands, the piano
offers an excellent medium with which to increase joint motion. In
depressing the keys the fingers are forcibly flexed. The key surface is
much broader and easier to manage than that of the typewriter key. The
piano, therefore, offers less of a psychological deterrent to use than
does the typewriter. Mistakes at the piano are less annoying because
there is nothing to erase but a memory, and the memory of unpleasant
things is fortunately short-lived. By means of special musical
arrangements and additional notation written next to the printed notes,
some fingers can be exercised singly or in any combination desired.
The physical exercise or co-ordination of selected fingers can be
obtained more subtly by the use of marked music than is possible with
most crafts. Some instructors may prefer to mark the keys of the piano
with the letters to which they correspond, but this is not really
needed in the instruction of adults. A large diagram of the piano keys
placed above the musical scale for which they stand may be located to
advantage on the wall over the piano.

It is recommended that the first piano lessons cover fifteen minutes
and that the time be increased five minutes daily until the lesson
fills a half hour period. Inasmuch as the strain of piano playing is
very slight, the first lesson may last thirty minutes if the physician
so decides. The patient should be encouraged to practice freely at
other times during the day as long as his interest can be sustained.
Chief attention must be placed on the use of the fingers requiring
exercise. As is true in all forms of functional occupational therapy,
the impatient patient will try to speed his work by using unaffected
joints or by improper use of muscles. The musical aide must guard
against this temptation. Although standard music for beginners should
be used, it is well for the teacher to use simple arrangements of
popular tunes at each session for the incentive that it will give the
patient. If the patient expresses the desire to play a certain melody,
the instructor should write his own arrangement if none is available.

The keys of the piano can be reached effectively in many ways and
it is possible to exercise almost any of the muscles of the upper
extremity by playing from different levels. To exercise the muscles
of the shoulder girdle, loud notes may be played by holding the hands
fixed and raising and lowering the shoulders. The shoulder itself can
be abducted and adducted by wide lateral movements along the keyboard.
Flexion and extension of the wrist is accomplished by staccato
movements. Lateral motion of the wrists is partially restricted by the
bony structure but can be accomplished by arpeggio work.

Thumb action plays a very important part in piano playing. The
_opponens_ action (touching the last finger with the thumb) is very
necessary in playing _arpeggios_, particularly with large intervals
played _legato_. In fact there is hardly any known purposeful activity
which is more useful for full exercise of the _opponens_ range than
this activity. The music must be fingered with numbers that will keep
the index finger on one note as the thumb passes under for the next
higher note at an interval of two or three tones. In order to depress
the key, flexion of the thumb is necessary. The thumb can be abducted
to almost any degree by the playing of chords or by playing _legato_
passages.

All motions of the fingers are possible. For active or passive
extension of the fingers much use should be made of the black keys.
If the hand is held in position to play the white notes in the normal
manner, the black keys can be played only by extension. Various degrees
of flexion of the joints are possible by ordinary playing. Spread of
the fingers which is a function of the dorsal interossei muscles can
be accomplished by practising chords, the span of which should be
increased as power and range improve.

_Violin._ In most activities requiring the use of both hands, the
more delicate motions are performed by the right hand in right-handed
persons. For the violin family the situation is reversed, and these
stringed instruments are of greatest value for exercise of the left
fingers and right elbow. If the interest of the patient is great, there
is no reason why the normal positions cannot be interchanged so that
fingering is accomplished by the right hand on a violin with reversed
strings.

The violin is recommended for flexion of the left fingers, but is of
greater value for flexion and extension of the right elbow. It is
secondarily valuable for the flexion and extension of the wrist and
abduction and adduction of the shoulder. The motion analysis for the
cello and bass viol are similar to that of the violin. The heavier
instruments require more motion at the shoulder. String instruments
are less popular than the piano because two fundamental techniques
must be learned simultaneously; correct fingering and correct bowing.
The vibration of the struck piano strings is relatively uniform with
variable pressures[II.], but the quality of the violin sound as
produced by the beginner can be discouragingly unpleasant.

_Plectrum Instruments._ The plectrum instruments afford excellent
exercise of the wrist of the right hand and the fingers of the left.
The ukulele, when brushed by the fingers, offers better extension of
them than is found in most crafts. The guitar offers even stronger
flexion for the fingers which depress the strings than does the
violin. All these instruments require supination and pronation at
the wrist and some flexion and extension of the elbow. They are more
popular than bowed instruments and have the added advantage of being
so easy to learn that the performer will be able to play simple song
accompaniments in a relatively short period of time. The variety
of instruments in this category permits a wide range of energy
requirements.

_Foot Instruments._ Although there are several instruments in which
the lower extremities are used, there are only two which are readily
adaptable to hospital use--the pianola and the parlor organ. For the
former, no knowledge or musical ability is required and its use is open
to all. The distance between the bench and the pedals will determine to
some extent the energy expended and the range of joint motion which can
be accomplished. The speed of playing is related to the energy which is
required. If the library of pianola rolls is large and inclusive enough
to meet the demands of the patient’s taste, an adequate amount of work
can be expected.

The foot-pumped organ is also an excellent ankle exerciser. Even the
untrained will find some interest in the timbre of the notes and the
qualities of sound emitted with the pulling of different stops. The
lingering sounds and the novelty of playing an organ which is no longer
a commonplace in the home, are great incentives to playing. Instruction
on the organ, which has a smaller keyboard and slower manipulation
than the piano, is pleasant and simple. For combined upper and lower
extremity disabilities, the organ is an excellent instrument. Every
hospital music department should own one. There are enough unused
organs in the attics of this country to supply the needs of most
hospitals.

The bass drum with foot pedal attached is obviously not a solo
instrument, but when used in ensemble or with a full set of traps and
snare drum, it can sustain some interest and result in some benefit to
those suffering with ankle disabilities. Its use is limited to activity
of the muscles and joints below the knee. It can be used by patients
wearing a leg-brace pivoted at the ankle.

_“Pocket” Instruments._ Of all the wind instruments available for the
instruction of beginners, those which require no reed or lip knowledge
are most desirable. Easiest to play is the “kazoo”, or any other
instrument which embodies the principle of a membrane vibrating to the
sound of the human voice. Only the ability to hum is needed and it is
valuable for the patient who is difficult to teach because it permits
even the dullest to participate. The kazoo is especially useful for
children or psychiatric patients and can supply the melody for “rhythm
bands.” The ocarina, song-flute and related instruments are relatively
easy to master but the sound emitted is annoying to many. The recorder
is easy to play and produces a pleasant sound. The harmonica has been
developed into an instrument that is not unpleasant to listen to,
but the beginner’s efforts may not be too welcome. The fife requires
greater effort to operate and is harsh to the ears of some. The flute
is too difficult for hospital use and the beginner in his anxiety might
experience a “black-out” from sustained blowing.

The reed and brass wind instruments are not suitable for functional
use. Their use is limited to chronic patients because of the large
amount of time required to learn to operate them satisfactorily.

Wind instruments can be used for patients whose pulmonary pathology
has cleared to such an extent that the physician feels lung exercise
is indicated. The early use of lung exercise following atypical virus
pneumonia has been found especially beneficial.

Wind instruments may also be used for exercising the facial muscles
during the recovery phase of facial palsy. Their possibilities in
stretching the scars about the mouth and cheeks should be considered.

_Percussion Instruments._ The snare drum offers motion to the wrists,
elbows and shoulders. Few men or children can resist the temptation
to play the snare drum. The desire for prolonged playing is not too
great, but if recorded music is played during the exercise the duration
can be prolonged for an adequate period. The bass drum, as previously
mentioned, permits flexion and extension of the ankle when used with
the pedal, and this, too, can be made interesting if recorded music is
played simultaneously.

Other percussion instruments may not be generally available in
hospitals but the possibilities offered by them will be listed. The
kettle drum offers rotation of the arms. The xylophone and marimba do
not evoke great ranges of motion but bring the muscles of the upper
extremities, neck, and back into play, and promote co-ordination. For
children, the toy xylophone is a welcome plaything and an excellent
form of occupational therapy for the upper extremities. A new toy, the
_Typatune_, operated like a typewriter affords opportunity for finger
exercise.

There are still other instruments which may be classed as musical that
offer opportunities for exercise. It is just possible that a portable
hand organ may be available. The novelty of operating one of these
is not to be underestimated as an incentive to work, particularly in
younger people. Both the hurdy-gurdy and the hand-cranked victrola
offer exercise to the wrist, elbow and shoulder. By placing these
instruments at different distances from the floor or patient, many
ranges of motion can be obtained.

The harp offers excellent exercise to the serratus muscles as well as
to the muscles and joints of the upper extremities, but its operation
is more complicated than that of most instruments, and even if
available, would require the instruction of a harpist, of whom there
are too few.


TECHNIQUE

Assignment of patients to instrument-playing should be made in the
same manner as other assignments in functional occupational therapy.
The physician should prescribe the instrument which best meets the
convalescent’s needs. He should explain to the musical aide in the
presence of an occupational therapist the motions desired and the
precautions to be followed. He should set the time limits for the
first and succeeding lessons. In general, it may be said that the
first lesson should last about fifteen minutes, or until such time as
the patient shows signs of fatigue. This period should be extended
gradually to a half hour. The patient should be encouraged to return to
the instrument as often as is practicable for further study. When the
number of patients receiving lessons is large, a regular schedule for
additional practice periods will have to be posted. After a relatively
short period, the musical phase of occupational therapy will operate
smoothly and the physician will be able to delegate most of the details
to the occupational therapist, who should frequently supervise the
lessons to ensure desired joint motion and to note progress. The
occupational therapist should make progress measurements and notes.
When properly supervised, the use of music as functional occupational
therapy can be as scientific as any other branch of occupational
therapy and is the one use of music at this time which may properly be
termed “musical therapy”.

The following table is offered as a reference for some of the motions
possible with a few of the instruments described.

 +----------+-----------------------+-------------+
 | _Part_   | _Motion_              | _Instrument_ |
 +----------+-----------------------+-------------+
 | Fingers  | All                   | Piano        |
 | Fingers  | Extension             | Ukelele      |
 | Thumb    | All but adduction     | Piano        |
 | Wrists   | Flexion--Extension    | Piano        |
 | Elbow    | Pronation--Supination | Guitar       |
 | Elbow    | Flexion--Extension    | Violin       |
 | Shoulder | Abduction--Adduction  | Piano        |
 | Neck     | All Motions           | Xylophone    |
 | Back     | All Motions           | Bass Viol    |
 | Hips     | Abduction--Adduction  | Organ        |
 | Knees    | Flexion--Extension    | Pianola      |
 | Ankles   | Flexion--Extension    | Parlor Organ |
 +-----------+-------------------------------------+


VOICE

Singing has long been used for the treatment of stammering and other
speech impediments. Singing can also be used to exercise the jaws,
larynx, lungs and diaphragm. With proper instruction, singing can be
an excellent exercise for the muscles of the chest and abdomen as well
as a breathing exercise.

For the patient with a recently wired fractured jaw, singing gives
gentle joint motion and restores confidence in the ability to use
the jaw again. The same thing applies to patients with recovering
tempero-mandibular joint pathology. A patient with poor jaw motion
cannot articulate well, but can sing more nearly like the well patient
than he can talk. Singing can begin at the level of humming and
progress through scale practice to actual song instruction.

When several patients are available for vocal exercises, a trio,
quartet or other group arrangement will create greater interest. Except
in hospitals devoted to the treatment of chronic disease, the turn-over
in patients will make group singing uncertain.


FOOTNOTES:

[II.] “_a discussion took place in 1913 on the physical significance of
that mystic quality called “touch” by which a player attempts to vary
the quality of the notes ... but it was concluded that the velocity of
striking was all that could be varied by the player._”

  _Richardson, E. G.--Sound, p. 106_




_CHAPTER FOUR_

PSYCHIATRY AND MUSIC

  “His music mads me, let it sound no more,
  For though it helps madmen to their wits,
  To me it seems it will make wise men mad.”

  _Richard III_, Shakespeare


Gaston[31] believes that

 “The basic reason for the arts throughout the history of mankind has
 been the resultant mental hygiene benefits. The common creative urge,
 desire for diversion, and search for satisfactory expression exist in
 all people. Music--above all arts--guarantees the fulfillment of these
 elemental urges, and therein lies its greatest value.”

The suggestive power of music has given rise to a series of legends
which go back to the very origin of civilization. But the methods of
experimental physiology, so precise in the study of organic function,
lead to no clear and easy picture in the presence of reactions as
complex and subjective as those of esthetic emotion and artistic
pleasures. The task of evaluating the effect of music on the mind is
made increasingly difficult by the personal equation, and when to this
is added the distortion of mental disease, great caution must be used
in the approach, technique, and recommendations to be followed in the
use of music as applied to psychiatry[27]. Altschuler[3] finds that
music stimulates the libido, which he defines as

 “the great amorphous power, the vital spark, out of which the will to
 pleasure, the longing for love or passion for procreation take their
 origin.”

He believes that music is the only “medicine” which helps to convert
instinctual forces into socially acceptable forms.

 “Stimulated by music, man can still offer his lowly instincts free
 expressions, camouflaged by jitter-bugging and boogie-woogieing....
 Indeed there is therapeutic acumen to an agent which is capable of
 reconciling the instinctual with the social, and the sensual with the
 spiritual.”

The relationship between music and the mind is obvious, but the nature
of the relationship which has led some musicians to facile claims
of artistry remains for most psychiatrists a tempting but obscure
field. Most of the writing on this subject has been done by musicians
and so-called results obtained with music in mental patients have
been evaluated without medical guidance or the use of scientific
method. Physicians are hesitant to accept new ideas which are not
founded on unquestionable evidence. Enthusiastic laymen might call
this reactionary, and they would not be entirely wrong. It is the
reaction to the too rapid spread of folklore, cults, and nostrums which
physicians have had to combat to keep medicine on the highest possible
plane. It is the only tool with which they can protect the sick from
unscrupulous or even well-meaning people who, for personal gain or with
ill-founded conviction, promise cures by the citation of accidental or
falsified results. By custom, ethics, and state laws the treatment of
disease is the province of the licensed physician.

The term “musical therapy” has been applied almost exclusively to the
treatment of mental disease with music. The term “therapy” is derived
from a Greek verb which means _to cure_. A cure can be practiced and
determined only by a qualified physician, or under his direction.
Claims can be made by anyone. To establish the curative value of any
procedure, certain criteria must be observed. In the first place, the
disease must be accurately classified so that the affliction of a
series of patients can be scientifically grouped for study. Next, the
therapeutic agent must possess qualities of constancy which permit
controlled dosage. Last, the proper administration of the agent in
the same disease condition must show a reasonably high percentage
of results which can be proved to be of value in the control or
elimination of symptoms or disease.

Until a relatively short time ago, the causes of most disease
conditions were unknown and illnesses were named according to their
superficial characteristics. Most newly named diseases are designated
by the agents which cause them or by the variations from normal found
in the tissues of the body they affect (pathology). In psychiatry, most
diseases bear the names applied to their outward appearances.

A simplification of terms places mental disease into three general
classes. Psychoses, Psychoneuroses, and Behavior Disorders. The
subdivisions of these classes are not universally accepted and the
musician who works in a mental hospital will soon become acquainted
with the locally practiced terminology.

As a guide to vocabulary rather than an introduction to psychiatry, a
brief review of some of the prominent symptoms of mental disease will
be enumerated. The scientific material is based on Noyes’[62] excellent
text.

The following list of the more common mental diseases is based upon the
classification offered by the National Committee for Mental Hygiene.

  _Psychoses_
    General Paresis
    Alcoholic
    Hardening of the Brain Arteries
    Senility
    Involutional Melancholia
    Manic-Depressive
    Schizophrenia

  _Psychoneuroses_
    Hysteria--anxiety, conversion
    Hypochondriasis

  _Mental Deficiency_

  _Behavior Disorders_
    Maladjustment
    Habit or conduct disturbance

  _Psychopathic Personality_
    Amoral, immoral, emotional

Detailed descriptions are confusing to the layman because within one
disease subclass, the variations possible as a result of duration, time
of onset, mental background, etc. are very great. Only generalizations
will be mentioned.

The two major divisions of mental disease--psychosis and
psychoneurosis--are not always readily differentiated. In the
psychotic, the personality is usually distorted, whereas in the
psychoneurotic the personality remains normal in relation to the
realities of the world and social life. The psychotic is the more
obviously deranged, the psychoneurotic usually passes for almost normal.

_General Paresis_ is a late result of syphilis. The patient becomes
increasingly forgetful and disinterested in his surroundings and
social relations. There is a gradual loss of judgment and other mental
faculties. The facial expression becomes empty and the speech slurred.
This is the disease in which the knee reflex disappears, an indication
popularly associated with “crazy people”. It is a progressive disease
which becomes more difficult to treat as it progresses. The treatment
at this writing consists of the use of drugs containing arsenic and the
production of fever in the patient. The results are not remarkable,
ordinarily. Return to normal is unusual. Music for such patients could
in no manner be conceived as curative or even helpful.

_Alcoholic Psychosis_ results from continued excesses of drinking. The
patient usually resents criticism because he is convinced that his
reverses have driven him to drink. The prolonged use of alcohol relaxes
inhibitions, produces anti-social actions, and results in more sorrows
to drown in more alcohol. Alcoholic psychosis usually begins suddenly
with mental confusion, muscle twitches known as tremors, and vivid,
visual imaginary thought known as hallucinations. The treatment for
such patients includes withdrawal of alcohol and the use of sedative
measures. One of these measures is a prolonged bath in a tub of water
just below body temperature. Once the patient has recuperated to the
convalescent stage, music may be employed. Some alcoholics like to join
in group singing, especially if the group is made up exclusively of
fellow inebriates. Any encouragement to join non-alcoholics in group
singing, or any use of music which may stimulate a permanent interest
in a new instrument or diversion would be valuable. These patients lack
self-imposed discipline. If music can be used as a discipline, it might
lead to decreased drinking.

_Arteriosclerotic Psychosis._ As its name implies this is a condition
of the aged and is probably related to hardening of the brain arteries.
The symptoms may include emotional instability, mental fatigue,
disinterestedness, and some loss of memory. The patient begins to
look and act old. The treatment consists of custodial care, physical
rest, and mental occupation. Music is well suited to this combination.
Oldtime favorites played softly for several periods daily is indicated.
Obviously, where specific musical numbers are requested they should be
played.

There is another disease which resembles this called senile psychosis.
Usually it can be handled in the home, and is.

_Involutional Melancholia_ occurs at an age when certain important
biologic functions of the body begin to regress or involute. For women
this age is usually forty-five, but for men it can be ten or more
years later. The condition is seen especially in those who did not
lead an average life previously. A study of the personality of such
patients usually shows them to have been uninterested and uninteresting
people, with few close friends. An unfavorable experience may bring on
worry and unrest. They become saddened and exaggerate the minor sins
of their past. They develop false beliefs known as delusions about
their surroundings or themselves. At least half of them never recover
completely.

There is little that can be done for them, except to encourage
healthful diets and hygienic regimes to keep them physically well.
Some physicians might encourage the use of music for such patients
to distract their attention from themselves. Familiar melodies are
recommended, because of the age group, old time favorites will be the
most suitable.

_Manic-Depressive_ psychosis is a relatively common condition in most
large mental hospitals. It is so called because the same patient
may have periods of excitement or depression separated by phases of
apparent well-being. The stage of excitement begins with arrogance,
assurance, exuberance and energy, and may superficially resemble the
pleasantly boisterous drunk seen at a national convention. The patient
talks rapidly, histrionically, and with a play on words called “flight
of ideas” because each new phrase suggests new ideas on which the
patient will embark, leaving the main thought-stream. This excitement
may continue to the point where the fatigueless drive is remarkably
great. This may or may not be followed by an opposite reaction.

In the depressive phase patients may feel gloomy, speak slowly, and
look worried. A feeling of inadequacy may lead to self-punishment and
suicidal intent. The symptoms may progress to the complete inactivity
known as stupor.

The first manifestation of this disease is usually manic with the first
depressive state years later. Attacks last about six months or longer
and although they usually recur at a future date, may not. In the time
between attacks the patient may appear quite normal and return to his
previous activities.

In the manic phase, sedatives are frequently administered. Stimulating
music would only tend to increase the disturbance. If the physician
prescribes music it should be of the restful type, preferably a
selection which will attract the patient’s attention by its familiarity.

In the depressive phase, patients should not hear cheerful and gay
music. Entertainment often deepens the depressive state because of
the contrast, and the awareness of their own problem, which prevents
enjoyment.

_Schizophrenia_ literally means splitting of the mind. It is a group
of conditions in which the usual harmonious blending of emotions,
intellect, and drive are disorganized into a seeming inactivity and
resultant apathy. In the _simple_ type the patient becomes uninterested
in his environment and responsibilities. This result is seen in the
vagrant and the delinquent.

In the type known as _catatonic_ there are phases of excitement or
stupor. In the stuporous state the attitude of the patient resembles
that of an automaton. In this state it is difficult to make any contact
with the patient who refuses to co-operate or even move. Catatonic
excitement sometimes follows the stupor and is evidenced by the same
purposeless absence of emotion, but may include unexpected acts of
destructiveness.

There is another type called _paranoid_ in which the patient develops
false beliefs of persecution, and a hebephrenic type in which the
patient becomes even more inaccessible and inattentive.

Schizophrenia, once thought incurable, is now considered amenable to
treatment and about one fourth of the stricken recover completely after
the first attack.

In treating these patients an attempt is often made to promote an
interest in real things and social consciousness. It is necessary to
stimulate attention and redirect it to things outside the patient.
Music has a more important place in this disease than in any other
mental condition, and this disease may account for more than half the
population of many mental hospitals.

Altshuler and Shebesta[4] tried music in the treatment of four excited
female schizophrenics in conjunction with hydrotherapy. To have some
basis for evaluation of effect, the amount of vocal productions
and head movements were recorded for thirty minute periods. This
combination is referred to as “output”. Observations were made for a
six week period, five days a week for two to three hours a day. Two
patients were given continuous baths and two were given cold wet sheet
packs during the observation periods. A violinist played behind a
screen for the first thirty minutes. During the first ten to twenty
minutes of playing no changes were noted, and the patients seemed more
or less inattentive to the music. Soon it was found that familiar tunes
were most effective in centering and keeping their attention. Thus,
very noisy and upset patients might begin to sing a familiar song
with the violin, keeping their output of energy at the same level but
changing from irrelevant purposeless activity to the directed activity
of singing or humming a tune. It was also noted that the effect of
familiar tunes extended far beyond the termination of the music, as
manifested by continued singing after the music stopped. Familiar
waltzes were found to be the best type of music to use in quieting the
patients, but these were more effective when preceded by more lively
tunes which secured their attention.

As a control, patients were placed in dry sheets and after twenty to
thirty minutes of music the output diminished in the same degree (50%)
that was observed with patients in wet packs. This showed that possibly
the music alone may have been responsible for the quieting effect.

These authors conclude that musical accompaniment tends to prevent
the feeling that hydriatic measures are punitive and that the return
of real memories is a natural substitute for states of phantasy and
excitement.

Julia Eby[29] feels that

 “If in the development of a person’s talent for music, stress is laid
 upon the enjoyment it will give further listeners, he is being made
 conscious of the social significance of his own accomplishments and
 this helps the development of the personality as a contributing member
 of the community.

 “Music contributes emotional energy needed to turn dissatisfaction
 into mental reconstruction. The playing of music arouses associations
 which stimulate the intellect and if this is sufficient it gives
 satisfaction and enhances self respect.” But “We must be careful to
 excite only those activities that will be followed by a feeling of
 success”.

 “The intellectual stimuli of music bring the expenditure of emotional
 energy from unconscious levels to conscious and intellectually
 controlled levels ... a concentration on environment stimuli instead
 of intrapsychic impulses, a perseverance in effort to adjust one’s own
 conduct to group standards.”

Altshuler[2] points out that the seat of all sensation, emotion, and
esthetic feeling (the thalamus) is not involved in mental illness, and
is directly attacked by music. The musical stimulation of the thalamus
automatically transfers from this “below awareness” level to the brain
cortex.

 “Little constructive therapy is possible as long as the patient is
 acutely disturbed; therefore anything which may lessen disturbance and
 bring about association familiar to the patient and which will revive
 thoughts to a real level will be desirable.”

_Psychoneurosis_ differs from psychosis in that the patient recognizes
that he is ill and wants to get well, although his more powerful
subconscious desire does not. Several types are recognized.

_Hysteria_ is an unconscious reaction on the part of an individual
to solve a personal problem by the acquisition of some symptom or
symptoms. If this is done consciously it is called _malingering_.
Any and every physical or mental symptom is possible. Examples of
physical involvement are blindness, paralysis, aches and pains.
Mental manifestations may include loss of memory, delirium, etc.
Hysteria permits the patient to achieve his purpose and maintain his
self-respect. It is an escape mechanism to evade responsibility, excuse
failure, or gain attention.

Many forms of treatment have been used and each physician uses his own
approach. The more commonly accepted methods include psychotherapy,
persuasion, suggestion, and psycho-analysis. Psychotherapy encourages
the patient to talk about his condition and with the guidance of the
psychiatrist discover the basis of his difficulties. Logical persuasion
is used but is not considered effective by most. Suggestion under
hypnosis is used by some who are expert in hypnotism. Psychoanalysis
attempts to discover the subconscious thoughts and experiences which
have caused the disturbance.

Music may be of some value for this group. Levine[56] believes that

 “Many individuals achieve a feeling of self-confidence if they develop
 hobbies such as music. Learning to play musical instruments may
 compensate a feeling of inferiority, especially when the individual
 has ability which he underestimates.”

Listening to music may stimulate the patient to talk about his
condition or about things that trouble him. Altshuler[3] feels that
where large groups of patients must be treated with limited personnel,
such as exists in hospitals which handle cases of war neuroses,
group treatment is the only solution, and that when there is group
psychotherapy music is indispensable, for it not only can “turn any
aggregation of people into an ‘organic’ group. It is one of the
mightiest socializing agents.”

Harrington[43] believes that music has an important place in the mental
hospital although he regards technical instruction for heterogeneous
groups unworthy of the effort. He is convinced that, “Mass singing has
therapeutic value, and that subdued instrumental music during mealtimes
is desirable.”

According to Kraines[54]

 “Recreation and hobbies are also extremely important energy release
 techniques. The apparently passive listening to music may accomplish
 release of energy. The passivity is only seeming. The person following
 the music tends by identification to swing muscularly with the music,
 nodding his head, tapping his feet; and even when there is no manifest
 movement, there is often a non-observable but yet definite movement.
 In many forms of music such rhythmic movements can be performed only
 by relaxed muscles; and tense persons who are influenced by harmonious
 music are perforce relaxed. Some sanatariums very effectively utilize
 dancing to music as a means of relaxing patients. Moreover in this
 general relaxation and harmonious appeal to the senses, the person
 “feels” that peace and harmony do exist outside himself and will
 continue to exist despite his own troubles; and by such general
 “feeling tone”, the person puts aside his conflicts for the while.
 On the other hand some types of music will stimulate persons into
 increased activity (e.g. martial music, dance music) by reason of the
 tendency to make rapid and staccato rhythmic movement in time with
 the music. The rhythmic muscle movement can, under the influence of
 a skillful composer, increase to such a pitch as to make the person
 excited, exhilarated, etc. Outlets for energy release should be
 selected which will give enjoyment to the patient.”

In chronic mental institutions the patient band has been found most
valuable. Pierce[66] believes that

 “Music can be a co-operative effort for a wholesome discipline.
 It tends to break down the sense of isolation so common to mental
 disease. It assists in adaptation to the mental state.

 “First, playing must be made a pleasure to the members. This means
 there must be no severity of discipline and great tact must be
 exercised in correcting errors--preferably privately so as not to be
 humiliating to the patient.

 “Second, have some easy numbers: otherwise the results may discourage
 the patients.

 “Public appearances away from the hospital have the advantages of
 enhancing self respect and pride.

 “Admit a small number of hospital personnel to the band--but not
 those of great ability. The more varied the instrumentation, the more
 gratifying the result to the participants.”

_Mental deficiency_ means the incomplete development of the mind which
makes independent living impossible for the victims. The degrees
of deficiency are classified according to the results obtained in
intelligence tests: 1. Idiot--mental age of less than three years. 2.
Imbecile--age of three to seven. 3. Moron--above the age of eight, but
deficient. The treatment for these groups consists of custodial and
hygienic care plus any education which can be attained, and of course
music will play its part in this in a purely academic manner.


SUMMARY

Music can be used in psychiatry for its value in listening, group
participation, and creation of sound, as follows:

  1. _By listening_

     A. To improve attention.
     B. To maintain interest.
     C. To influence mood (to produce exhilaration, etc.).
     D. To produce sedation.
     E. To release energy (by tapping of foot, etc.).

  2. _By participation_ (in group singing, bands, etc.)

     A. To bring about communal co-operation.
     B. To release energy.
     C. To arouse interest.

  3. _By creation of sound_ (playing of instruments)

     A. To increase self respect by accomplishment and success.
     B. To increase personal happiness by ability to please others.
     C. To release energy.




_CHAPTER FIVE_

BACKGROUND MUSIC


The average mind is incapable of engaging effectively in two thought
processes simultaneously, but it can in the course of daily routine
accept a multitude of mental stimuli at any one moment. If one of
these stimuli is sound, it may be the natural complement to the visual
experience without which a feeling of incompleteness may result. The
observer at the sea-side is intrigued by the cyclic rolling of the
waves, and the periodic crashing of the breakers is an integral part
of the pleasure of watching waves. Yet, that same series of sounds
might be very disturbing to the same person who is trying to work
out his income tax return in the quiet of his study. The importance
of complementary sound becomes more apparent when one studies the
reaction of an audience attending the “movies” during periods of faulty
mechanical silence. Sound as a background to mental or physiologic
processes may be natural or undesirable but can be very important. If
carefully selected, there are few situations in which music cannot be
used advantageously as a background to improve the quality or pleasure
of activities and living.

At this point it must be repeated that the importance of music in the
lives of people is not uniform and that, for those few who dislike
music, background music is not recommended.

Background music, as its name implies, is always secondary to some
other activity. Only those phases of the subject which touch upon
hospital life will be discussed here, and they are, in order of
importance: the music which accompanies meals, painful procedures,
calisthenics, and work. Inasmuch as the latter two are not encountered
in all hospitals they will be given only brief consideration. The
subject of mealtime music is of sufficient importance to be treated at
length and will be discussed in the following chapter.

Counter-irritation is a very old method of treating pain. For painful
conditions where specific relief can be given in no other manner,
physicians did and still do try to distract the mind from the site and
severity of the pain by transferring attention to another area. This
can be accomplished by irritating the skin over the affected area in
the hope that the resultant inflammation will be more superficial and
visible and in that way neutralize the pain. In a less physical sense
people “take their mind off” unpleasant subjects by exposure to humor
or other forms of entertainment. Avicenna, the great Bagdad physician
(980-1037 A.D.) included in his Canons of Medicine[37] the following
suggestions:

 “1084 ... Other means of allaying pain: 3. Agreeable music, especially
 if it inclines one to sleep. 4. Being occupied with something very
 engrossing removes the severity of pain.”

Music has been used against pain for centuries not only by musicians
and physicians, but by the people. We find this practice referred to in
a letter from Maria Cosway to Thomas Jefferson concerning his recently
sprained wrist:

 “I wish you were well enough to come to us tomorrow.... I would divert
 your pain with good music[12].”

In 1915 two surgeons named Burdick and Kane used music as a diversion
during local anesthesia. They ascertained the musical preference of the
patient prior to operation and played recorded music in muffled tones
during the operation. Later they played music in an adjacent room while
general anesthesia was being induced and found that it was accomplished
with less resistance[32]. Since that time other surgeons have used
music for similar purposes. There are some operations which are done
under local anesthesia and are prolonged. The absence of sounds other
than awe-inspiring whispers, or the presence of technical talk may
cause the patient unnecessary alarm.

The use of well selected music or a good radio program may be of great
benefit in the operating room. Its value will depend upon the operating
surgeon and how well he can operate while music is being played. There
are times during an operation when delicate maneuvers become trying
and the wrong music or increased volume might lead to exasperation.
One advocate of music in the operating room has called it a “psychic
anesthetic”[53].

The use of local anesthetics in dentistry has made possible the
painless extraction of teeth. Most dentists, however, do not inject
local anesthetics before drilling cavities. For many people, drilling
is a frightful experience. Some dentists have advocated the playing
of music at a loud level during this procedure. Still another has
incorporated ear-phones into the head rest of the dental chair for
diversional sound.

A more obvious use of diversional sound in the professional office
is in the reception or waiting room to supplement the magazines and
diminish the terror of waiting. Music may also be used during such
time-consuming treatment as physical therapy, deep x-ray therapy, and
fever-therapy.


PHYSICAL EXERCISE

Some forms of physical exercise are carried out most successfully
when accompanied by music. Plato recommended such a practice in his
_Republic_. In the ancient triremes or boats with three banks of oars,
there was always a tibicen or flute player, not only to keep uniform
rhythm among the workmen, but to sooth and cheer them. From this custom
Quintillian took occasion to say that music enables us more patiently
to support toil and labor[15].

During the Six-Day Bicycle Race at the Madison Square Garden in 1911
forty-six mile races were separately timed on three evenings; half were
ridden to music. The average time with music was 19.6 miles per hour,
and without it only 17.9[5].

Tarchanoff found that

 “if the fingers are completely fatigued, either by voluntary effort
 or by electric excitation, music has the power of making fatigue
 disappear.”[74]

Such an observation leaves little doubt that physical endeavor is more
productive when done to music.

_Calisthenics._ This is not the place to discuss the value of
calisthenics or its use in hospitals. Exercise has come to be
considered the important physical conditioner, and calisthenics is the
universally practiced exercise. Its proper performance will depend
upon the ability of the leader, the willingness of the participants
and the ingenuity expended to make it interesting. The willingness of
the group can be enhanced by large numbers of performers, but under
any circumstances, since it is unproductive and involves work, any
adjunct which will increase interest is welcome. The exponents of
both the Swedish and the German systems of calisthenics claim equally
good results, but the former do not use any musical accompaniment,
whereas some schools in Germany, particularly the one at Hellerau, make
extensive use of it. In fact, Dalcroze and his followers have built an
entire philosophy of esthetics called “Eurhythmics” based upon the
relationship between body motion and music.

Unproductive exercise can undoubtedly be made more interesting by
musical accompaniment. Music can regulate the orderliness of action by
relating the sense of hearing to the sense of muscular movement.

Johnson[51] believed that the strength of muscle contraction increases
with the intensity and pitch of accompanying music, and that the point
of fatigue is postponed when calisthenics is given to music, but
that unsteadiness might result from variation in the musical score.
Anything that will divert the attention from the proper execution of
the exercise is a hindrance, and music should not be used until the
exercise has become thoroughly mastered. Once the exercise has become
second nature, music becomes very useful because it acts as a stimulus
and adds interest.

It is difficult to move rhythmically out of time with the music. Most
popular recorded music is in a tempo too rapid to be satisfactory for
calisthenics. For this reason live music is far more satisfactory as an
accompaniment, and a single instrument, preferably the piano, is most
suited to it. The pianist can take the cue from the exercise leader
for tempo. The piano should be played in a steady unvarying rhythmic
style. Well known tunes and folk-songs should be used. The piano must
be played loud and with strongly accentuated rhythm. Hulbert[49] relied
largely on waltzes, marches, and folk-songs played slowly. The songs
he used to advantage include “Believe Me If All Those Endearing Young
Charms,” “Bonnie Dundee” and “O No, John.” In this country such songs
as “The Skater’s Waltz” and “There’s a Long, Long Trail A Winding” are
popular for this use.

Ideally, live music should be used to accompany exercise so that the
tempo can be readily adjusted to the speed of the participants. If
commercial recordings must be used they should be carefully selected
to rule out those containing vocal or other interludes which break up
the continuity of the rhythmic pattern, and the operator should silence
the machine between successive exercises.

The use of music during exercises will depend upon the value attached
to it by the instructor. Some may find the time and trouble required
unwarranted. Others may find in it a way to get better co-operation or
increased pleasure. There is one use of music in connection with group
exercise which is strongly recommended. Preceding the actual period of
exercise the playing of a stirring march, while the participants march
to their places of assembly, acts as a stimulant and conditioner for
the activity to follow.


REMEDIAL EXERCISE AND DANCING

When one or more groups of muscles have become weakened as a result
of misuse or disease, it is proper to engage them in strengthening
gymnastics called remedial exercises. Although these can frequently be
given to groups, the groups are ordinarily small. The nature of these
exercises and their administration may lead to boredom rapidly. Soft
music can be used as an antidote to their monotony. Those exercises
for the correction of spinal deformity which require crawling and free
swinging are well adapted to musical accompaniment, and exercise in the
form of the dance used for correction or maintenance of good posture is
undoubtedly enhanced by background music.

Although not in common use for such purpose, ballroom and tap-dancing
could be used to advantage in selected groups of patients for the
improvement of disabilities of the ankles, knees and hips. Modern or
interpretative dancing may in like manner be used for upper extremity
strengthening and co-ordination.


SHOP WORK

In those hospitals which possess an occupational therapy shop, music
may be used to increase the pleasantness of the surroundings and
possibly to increase the endurance and efficiency of work projects.

Music is not recommended as a background to work which requires mental
concentration, even though it is used by a great many students who
believe that they can do their home-work better with the radio on. If
the melody is too interesting or too popular at the time, it may be
distracting, but where the work is largely physical, soft music has
been shown to be a desirable adjuvant. Gatewood[33] studied the effect
of background music on workers in an architectural drafting room and
discovered that although a minority found it distracting, most of the
workers worked better and faster. They preferred familiar music and
found instrumental music less distracting than vocal renditions.

More recently this subject has received the attention of many
investigators who have shown its value among factory workers and have
called it “Industrial Music.”[III.] Their findings and conclusions are
so closely allied with the use of background music that a few excerpts
from the growing literature will be mentioned.

Beckett[9] analyzed the reports made by those factories which have been
broadcasting music to their employes through public address systems.
There was improved morale in every plant where the music lasted for at
least one hour daily. Two-thirds of the factories which played music
for at least one hour on each shift claimed an increase in production
of from five to ten percent. Greater efficiency results from using
music to relieve the boredom of repetitive operations, to reduce
nervous tension, to take the worker’s mind off himself, and in general
to make the shop a more attractive place in which to work. He finds the
evidence undeniable that music can increase production, but points out
that this result will depend upon how the project is managed. If the
acoustics or mechanical reproduction is poor, the value of music may
be lost. The most important short-coming at present is the difficulty
in obtaining suitable commercial recordings. Because of the noise in
the average plant, the volume of the music must be slightly greater
than that produced by the machines. But the average recording has such
fluctuations in volume that some parts will be drowned out by the hum
of the work and other sections will be too loud. Ideally, recordings
for industrial music should vary only slightly in volume, from “plus or
minus two decibels of tone intensity”, and these are not available in
variety at present.

“The kind of music played is of paramount importance, but no one
type of music can be used exclusively without becoming a bore to the
listener. When request boxes are installed, it is often the young
and enthusiastic ‘jive fans’ who use them to the fullest, while the
more conservative music lovers usually sit back and take what comes.
Sometimes this has led to the mistaken view that the whole plant
desired the more raucous music. After a trial of this type of music
some firms received unfavorable reports on production and lost faith in
music. In some instances music was then abandoned altogether, whereupon
there was such an outcry from the workers that the program was
reinstated with hot swing entirely eliminated. Both extremes are bad.
Giving the workers what they want is a more difficult problem than it
appears at first. It requires not one but a number of questionnaires
over a period of time to keep up with changing tastes.”

“Music must be played at the right time to obtain the best results.
Marches create a cheerful atmosphere and should be played at the
beginning of sessions, as well as at the end. The best time of the day
for Strauss waltzes is at the so-called ‘fatigue periods.’ There is
something about three-quarter time that is very refreshing at moments
of fatigue. Besides the music is gay and light-hearted, and leads all
other forms in popular appeal according to questionnaires filled in at
three large plants.”

In the hospital occupational therapy shop, music may originate from the
public address system, a record player, or the radio. It would seem
that the most suitable in the average hospital would be the use of the
radio, which the therapist can change at intervals of fifteen minutes
or longer in an attempt to get unexciting music at a low volume level.


FOOTNOTES:

[III.] _The use of industrial music is not to be confused with working
songs. Working songs are those sung by groups performing tedious or
strenuous work to help them maintain good rhythm and spirit. Bücher
(Bücher, K., Arbeit und Rhythmus, Leipzig, 1909) analyzed a long list
of working songs and concluded that: 1. Through rhythm they facilitate
the synchronous expenditures of energy by individuals engaged in
a common task. 2. They spur the worker on through jest, abuse, or
reference to the spectators’ opinions. 3. They mention the work, its
progress, pleasures, vexations, difficulties and rewards. 4. They
inform everyone of the wishes and aspirations of the workers. These
slow rhythmic songs are entirely unsuited to the machine age where the
machine sets the inelastic rhythm for the worker._




_CHAPTER SIX_

MEALTIME MUSIC


Patients who are confined to bed, or for that matter, to a hospital,
find meals progressively monotonous in spite of the fact that there is
a greater variety offered them than was theirs at home. This monotony
results in part from the color and nature of the environment, the
personnel, the general atmosphere of the hospital, and the constraining
nature of institutional restriction. While dining at home some of these
factors are subconsciously dissipated by trivial intimate conversation,
friendly faces, individual attention and the security of the things for
which “home” stands.

There are only a few things which can be done to make hospital meals
more enjoyable, aside from those features best handled by the chef
and menu planner; but it is possible to increase the pleasure of meal
periods through the manipulation of certain environmental factors. One
of these is the use of color and _decor_ in hospital dining halls to
simulate home surroundings. In the ward this is most difficult where
little can be done, except by introducing attractive hangings which are
less hospital-like, or by the application of paint in cheerful colors.
The latter method is sanitary and practical.

Since ancient times music has been used as an accompaniment to meals.
The instruments used by the ancients for this purpose were usually
those which emitted soft sounds. Voltaire said that our purpose in
going to the opera was to promote digestion. During the preceding
century, dinner music became stylized and consisted largely of
semi-classical pieces or waltzes played softly in slow tempo by string
ensembles. During the past twenty-five years there has evolved a form
of dinner music which is not only a marked departure from the old, but
has come to be used as a source for dancing between and during courses.
Whether the physiologic and psychologic effects of dancing during
a meal are harmful, beneficial, or of no moment remains undecided.
Certainly there seems to have been little interest in analyzing its
effects. During the period when dinner-dance music was available only
in a few places, the number of those who could be affected by it was
very small. But, with the more recent installations of “juke” boxes,
and other forms of mechanically reproduced music, into all varieties of
dining places, the problem is worthy of investigation.

Most people derive pleasure from the consumption of appetizing food.
Most people derive pleasure from music played to their taste. Although
the logic of the following thought is subject to criticism, it does
sound reasonable to state that two pleasurable experiences enjoyed
simultaneously, should add up to a greater happiness than that afforded
by either individually. Food has received thorough study with respect
to preservation, preparation, serving, and the time of day when each
item is most satisfying. Some of the conclusions have been arbitrary,
but for the most part, people eat the food that agrees with them
physiologically and psychologically. There is no especially good
reason why cereals should be eaten by adults only in the morning. It
has become a matter of custom or advertising, and the minds of the
masses have become conditioned to feel that cereal is especially good
at breakfast time. A generation ago the breakfast menu in some homes
differed little from the present day dinner fare. Eating habits have
become set in the minds of most people and there is little that can be
done to change them rapidly. Daily routines have given rise to certain
music conventions as well. Until recently, music at breakfast was
uncommon. Bernard Shaw[65] wrote, “Music after dinner is pleasant:
Music before breakfast is so unpleasant as to be clearly unnatural.”
With the advent of radio this has changed even if Shaw has not. Lunch
rooms, barbershops and other public places where people spend time
inactively, are equipped with mechanisms for reproducing music. The
practice of reading or even studying school work at home with the radio
on has become increasingly prevalent. The tempo of living has stepped
up to the point where most people, especially the younger, like to do
two things at once, especially if one of these is to listen to music.

The effect of different foods upon digestion and health is known, and
most persons eat with a regularity which is related to capacity and
needs. They are usually able to select the items they desire, the time
at which they will eat, and the period for consumption.

The ideal attitude while eating is one of mental serenity and physical
repose. If certain criteria are observed music can be relaxing. The
elements which increase relaxation are melody, rhythm, and softness.
If the music which accompanies meals is carefully selected it can make
eating more pleasurable, and this is desirable for patients in the
hospital.

Mealtime music must be unobtrusive. It must lack stimulating qualities
which attract attention. If the diner can promptly name the selection
played five minutes earlier, that piece was too impressive in score or
performance. Perhaps the most suitable form of dinner music is that
played by a small string ensemble. The piano and harp are also very
satisfactory, alone or in combination with the ensemble. When the
piano is played in the hesitant legato style of Eddie Duchin it is
particularly desirable. The shrill sounds of the flute or the brassy
sound of the trumpet must be omitted. The music must be soft and slow.
Avoid vocals and strange instruments.

The volume of the music should be maintained at as nearly the same
level as is consistent with the source of the music. It should begin
without fanfare or any attempt to attract attention. The level of
intensity should not interfere with conversation, for, if the loudness
of the music demands an increased volume of voice to carry on normal
conversation, it defeats the purpose of relaxation by evoking increased
energy on the part of the speaker. When possible the end of the
selection should fade out. There should be nothing abrupt about the
selection, and unusual sequences or novelties should be avoided. The
music should be fluent and entirely unexciting. The interval between
pieces should be brief in order to sustain auditory reception at
a fairly continuous level. Five to ten seconds between numbers is
recommended, and this coincides approximately with the time required
to change discs on an automatic or manually controlled record player.
Musical selections should be played in groups. The groups should last
a total of about fifteen minutes with rest intervals of about three
minutes. This simulates the requirements and performance of the live
ensemble and has become a part of stylized dinner music. The music
should last as long as the meal.

Ideally, the source of the music should not be obvious, and to this
end a concealed loud speaker has an advantage over the live ensemble,
which through its motions or the physical appearance or mannerisms of
its members may distract diners. There should be no vocal announcements
between selections. Occasionally a listener will want to know the name
of the song being played because it is familiar, reminiscent, or sweet.
When the budget will permit, printed or mimeographed programs are most
welcome to those whose interest is aroused.

The music recommended, is the music which has been played by dinner
ensembles for years. Their repertoires usually include waltzes by
Strauss and his contemporaries; selections from operettas by Herbert,
Friml, and Romberg, and the popular favorites of the past decade,
such as selections from the musical comedies of Kern, Cole Porter and
Gershwin, or the songs of Carmichael and Berlin.

It cannot be emphasized too strongly that mealtime music must be
physiologically non-stimulating, and noisy music is to be avoided.
“Douglas Jerrold declared that he hated to dine amidst the strains of a
military band; he said he could taste the brass in his soup.” (Hadden,
J., “_Music as Medicine_,” 1895, 9:369). A foreman of a shop in which
music was played during mealtime begged that raucous music be omitted
“to give the digestion a break”[9].

Some orchestra leaders habitually use arrangements which approximate
the qualities desirable for mealtime music. Among these are: Wayne
King, Marek Weber, Andre Kostelanetz, David Rose, Frankie Carle, Carmen
Cavallaro, Eddie Duchin, Guy Lombardo, and the following orchestras:
Boston “Pops”, New Mayfair, Percy Faith, Anton and Paramount, Victor
Salon, Victor Continental, Palmer House Ensemble, Selinsky String
Ensemble. All these have been recorded and a sample list of their
recordings follows as a nucleus of a mealtime music library.

 _Victor Recordings_

  Southern Roses             26322 B
  Sweetheart Waltz           26322 A
  Black Eyes                 20037 B
  Our Waltz                  27853 B
  Holiday for Strings        27853 B
  Frühlingstimmen             4387 A and B
  Dream Waltz                V 214
  None But The Lonely Heart   4413 B
  Song of The Islands        27224 B
  La Golondrina              27451 B
  Lover, Come Back To Me     27397 A
  Indian Love Call           27397 B
  Le Secret                  20416 A
  Pirouette                  20416 B
  Wine, Women And Song        6647 A
  A Shepherd’s Tale           9479 A
  Narcissus                   9479 B
  Come Back To Sorrento      27917 A
  Gavotte from Mignon        27917 B
  Zigeuner                   24609 B
  Tales of Hoffman           20011 B
  Badinage                   12591 A
  Air de Ballet              12591 B
  Gold and Silver            25199 B
  Blue Danube                25199 A

 _Columbia Recordings_

  Begin the Beguine           4265 M
  Easter Parade               4292 M
  With A Song In My Heart     4292 M
  The Touch Of Your Hand      4291 M
  Somebody Loves Me           4291 M
  Falling In Love             4266 M
  Tea For Two                 4266 M
  Josephine                  36692
  Louise                     36692
  Estrellita                  4236 M
  London Again               69264 D
  By The Tamarisk            69264 D
  Swan Lake                  69357 D
  Rosalie                    36543
  Speak To Me Of Love        35551
  Pavanne                     7361 M
  Clair De Lune               7361 M

 _Decca Recordings_

  The Very Thought Of You     3110 B
  Cocktails For Two           3110 A
  Every Little Movement      18300 B
  Minute Waltz               18466 A
  Blue September             15050 A
  Valse Bluette              15049 B
  Sleepy Lagoon              18286 A




_CHAPTER SEVEN_

MUSIC IN BED


Modern hospitals are so different in organization and equipment from
what they were a century ago, that it may be said that the hospital
is a recently acquired phase of community life. Originally, the sick
were treated in their own homes. The inconveniences and inadequacies
of caring for the seriously, and especially the contagiously, ill at
home led to the development of hospitals. The primary purpose of the
hospital has not changed, and the musical aide must never forget that
medical care and rest come before all else.

Some bed patients are too ill to listen to music. It is possible that
judiciously offered music might be of value to all patients but it is
safer to deny a few in the absence of expert medical guidance than to
disturb the sick. The musical aide may not question the wisdom of the
physician in prohibiting the use of music in some wards or for some
patients. The physician knows many things about the patient which are
unknown to the musician and there is insufficient time to explain
these to the musician. In institutions where the public-address system
distributes music through ear-phones rather than through loud speakers,
listening presents no problem and head-phones are not supplied to
patients until the physician permits it. When only loud speakers
are available, and the ward houses a mixture of seriously ill and
convalescent patients (as is fairly common in large public hospitals)
it may be necessary to deprive the ward of music for the sake of the
few who should not have it.

The number of possibilities which may be found on any one ward is
so great that only the most general kinds of use will be mentioned.
Pediatric wards are frequently arranged so that the acutely ill are
segregated, and this permits ward music at most times. Where patients
are intermixed, the attending physician will make the decision. The
importance of scheduling for children is enhanced by the fact that most
children prefer their music loud, and this can be especially annoying
to the sicker children. As a general rule it might be stated that with
the progress from childhood to old age, the preference shifts from fast
loud high-pitched music to softer and slower music. The speaker volume
on the pediatric ward may be increased to gain the attention of some
children, and drown out the crying of others. Children can listen to
the same set of records almost endlessly. They prefer to hear music
with which they are acquainted. They like songs with words.

One reason for hospitalization is to get the patient away from the
annoyances and noises of home. One of the modern noises is the radio.
Most patients sleep and need more sleep than well people. In most
hospitals certain hours of the day are chosen for rest in the hope that
the patients will fall asleep. The usual period for daytime slumber
is directly after lunch. The filling of the stomach is in itself a
soporific. Warmth, darkness, and physical relaxation increase the
tendency to sleep. Since there is no universally sleep-inducing music,
music should be avoided at this time. It may keep some awake. If the
patient is in a private room and is willing to be played to sleep
it should be attempted. It must be remembered that if the music is
sufficiently interesting or if the reproduction is poor or scratchy it
may prolong wakefulness or even prevent sleep.

At those times when slumber music is requested by the physician or the
patient, a few common sense rules should be followed. For children
vocal lullabies should be tried. Slumber music should not be played for
more than fifteen minutes. If it has not been effective in that period,
silence is indicated.

Admission to a hospital usually means new eating and sleeping habits
for the patient. The hours for each are frequently earlier than
previously. Day-time naps and early “lights out” make it difficult for
some to fall asleep promptly at night for the first few nights. Slumber
music should take the form of restful music. The final fifteen minutes
of the day should be given over to sweet melodies of old time favorites
which may recall old pleasant memories and possibly place the patient
in a “dreamy” mood of relaxation removed from the specious present and
its worries. The operator of the sound control should gradually and
imperceptibly reduce the volume so that the final moments are barely
audible.

In hospitals equipped with “radio-pillows” in which telephones are
concealed within the pillows, the music may remain continuous until the
patient falls asleep. Many people have developed the habit of falling
asleep to radio music or turning it off when they become sleepy. Radio
programs are not recommended as slumber music. The musical program
should use the old favorites or meal-time music selections (See Chapter
VI) at a very low volume. Loud and stirring music before bed-time
has been known to result in vivid auditory dreams, and should be
avoided.[24]


THE BEDSIDE RADIO

More than any other single factor, the radio has increased musical
knowledge and appreciation in this country. The programs of Bing Crosby
and Alec Templeton have great popular appeal because of the extensive
preparation, humor, and showmanship contained in them. Yet these
programs never fail to include classical music, and introduce serious
music to those who would not freely choose to listen to it. But more
than any other single factor, the improper use of the bedside radio
can make patients hate music. The most passionate lovers of music will
admit that it is possible to have too much music of the same kind for
peaceful consumption. In hospitals with large wards, two or more radios
may be found tuned in to different programs, and the desire to share
the program with others means excessive volume. In those institutions
which do not possess a public address system radios should be permitted
on the wards but certain rules should be observed. The volume should
be controlled so that patients who are not interested do not have to
suffer. The volume should be one that makes the signal just audible to
the owner and to those of his neighbors who wish to listen. For several
hours of the day interludes of silence should be observed by all owners
of radios. In hospitals with a loud-speaker system, all radios should
be turned off during the hours of its operation.

In hospitals for the chronically ill, such as tuberculosis sanatoria,
where the musical tastes on the ward may run a wide gamut, a schedule
should be arranged for those possessing radios, allotting certain
periods of the day to each owner and arranging the sound distribution
so that two or more radios may be turned on simultaneously but spaced
so far apart that the resulting sound will not result in a form of
punishment for those caught in between or not fortunate enough to own
their own radios.

After “lights out” radios frequently remain on unless supervision is
severe. It is true that many of the better programs are heard after
nine o’clock. Since some of the late programs are part of American
life, it is unfair to the chronically ill to deprive them of this well
planned entertainment. Yet there will be some on the ward who will want
to sleep, and they should be given maximum consideration. Others should
be permitted to keep their radios on at the lowest possible volume,
and the possibility of headphone installations should be reviewed. The
solution to this problem is possible but expensive. If a record-cutting
device is available, the program may be recorded at night and replayed
on the following day.


PUBLIC ADDRESS SYSTEM

Many hospitals have already been equipped with either loud-speaker
or headphone installations. For those hospitals which are still in
the deciding stage, some of the advantages of each will be briefly
considered.

Ideally, both speakers and head-phones should be available. This
is a luxury in which few will be willing or able to indulge. When
head-phones are used, they have a way of getting misplaced, broken or
broken-down. Head-phones or listening devices are usually distributed
to those patients who are medically eligible. Frequently the attendants
are busy and forget to supply them, to the chagrin of the patient. When
there are not enough to go around a further source of dissatisfaction
arises. Head-phones must be adjusted for proper reception and comfort,
and this may become a source of bother to patients or staff. Among
the advantages of ’phones are the quietness of wards at all times for
those who desire rest. Their use permits maximum focusing of attention
on the music because of the exclusion of most other sounds. They
become a mechanism of escape from the unwanted conversation of noisome
neighbors. When double-jacks or two-channel wiring is used the patient
is permitted some choice in music selection. The use of ’phones,
however, limits the physical excursion of the ambulatory patient.

The use of a loud-speaker system permits those patients not strictly
confined to their beds to visit other parts of the ward without
interruption in their listening. Some patients enjoy music as a
background to conversation or ward activities. The same switchboard may
be used for musical programs and hospital announcements, and this may
be desirable economically in some institutions. Strategically placed
speakers may be channeled exclusively as a call system.

Laughter is a communal reaction. We rarely react completely to a
radio joke if we are listening alone, but if several people listen
simultaneously laughter becomes more pronounced and prolonged.
Loud-speaker systems permit patients on the ward to enjoy music as a
group. They also permit the greater use of background music. Eating
with the encumbrance of head-phones is not desirable.

Each hospital will have to weigh these and other arguments of
the speaker-phone dilemma and choose according to its individual
requirements.

The most suitable number of channels for a small hospital is two. One
operator can readily handle two channels. When the number of channels
is increased above this the expense of installation and operation will
increase, especially if recordings or transcriptions are to be used in
addition to outside programs.

The operator of the public address system should be conversant with
the Hooper or Crossley ratings of the more important programs and be
certain to include the most popular at any one hour in re-broadcast.


PERSONALIZED MUSIC

The more musically inclined or susceptible patient may not be satisfied
with the routine musical program as furnished by the public address
system or even his radio. In hospitals where the majority taste is
for modern popular music, there will be a few who will hunger for
classical. If a musical aide is available this may be accomplished by
the use of a music cart. A box-like device on wheels such as is used
for many purposes on hospital wards may be fitted with a record player
and a rack for records and record albums. The music cart may carry
some small instruments and other materials for bedside use. Music can
be wheeled to the bedside for instruction, appreciation, diversion, or
entertainment.

_Instruction._ Bedside instruction may be used as occupational therapy
or for purely educational purposes. Small instruments such as the
ukelele, mandolin, or even the guitar may be taught to the bed patient
as upper extremity exercise. Instrumental instruction will usually have
to be limited to patients in individual rooms. Occasionally wards will
be arranged so that a day-room or sun porch is available for wheel
chair or partially restricted patients, and there will be times when
the patient may receive instruction there. There are some instruments
which may be played with a minimum of instruction. Unfortunately most
of these emit sounds which are quite annoying to all but the performer.
The ocarina and harmonica may meet with some acceptance among young
patients, but when older patients share the ward or adjoining room
their feelings will have to come first. Some young patients will
delight in the use of drum sticks on practice blocks, especially if
they can use them during the reproduction of music on the public
address system or the radio. If the block is made of rubber or some
other noiseless material it will not be too annoying to neighboring
patients.

Specially constructed “toneless” or “practice” instruments such as
the violin without the resonator are of genuine value in diminishing
neighbor annoyance. These may be built in the occupational therapy shop
from discarded instruments.

_Diversion._ For those who desire diversion and music appreciation, the
music aide may wheel the music cart to the bedside. By ascertaining the
musical appetite of patients on the preceding day, the aide may stock
the cart with the kind of recordings desired and play them for the
interested patient and any of the neighboring patients whose interest
she can stimulate. By making a few well chosen remarks before each
record is played much interest can be developed and the patient will
look forward to future visits. If patients express no special interest
in music, albums may be passed out for browsing and played without
predetermined continuity. If interest is greatly aroused the music aide
may suggest supplemental reading and call on the librarian to visit
the patient or supply some reading material from the music department
collection. The commercially available program notes for sponsored
radio programs should also be distributed.

_Entertainment._ Musical entertainment on the ward may take the form
of patient participation or “live” music. For patient participation,
there is nothing to equal ward sings. The music aide may use either the
record-player in the music cart or, preferably, a portable instrument
such as a small piano organ, or accordion. The words of the songs may
be mimeographed or flashed on a screen, wall, or ceiling with a small
projector. Hymn books or other books of songs may also be used to
advantage. Songs should be chosen for their popularity and familiarity.
Such songs as “Let Me Call You Sweetheart” and other old favorites are
“sure fire”. The top songs on the “Hit Parade” are always enjoyed. The
music aide should circulate if recorded music is used to stimulate
non-participants into singing. The session should last from twenty
to thirty minutes. It is desirable to have two of these per ward
each week. Duration and frequency can be varied according to patient
response.

Of all forms of ward music, good “live” music is perhaps the most
entertaining. Ensembles may be of fair quality but soloists must not be
mediocre or the presentation will suffer. The most popular entertainers
are the singers who can accompany themselves on the portable piano or
other instruments. They should keep the program at the popular-appeal
level. They should not ask for requests unless their repertoire is
adequate since the inability to grant them is both disappointing and
embarrassing to both performer and patients.

_Volunteers._ It will be difficult for one music aide to carry out a
music program by himself in a hospital of more than 500 beds. If the
budget does not permit a second aide volunteers from the community
should be enlisted to assist. This subject will be discussed further in
the next chapter.




_CHAPTER EIGHT_

DIVERSION AND ENTERTAINMENT


A program of musical entertainment is not needed at all hospitals,
nor for all patients. Entertainment is relatively new in hospitals.
A need for it arose when hospitals for the chronically ill became
greater in numbers and size. The average person soon becomes bored
when restricted to bed or even the confining walls of an institution.
Reading becomes tiresome for most because of position, eye-strain, or
satiation. Similar limitations exist to a lesser degree for craftwork.
There is a diminution in contact with the outside world except for the
too infrequent and short visits of friends or relatives. In hospitals
for the tuberculous adult or the crippled child, the average duration
of hospitalization may be a year. Few leave before a period of three
months and some remain for years. Life for the chronically hospitalized
patient may become more monotonous than is wise. Monotony leads to
discontent, irritability, apathy, and possibly disciplinary problems.
Monotony may make meals even less attractive than they are in some
hospitals. Lack of mental occupation may lead to a loss of desire to
get well or give the patient too much time to think about himself, his
helplessness and hopelessness. Most patients arrive at the point where
they crave amusement, and most of them would rather be amused than work
for their own entertainment.

In the field of entertainment, music is indispensable. In hospitals,
music is frequently the only form of entertainment. Music can be
used at the bedside, in the ward, the assembly hall, or when
weather permits, outdoors. In hospitals equipped with public address
systems the problem is decreased by the simultaneous performance
of mechanically reproduced music throughout the wards and rooms of
the hospital. Where public address systems have not been installed,
entertainment will depend largely on radios, record reproducers, and
personal appearances of musicians.

“Live” musicians are the most welcome source of entertainment. If the
hospital has a music aide, this aim is partially fulfilled by his
activities. If there is no full time musician, hospitals may be able to
secure the part-time services of a musician or recreational aide. Some
one person should have control of arranging programs, and an interested
person will usually be found on the hospital staff. It may be an
occupational therapist, a nurse, or even one of the physicians. The
person selected to direct music will have little difficulty in finding
in the community some musicians or groups of amateur entertainers who
will be willing to assist in this work. Groups from schools of music,
high schools, fraternal or benevolent organizations, women’s clubs,
music clubs and veteran’s societies constitute an incomplete list of
sources. Most communities have soloists or small groups which will be
willing to perform. Direct solicitation by the hospital director, the
ladies auxiliary, or members of the staff should be made personally or
through the press.

A schedule of performances arranged for at least one month in advance
is most important. There should be a regularity to performances even
if they occur only once a month. It will give patients something to
which they may look forward with the pleasure of anticipation. Whenever
possible, musical programs should be prepared for the same weekday or
night. These appearances should be announced or posted to increase the
interest.

In hospitals for the chronically ill there is usually an assembly
hall or recreational building, where entertainment may be given for
ambulatory patients. The appearance of famous musicians on its stage
will be rare or impossible, especially in hospitals not located near
large cities. This is not as unfortunate as might be believed, because
although some patients are impressed with names of national reputation,
maximum enjoyment will result for the majority from listening to their
fellow patients performing. Patient participation is always more
desirable for the ambulatory than passive entertainment. Patient music
may take one of three forms--formal, amateur, or spontaneous.

Formal presentations require much work on the part of the musical
aide and the patients. Orchestras of variable size may be formed,
depending upon the number and variety of talented patients. Inasmuch
as quality of performance is the prime consideration, the repertoire
of such groups will not be great. At the outset it will take almost a
month to develop a one hour variety program. With the progress of time
and increased work and co-operation it should be possible to rehearse
enough new numbers each week to produce a weekly program with too few
repetitions to arouse complaints on the part of the patients. The
program should contain all types of music so that during the course of
a performance almost everyone in the audience will have heard something
to his taste. Vocal numbers are welcome and audience participation at
one or two points will sustain interest. It is advisable for some one
to act as master of ceremonies to announce selections and to evoke
maximum response from the non-participating patients. There is usually
one patient with a desire to be a master of ceremonies and, if he
executes his work well, this will be a valuable asset to the project. A
master of ceremonies is important and if necessary an outsider should
be secured for this purpose.

Amateur programs have been present on the American scene for a long
time but the efforts of Major Bowes have made them an American
institution. People of almost all ages will attend them joyfully,
but the performers will usually be in the second and third quarters
of life’s span. There was a time when amateur performances were
unrehearsed or sounded so. Major Bowes has changed that, too.
The amateur show will now be found to demand rehearsals, expert
accompaniment, and a certain amount of theatrical display. These
factors should be encouraged and the music aide will do well to humor
patients along, because success depends upon the seriousness, energy,
and efforts of the performer. Care should be expended in careful
programming. The best performers should be well spaced and appear in
the second half of the program. Instrumentalists should be separated
by vocalists. The procedure should follow the set pattern of regular
amateur shows, including the award of prizes to the winner and second
best. Where patient turn-over is slow, it is likely that the same
performer may be first too often. Some limit should be set on the
frequency or total number of times the same patient may receive an
award to prevent participation from diminishing.

Spontaneous shows in the recreation hall will consist of community
singing, humming, whistling, and occasional rhythmic hand-clapping.
It is not difficult to get a group to sing but maximum response will
call for ingenuity on the part of the leader. The series of motion
picture shorts called “The Bouncing Ball”, “Community Sing”, and
others of a similar nature are excellent because they are complete
packages of music, words, direction, humor, and tricks. The song leader
should adopt as many of the novelties included in these films as the
facilities will allow. Next best to the motion picture is the lantern
slide. There are a few available with humorous illustrations, but they
may be difficult to obtain. Lantern slides may be made rapidly and
inexpensively by the music aide. The makings of simple slides may be
had in any large commercial photography supply shop. “Radio Mats” are
slide-sized pieces of clear cellophane enclosed in a folded piece of
carbon paper and surrounded by a black mask. The “Mat” is placed in a
typewriter and the words of the song are typed on it. The carbonized
paper is discarded, as is the back of the mask, and the cellophane with
words imprinted is easily mounted between the two glass cover-slips
joined by “Scotch Tape”. By this method a permanent slide may be
produced for about eight cents. If a projector is not available, the
words may be mimeographed, printed in the occupational therapy shop,
or obtained commercially printed in pamphlet form. The salient need is
that all may be permitted to read the words.

Community sings should not last too long. The music aide will soon
learn to sense the capacity of the audience. To extend the period,
patient participation may be interrupted by instrumental music or some
other form of interlude.


CHOIR

Listening to a combination of trained voices is pleasurable to most
people. Where the patient population is relatively static, the music
aide will be well repaid by time spent on training quartettes or larger
groups of singers. Such groups can be of value not only in any of the
musical programs for the assembly hall but may be used on the wards,
for religious services and on holiday occasions. If, as is usual, both
sexes are represented among the patients, the range of selections will
be limited only by the musicianship of the leader and the participants.
The range of repertoire should be suited to all occasions and tastes
from “barbershop” quartets to serious music.

All possible arrangements of voices should be exploited with a view
to competitive singing between sexes and among wards. The range of
usefulness of this activity will of course depend to a large extent on
the size of the hospital and the predominant age group.


DIVERSION

Music may also be used to help time pass less noticeably. Listening is
enjoyable but does not focus or sustain attention in any way comparable
to playing. There will always be patients interested in learning to
play music. The instrument of choice will depend upon individual taste,
which of course is conditioned by background, education, nationality,
age, and many other factors. The instruments which will be most
acceptable are those which are not too difficult to play and which emit
a pleasant sound with ease for a long period.

The piano is the instrument which best meets the qualifications of the
ideal instrument for hospital use. When reduced to pure physics, the
sound produced by striking a single note on the same keyboard will
be of approximately the same quality whether made by a child or a
virtuoso. This is not true of any other instruments, except to a degree
in certain other percussion instruments, that produce less pleasant
or interesting sounds. Piano fingering is more easily mastered than
that of stringed instruments, and offers greater latitude in precision
placement. The piano may be played in the restful sitting position
and requires little effort to play. More people know how to play the
piano than any other instrument. Patients may be interested in any of
the other instruments, but with the exception of the plectrum type,
may become too readily discouraged at the amount of practice required
to elicit pleasant tones. If a patient is interested in learning an
instrument for diversion, the piano should be the first offered. If
the problem of replacing musicians in or completing a patient band
arises, the missing instrument should be offered. But in order to
get the maximum co-operation and application, the patient should be
made to feel that the choice is his. The free choice might be vocal
instruction. It may even be a disappointment to the musician when
it turns out to be so-called instruments like the ocarina, but if
the aim is diversion a maximum will be reached earliest by initial
gratification. Perhaps at a later date the music aide may be able to
inculcate enough sophistication to lead to the choice of a more musical
instrument.

The scope of music as an educational diversion will expand in
proportion to the training, patience and energy of the music aide.
It will be limited by the number of patients who demonstrate an
interest and also upon their intelligence and perseverance. For the
major instruments, instruction is usually individual and much time is
consumed in the diversion of a single patient. In a large hospital
this will not be very practical unless there is a large staff, and
there are many activities available to patients. Group diversion can
be happily attained by some form of instruction in music appreciation.
The nature of this instruction should be tailored to the intelligence
and taste of the majority and the music aide must exercise common
sense and free himself of prejudice. If the patients are young and
uninterested in the classics he must devise a program around popular
music and discuss current personalities and popular forms. A driving
wedge into the classics may be constructed on the classic themes of
Tschaikowsky, Chopin and others which are currently popular. If the
group is very young, music appreciation demonstrations such as those
conducted by Walter Damrosch should be followed. Whenever possible, the
musician should illustrate with “live” music, but recordings will be
well received. As with all other features of a musical program in the
hospital, sessions should be regular and governed to some extent by the
will of the majority.




_CHAPTER NINE_

PUBLIC ADDRESS SYSTEM


Many hospitals now have public address systems. Before long most
hospitals of one hundred or more beds will have public address systems,
if for no other reason than emergency calls and to lessen the load on
the intramural telephone network.

The public address system originally installed as an emergency call
device may be used for music reproduction at relatively little
increase in expense. The same operator may be used for both forms of
transmission. Ideally, the system should include a loud speaker in
every ward and a “phone-jack” at every bedside. The central switchboard
should have a good radio and an automatic record player which may
transmit music to the patients by means of the public address systems.
The addition of a set of switches which can cut wards in or out at
will can prove most useful. If there are halls or buildings from
which programs of general interest emanate frequently, they should
be equipped with microphones which are connected with the central
switchboard so that musical programs from the assembly hall or the
church services from the chapel may be broadcast to the non-ambulatory
patients.

The central switchboard should be housed in a relatively sound proof
room or booth. Additional equipment for it should include shelves for
recordings and a telephone for which the usual bell signal is replaced
by a light signal. An instantaneous record-cutter which permits the
operator to record programs from the radio or microphone will be found
of great value, but the expense involved may be too great for most
hospitals of fewer than 500 beds.

It is most advisable that a full-time operator for the system be
employed. The operator should have a pleasant voice, but even more
important, a highly intelligible one. He will require some basic
training in the operation of the switchboard and its accessories and
this should be the obligation of the organization which installs the
equipment. The operator should be required to keep a written record
of everything that emanates from the studio. He should be responsible
for the routine care of the apparatus and know enough about its parts
to recognize defects early and to correct some of the simpler ones. He
must be prepared to live a lone life. There is always a temptation to
invite or permit guests in the studio, and the resultant diversion or
conversation might adversely affect the broadcast.

If an instantaneous record cutter is available he should read “_How
to Make Good Recordings_” (Audak Co. of New York) which is not only
valuable for the recording of music but gives some excellent advice
concerning the use of the proper needle for music reproduction and the
use of the microphone.


PROGRAM

_Music._ The public address system should be operated on a rigid
schedule in imitation of a commercial radio studio. This is necessary
because the patients will come to expect certain features at specified
times of the day and fluctuations may result in disappointment and
reduced morale. The program policy should be the direct concern of the
hospital superintendent and any service chiefs who are interested.
The hours of use will vary considerably with the individual hospital
from a few hours to a very full program. Because of the great number
of possible variations, some general applications will be considered
first and then a model program will be suggested.

The hour of awakening for patients may vary from about six to seven.
At some time during that hour, a program of exhilarating music is
indicated to start the day off right and perhaps get better cooperation
between the patients and the nursing personnel in morning care. To this
end, military or other marches are suggested as well as gay melodies,
because as Seashore[73] has shown, “pronounced rhythm brings on a
feeling of elation,” and martial music is traditionally stirring. This
program should last from fifteen to thirty minutes, and should be
followed by silence for at least fifteen minutes before breakfast is
served. It is unwise to begin eating while too stimulated.

During the breakfast, luncheon and supper periods, mealtime music
should be broadcast for the entire duration of the dining period.
The nature of mealtime music may be the same for all meals. This is
discussed in Chapter VII.

The period between eight and ten in the morning is frequently reserved
for routine dressings or medical rounds and a period of silence should
be observed in the wards during the hours of maximum professional
services. Obviously, music should not be broadcast at any time during
the day when rounds are held. The operator should be supplied with a
schedule of ward rounds and cut out those wards which are concerned.

The duration of rounds will vary from very brief periods on the
surgical wards to prolonged ones on the medical wards. Soon after
rounds the operator should broadcast to wards on which no regular
activity is taking place. A half hour program of request music in the
morning between ten and eleven is suggested. This should be followed by
the pre-meal period of silence.

Where desired, luncheon music should be followed by restful or very
soft music. If the blinds are drawn and silence among patients is
maintained maximum benefit will result. Those patients who can fall
asleep readily at this time will do so. Those who find it impossible to
nap in the afternoon will be grateful for the diversion of music which
will permit greater relaxation. It is more difficult for some people to
rest in absolute quiet than with soft background music.

Another request program of music lasting one hour may be begun between
two and three o’clock. It is advisable to mention specific names of
patients who request music to stimulate patient interest in communal
participation and listening. During the evening hours following supper,
it is suggested that the most popular radio programs be transmitted
over the system. These should be chosen on the bases of Hooper or
Crossley ratings so that the greatest number of patients will be
satisfied. When more than one channel is available, the second program
selected should be of a different nature from the first.

_Announcements._ Announcements should be kept to a minimum. Routine
announcements should be made at specified hours daily, such as after
breakfast, before lunch, and after supper. Emergency calls should
be limited to genuine emergencies or they will not be regarded as
compelling, as they should be.

Newscasts are a much appreciated and desirable feature for patients
who, until their admission to the hospital, may have read or listened
to the news daily and will want to keep up with it. The newscast should
be given in an unsensational manner and news which is too depressing or
exciting should be deleted or reworded, for psychiatric patients.

_Special Programs._ There should be a weekly religious program sent
out over the system for those in bed. The minister affiliated with the
hospital should be able to fit the hospital into his Sunday morning
schedule. If no minister is available, a regular radio program should
be rebroadcast, but a Sunday service of local origin will be more
personal, and therefore will be more appreciated. There are many
suitable religious recordings available for incidental service music,
particularly the series of albums pressed by Bibletone.

Holidays should be observed by the reproduction of appropriate music or
radio rebroadcasts.

For the small hospital with limited personnel a two-channel system
continuously tuned to the two most popular networks locally available,
should be used.




_CHAPTER TEN_

EQUIPMENT AND LIBRARY


A hospital which wishes to use music as an adjunct to medical practice
must be willing to offer the space required for its activities. The
extent to which music will be needed will depend upon the nature of the
illnesses treated and the average stay of the patients. For mental and
tuberculosis hospitals, music is a “must.” The chronic hospital usually
has an assembly or recreation hall for musical performance. This hall
will generally be adequate for band rehearsals, and may also be used at
other hours of the day for instrumental practice. Where funds and space
can be spared, additional rehearsal rooms should be built so that more
patients will be able to participate. Space can be saved by building
small cubicles sound-proofed with any of the sound absorbing fabricated
wall boards such as _Celotex_ or _Transite_. Cubicles should be built
with much glazing so that the patient will not feel the smallness of
the room. If there is only one music aide, there will be an advantage
in centralizing all music activities, but if more help is available,
music rehearsal rooms should be available in the different pavilions or
wings of the hospital so that newly convalescent patients will not have
to walk too far.

If the age range of the patients runs the full gamut, seating and
instrumental provisions will have to include provisions for all. This
means adjustable piano benches, music stands, etc. Chairs should be
provided not only for musicians but spectators. Patients should be
encouraged to attend band and other group rehearsals as a method of
stimulating their interest in music and for the diversion which it will
afford. Music stands for the bands should be dressed up to resemble
those used by popular bands. These stands are colorful, collapsible,
and hence transportable for any outside performances which the patient
band may contract.


INSTRUMENTS

_Participation._ The number and nature of instruments which a hospital
should have will depend only upon budget limitations and the interest
of the community. There is no limit except storage space to the number
and variety of instruments which a hospital should accept as gifts.
Ideally there should be at least one of each of the major instruments.
Each instrument should have its own case, and it is wise to engrave the
hospital name on each instrument to minimize loss. The initials of the
hospital may be cut into an inconspicuous part of the instrument such
as the inside of the brass bell or the under side of the wood body. All
the instruments should be locked in cabinets when not in use.

In addition to regular band instruments, small instruments which can be
played in bed should be acquired. These can be divided into those of
normal construction such as the ukulele, mandolin, and autoharp and the
toneless instruments which can be made by removing the resonating body.
A toneless violin can be constructed from a donated violin in poor
condition by mounting the tailpiece, bridge, and fingering element on a
narrow strip of wood or plastic. A piece of rubber “kneeling” pad makes
a good practice drum head.

For children toy instruments such as the Typatune, the toy-xylophone,
trumpet, maracas, etc. should be available.

_Listening._ A room should be designated as a “Music Listening Room.”
For economy of use this may be a multi-purpose room. It may be a
combination of the music aide’s office and musical library used at
selected hours of the day for both practice and listening. It should
contain an instrument for playing recordings. The choice of record
player should depend upon the sound produced by the instrument rather
than its name. The record player for the listening room should have an
automatic changer and wide tone control if possible. Because of the
excellence of many musical broadcasts a combination radio-record player
is most desirable.

Portable record players are also desirable for the bedside listening
of those who request it. In hospitals not equipped with public address
systems, the portable record player can act as an excellent substitute
for it. If the player is mounted on a cart fitted with shelves for
records and albums, it can be wheeled from one ward to another for
daily musical periods. If the hospital has small-sized lantern slides
with words to songs imprinted (such as those supplied Service groups
during the war by the USO), a small slide projector should be added to
the music cart to be used on the darkened ward for ward songs.


THE MUSIC LIBRARY

The hospital music library may vary from a few recordings to a
composite collection of all forms of musical literature available.
General hospitals which treat all diseases and age groups will
require the most extensive and catholic varieties of all kinds of
music. Specialty hospitals can operate on a library tailored to their
individual needs. A hospital for the aged will not require too much
of contemporary popular music. For purposes of inclusiveness, the
ideal will be discussed in the hope that some hospitals will be able
to afford it and that others will be able to select those items which
become possible for them.

_Recordings._ The choice of recordings will be determined by the usual
hospital population. In building up the record library the music aide
should submit check lists to every patient in the hospital on any
one day. The list should include ten specific titles in each of six
categories: symphony, opera, operetta, folk-songs, old-time favorites,
and the currently popular songs. These should be carefully tabulated
and should be used to form the nucleus of the permanent collection. A
space should be left for patients to write in other pieces than those
named. Records should be purchased in the order of their numerically
recorded popularity. A collection should begin with one record per
hospital bed. This method of starting a library is very tedious but
well worth the effort, because only by determining the musical tastes
of patients can you give the majority the music they want. The musical
tastes of the patients will not vary significantly after a complete
turn-over in patient census, since most hospitals derive their patient
population from the same geographic area, and the tabulation of musical
desires arrived at in this manner will correspond satisfactorily with
the tastes of the same age group in the community. If the budget will
not permit an original collection of this size, it might be reduced to
half of that recommended, but that is a minimum.

The collection should be built up at a rate of approximately one record
for every ten new patient admissions. The choice of additional records
should be on a request basis, but the proportion of the six categories
as originally determined should remain relatively constant to keep the
collection balanced.

Whenever there is a choice of two or more recordings of the same piece,
the discs to choose are those which are played softly or sweetly so
that they are adaptable for the additional purpose of mealtime or
restful music.

In the library of recordings there should be included albums of
records for special occasions and holidays. Patients look forward to
hearing Irish songs on St. Patrick’s Day and appropriate songs on
other holidays. To accompany religious services the albums prepared by
Bibletone are valuable. A glance through any standard record catalogue
will readily permit the music aide to assemble a suitable collection.

The following is a list of records suggested for Easter Sunday and St.
Patrick’s Day.

 Easter Recordings:

  I Want a Bunny for Easter                  Decca 18654 A
  Easter Sunday With You                     Decca 18591 B
  Easter Parade                              Decca 18425 B
  Easter Sunday on the Prairie               Decca 18654 B
  Chorale for Easter Cantata                Victor 15631 B
  Requiem, by Gabriel Faure      Victor 18301, 2, 3, and 4

 St. Patrick’s Day:

  Molly Brannigan                        Columbia 35496
  That’s How I Spell Ireland             Columbia 35496
  Come Back to Erin                      Victor 27770 B
  Mother Machree                         Victor 27772 A
  Eileen                                 Columbia 36585
  A Little Bit of Heaven                  Sonora 1069 B
  You’re Irish and You’re Beautiful       Sonora 1068 A
  Irish Lullaby                           Decca 18621 A
  Same Old Shellalagh                   Columbia 354986
  Macushla                               Victor 27770 A
  I’ll Take You Home Again Kathleen       Sonora 1067 B
  Little Town in Old County Down          Sonora 1070 B

All recordings should be kept in their albums or jackets. Because
jackets have a way of getting lost or torn, there should be a stock of
unused jackets on hand. Each jacket should be labelled according to its
contents. In addition a cross-index catalogue file should be maintained
by the music aide for all records in the hospital collection. Three
cards should be filled out for each face of each record: one card for
composer, one for title, and one for performer. This seems like a lot
of work but is worth the effort because it is only in this manner that
a program can be rapidly assembled from the record library. Any filing
system will suffice, but if the collection is large, an elaborate
system will be found worth the effort. Cards of three different colors
may be used to separate classical, popular and miscellaneous. Tabs may
be placed on those cards which list music for occasions. Tabs in one
corner may refer to meal-time music and tabs in another holiday music,
etc.

It is well to have the entire record collection in one room, and
shelves for holding records should be built of very heavy lumber
because recordings when closely packed are very heavy. It is best
to add records to shelves with continuous accession numbers in each
category and to rely on the file for alphabetic listing. If there
are duplicates, they can form the nucleus for a second or lending
library. Broken, cracked, or defective discs should be placed in a
separate section of the shelves for replacement when budget permits and
popularity demands.

_Instantaneous Recordings._ A few hospitals will have the good fortune
to acquire a record-cutter for hospital recording of radio music.
When this is possible, the record collection can be augmented most
satisfactorily. The music aide should study all radio programs to
determine the hours during which the best performances of desired
music are played. By listening to several carefully selected programs
each week he will soon discover which programs use music employed in a
manner most desirable for hospital reproduction. The orchestrations of
Kostelanetz and Lombardo are especially suitable for easy listening in
the field of popular music. The broadcasts of the Metropolitan Opera
Association include passages not commercially recorded or at least not
recorded with the most popular singers. There are many other radio
features which are worth recording for the hospital record library.

It is relatively easy to operate a record-cutter, but there are many
minor details which must be known for maximum efficiency. An excellent
book for beginners is that published by the Audak Company of New York,
_How to Make Good Recordings_.

_Sheet Music._ A library of sheet music will once more depend upon
the local needs. It may include orchestral, instrumental, vocal, and
band music. In the hospital for the chronically ill, a large number of
varieties will be needed. Inasmuch as the simplest group performance
will be vocal, music for group singing should head the list. The music
should include old-time favorites, hymns, spirituals and any other
items which the aide can determine from the intellectual and musical
qualifications and desires of the patients. This type of music can be
purchased individually and increased according to the interest shown.

If there is a patient band, the musical scores should include a few
marches which may be used at the beginning and end of its concerts.
The perennial favorites most desirable for community singing should
constitute a major portion of the orchestral literature. The readily
available medleys of Victor Herbert melodies and similar stand-bys can
complete the initial group.

Sheet music should be catalogued and filed in cabinets. A simple system
of shelving consists of grouping music according to use: one shelf
for group playing, one for solo and beginners instrumental books, and
another for vocal selections. The numbers most commonly and currently
used by the band can be placed in folders according to the accepted
usage among bands, and if there are daily rehearsals they can remain on
the band stands at all times.

The library should also contain books, printed forms, or mimeographed
collections of songs for distribution to patients during community
singing.

_Books About Music._ The average hospital library will have relatively
few books about musical appreciation or history. This will depend
first on the budget and second on the demand. The addition of a music
aide to a hospital staff will usually increase the demand. The music
aide should be consulted concerning the books he thinks will appeal to
patients. Books on music should also be available to help the music
aide in preparing commentaries on the music he plays for the patients.

The following are some books suggested for inclusion in the hospital
patient library:

  Copland, Aaron--_What to Listen for in Music_, 1939.
  Goss, Madeline--_Unfinished Symphony_, 1941.
  Elson, Arthur--_Music Club Programs From All Nations_.
  Erskine, John--_What Is Music_, 1944.
  Ewen, David--_Tales From The Vienna Woods_, 1944.
  Ewen, David--_Gershwin’s Life_, 1944.
  Ewen, David--_Men of Popular Music_, 1944.
  Gronowicz, Antoni--_Chopin_, 1943.
  O’Connell, Charles--_Victor Book of Opera_, 1936.
  Taylor, Deems--_Of Men and Music_, 1945.
  Taylor, Deems--_The Well Tempered Listener_, 1944.
  Siegmeister, Elie--_Music Lover’s Handbook_, 1943.
  Spaeth, Sigmund--_At Home With Music_, 1945.

For young patients there are the new series of colorfully illustrated
lives of composers from Bach to Gershwin by Waldo Mayo, as well as a
great number of old and good titles.




_CHAPTER ELEVEN_

DIRECTION


The introduction of music into the hospital will depend not so much
upon its proven value as an aid to medical practice as upon the
interest of someone on the staff who loves music or recognizes its
importance in the mental hygiene of the patients. There are many
reasons for the absence of music in some hospitals which may seem
difficult for the musician to comprehend. The acceptance of a music
program in a hospital calls for increased budget and space. These are
two items which constantly beset the hospital director and they are
sometimes matters of improbable solution. For the chronic type of
hospital the problem must be solved. Other drawbacks are found in the
contemplated interference of medical and nursing procedures. Hospitals
are traditionally havens of quiet and the uninformed hospital director
or his staff may envisage a conversion to a three-ringed circus of
sound. The progress of music in hospitals will depend largely upon the
ingenuity and intelligence of existing organizations and the examples
they can set for prospective hospitals.

The musical program of a hospital need not necessarily be conducted
by a musician, but a trained person is most desirable. There are
people with an intense love for music and so comprehensive a grasp of
its many fields that they might be capable of conducting a hospital
program although unable to play an instrument. At some institutions
music has been guided by volunteers with great satisfaction to staff
and patients, but this is an age of specialization and a paid, trained
musician will usually be worth the salary in efficiency, dependability,
and control.


DIRECTOR

Music for patients differs from music for the well. The average
musician is not qualified to decide which patients should or should not
have music. There are too many well meaning musicians who have had one
or two personal experiences or heard of others in which the efforts of
the musician were rewarded by apparent miracles of mental reaction.
Musicians are not capable of evaluating such changes nor do they bother
to recount what the condition of the patient was an hour or a day after
this personal exposure. Musicians must have medical direction. The
medical director of music does not have to be a trained musician but
he should be acquainted in a general way with most musical forms which
appeal to a majority of patients. His most important qualification will
be the ability to rise above personal prejudices of musical taste. He
must recognize that musical tastes can be as diverse as individual
appetites for different foods, and feel free to order music as he
would food for patients. It will be his duty to prescribe quantity,
quality, duration, and intervals of music; to contraindicate music for
the irritable, certain post-operative patients, the acutely ill, and
any others for whom he thinks music is wrong. It will be necessary for
him to protect the patients from the possible musical whims, hobbies,
convictions or over-enthusiasm of the musical aide.

The director should be selected from volunteers on the staff. For the
physician director of music to be chosen in any other way is to hamper
the musical program. He must be a physician who has the time or can
make the time to carry out his part adequately. At the outset the
director should have daily conferences with the senior musical aide in
which he should not only outline the procedures desired but should
observe the musician at work with patients.


MUSIC AIDE

There is considerable disagreement concerning the title most desirable
for the person conducting music in the hospital. The term “musical
therapist” implies a training not only in music but in treatment. The
occupational therapist has had a training not only in crafts, but
in basic medical subjects, psychology, and some clinical subjects.
Until musicians can take similar courses at accredited schools a
different title seems wiser. At some hospitals the workers are called
recreational aides, but such people also conduct other recreational
activities. It seems picayune to argue over terminology, but the
hospital music worker must be called something and it is hard to
conceive that anyone would find fault with the appellation “music aide”
for those people who bring music to the patient.

A music aide may be of either sex and of any age. The choice
will depend not only upon what is available locally but on
such considerations as the personalities involved and personal
recommendations. If intelligence is not exercised, the program will
fail because the senior music aide is the keystone of the entire
structure. For a children’s hospital, a woman who has raised children
would seem most suitable. The aide for children should be able to sing
and play the piano. She should also be able to play musical games with
children.

For a hospital of young adults, such as the average hospital for the
tuberculous, a young woman between thirty and forty will have the
energy, drive and spirit to match the requirements and contemporary
tastes of the patients under her care. The aide for this type of work
should also be able to lead group and mass singing and be able to play
an instrument. Ability to play a second instrument, or to teach it is a
valuable asset.

For the mental hospital an aide should be mature, patient, well
informed and have the urge, but not the preformed opinions, for
handling the mental patient. For the hospital treating the aged or
other chronic patients, an older man or woman is desirable.

It is preferable for any aide to have had some formal musical
instruction. Most desirable is a graduate of a musical conservatory
or of a college which offers a major in music. The music aide should
play at least one instrument, and preferably the piano. If the hospital
budget permits additional music aides each successive one should know
another instrument. The aide should be able to play music at sight and
sing with an acceptable voice. The chief qualification should be the
absence of “artistic temperament.” Patients are admitted to a hospital
for medical care, not musical knowledge. The aide should not consider
them as music students. Music should be given to them with patience and
without undue emotion. If music evokes a marked mental response it may
be beneficial, but it should be the music and not the musician which
elicits such reactions. Previous experience in teaching music is a
valuable asset to the music aide.

The duties of the music aide will vary with the number and type of
patients. In hospitals with a large number of ambulatory patients
emphasis will be placed on group activities; in hospitals where
children predominate music will be used largely as diversion, in
games, dancing and other bodily activities called “rhythms” which is a
development of Eurhythmics.

Under the supervision of the medical director, the music aide should
outline a definite schedule of musical activities and adhere to it.
This will require much preparation and the best hours for preparatory
work will be those during which patients are resting, sleeping, or
receiving active medical and nursing care. The preparation will include
maintenance and cataloguing of instruments and the medical library;
tabulation of patient requests for instruction, books and recordings;
programming for concerts, ward songs and the public address system;
correspondence with musicians and musical groups in the community;
ordering of equipment and music; and scheduling.

The schedule should be patterned to fit into the hospital routine. The
first hour of the day should be reserved for preparatory activities.
Individual instruction in music may be given from nine until ten. At
ten the music cart may be taken to the wards until mealtime. Following
the meal hour, the aide can prepare for the afternoon ward visits.
Recreation Hall activities or the listening room may be scheduled for
the period of two to three. Three to four-thirty may be used for ward
entertainment, either with the music cart or with portable instruments.
On one or two nights a weeks, an hour or more may be set aside for the
hospital concert or a music appreciation hour.


TRAINING

At present, no accredited school of music or medicine offers a compete
course of instruction leading to a degree in music in medical practice,
or a major in that subject. It is believed that eventually the demand
may bring about the establishment of such a course in a musical
college, where it belongs. It will be necessary for the school of music
to secure liaison with a medical college or school of occupational
therapy and this will limit instruction to those cities where grade
A institutions of both kinds are to be found. There are at least ten
cities scattered throughout the United States in which this happy
combination may be found, but there is hardly need for more than six.

Applicants should be interviewed by a representative of both the
medical and music schools. A projected curriculum is suggested as
follows:

 _First Year_

  Piano                   8 Credits
  Solfège                 5 Credits
  Counterpoint            2 Credits
  Harmony                 2 Credits
  English                 6 Credits
  History of Medicine     1 Credit

 _Second Year_

  Piano                   4 Credits
  Solfège                 2 Credits
  Harmony                 2 Credits
  Counterpoint            2 Credits
  History of Music        4 Credits
  Nursing anatomy         6 Credits

 _Third Year_

  Violin                  4 Credits
  Harmony                 4 Credits
  Musical Form            4 Credits
  Physics                 6 Credits
  Physiology              2 Credits
  Kinesiology             2 Credits
  Psychology              4 Credits
  Conducting              2 Credits
  Piano Sight Playing     4 Credits
  Ensemble                2 Credits

 _Fourth Year_

  Violin                  4 Credits
  Choral Class            0 Credits
  Conducting              2 Credits
  Contemporary Music      4 Credits
  Occupational Therapy    4 Credits
  Music in Medicine       6 Credits
  Abnormal Psychology     6 Credits
  Orchestra Reading       2 Credits

A brief explanation of courses not normally found at music schools and
which should be given at medical or professional schools follows.

_Anatomy for Nurses._ This should consist of a brief survey of the
anatomy of the human body with especial reference to the muscles,
nerves, brain, and a casual introduction to the internal organs.

_History of Medicine._ This would be an orientation course on the
development of medicine and hospitals.

_Physiology._ Especial attention should be drawn to the physiology of
the nervous system and the muscles.

_Psychology._ Normal psychology, including laboratory experimentation
in the psychology of music, would be the basis of this course.

_Kinesiology._ The standard course as taught in schools of physical and
occupational therapy, and physical education, would be sufficient.

_Occupational Therapy._ An introduction into craft analysis and
psychiatric occupational therapy is necessary.

_Abnormal Psychology._ An introduction to psychiatry is sufficient.

_Music in Medicine._ A course of lectures, including the subjects
discussed in this volume, should be offered.

In the summer between the third and fourth years, the student should
be affiliated with a hospital with a music program to work under the
hospital staff.

These are suggestions only, and each school in consultation with an
approved medical college will want to work out its own schedule. It is
hoped that the above outline will be of definite assistance.




BIBLIOGRAPHY

[1] Albrecht, W., De effect. mus., Sect. 314, _in Roger, J. L._

[2] Altschuler, I., _Occ. Ther. Rehab._, 1941, 20:75.

[3] Altschuler, I., _Proc. Mus. Teach. Nat. Assoc._, 1944, p. 154.

[4] Altschuler, I., and Shebesta, B., _Journ. Nerv. Ment. Dis._ 1941,
94:179.

[5] Ayers, I., _Am. Phys. Ed Rev._, 1912, 16:321.

[6] Barker, L., _Psychotherapy_, New York, 1940.

[7] Bauer, M., and Peyser, E., _Music Through the Ages_, New York, 1932.

[8] Beaunis, B., “L’Emotion Musicale”, _Rev. Phil._, 1918, 86:353.

[9] Beckett, W., _Music in War Plants_, Washington, 1943.

[10] Bissell, A. D., The Role of Expectation in Music, New Haven, 1921.

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INDEX


  Aesclepiades, 6

  Aide, duties of, xvii, 121

  Aide, qualifications of, xvi, 120

  Albrecht, Wilhelm, 11

  Alcoholic psychosis, 63

  Altschuler, I., 60, 66, 68, 69

  Amateur shows, 101

  Amphion, 2

  Analysis, instrumental, 57

  Anesthesia, use with, 75

  Ankle exercise, 54

  Appetite, musical, 42

  Apollo, xi

  Aquinas, St. Thomas, 42

  Areteus, 8

  Aristotle, xi

  Armstrong, John, 1

  Arteriosclerotic psychosis, 64

  Atheneus, 6

  Aurelianus, 6

  Avicenna, 74


  Background music, 73

  Bacon, 8

  Band, patient, 70

  Beacham, H., 9

  Beaunis, B., 17

  Beckett, W., 79

  Bedside instruction, 95

  Beethoven, L., 29

  Bites, treatment of animal, 7

  Boerhaave, H., 8

  Books about music, 117

  Brocklesby, R., 12

  Bücher, K., 19

  Butler, Nicholas M., xii


  Calisthenics, music for, 76

  Capella, M., 6

  Carle, F., 86

  Cart, music, 94, 112

  Catatonic schizophrenia, 66

  Cato, 5

  Cavallero, C., 86

  Celsus, A. C., xii, 8

  Champlain, S., 11

  Chateaubriand, 2

  Children, music for, 90

  Chiron, 5

  Chomet, Hector, xix, 12

  Chopin, F. F., 30

  Chronically ill, music for, 98

  Color in sound, 28

  Community sing, 69, 101

  Confucius, 5

  Counter-irritation, 74

  Criteria of therapy, xiii, 61

  Crosby, Bing, 18, 91

  Curriculum for aides, 123


  Dalcroze, J., 76

  Damon, K. F., 28

  Dancing as exercise, 78

  David’s Harp, xi, 5

  De Marian, 28

  Democritus, 11

  Densmore, F., 3

  Dentistry, music in, 75

  Desault, P., 7

  Direction of hospital music, 118

  Diserens, C. M., 42

  Dorian mode, xi

  Duchin, E., 84, 86

  Duration, effect of, 18

  Dunlap, K., 19


  Easter music recordings, 114

  Eby, Julia, 67

  Egyptian use of music, 4

  Emotional response to music, 32

  Enjoyment of music, 32, 39

  Epilepsy, music in, 8, 11

  Eurhythmics, 77

  Exercise, effect of music on, 75

  Exercise through music, 50

  Expectation, role of, 27


  Factory, use of music in, 79

  Faith, Percy, 86

  Farinelli and Philip V, 10

  Fatigue, effect on, 76

  Flute, the magic, 11

  Functional Occupational Therapy, 45


  Galen, 7

  Gaston, E., 59

  Gatewood, E., 79

  Gehring, A., 28

  Gellius, A., 6

  General paresis, 63

  Gilman, B., 30

  Goldman, Edwin Franko, 31

  Good music, 38

  Grosseteste, R., 8

  Group singing, 69, 101

  Gundlach, R., 18, 26, 34

  Gurney, E., 21, 25, 31


  Hanson, Howard, 26, 27

  Harrington, A., 69

  Hauptmann, M., 20

  Head-phones vs. loud-speakers, 93

  Hebrew use of music, xi, 5

  Heinlein, C. P., 17, 22

  Helmholtz, H. L. F., 20

  Hevner, K., 22

  Homer, 5

  Hulbert, H., 77

  Hydrotherapy, music and, 66

  Hysteria, 68


  Imaginal response to music, 37

  Indian, American, 2, 34

  Industrial music, 79

  Instantaneous recordings, 106

  Instrumental analysis, 57

  Instrumental instruction, 103

  Iriquois practice, 3

  Intensity, effect of, 17, 22


  Jacobson, E., 19

  Jaw fracture, music in, 58

  Jerrold, D., 86

  Johnson, M., 77


  Karwarski, T., 28

  Key, effect of, 23

  Kostelanetz, A., 86

  Kraines, S., 69


  Lacedemonian music, 5

  Lantern slide preparation, 102

  Levine, M., 69

  Library of music, 116

  Listening to music, 36

  Live music, 34, 96, 99

  _Loca dolentia decantare_, 6

  Lombardo, Guy, 86

  Lower extremity exercises, 53

  Luther, Martin, 3

  Lydian mode, xi


  Manic-depressive psychosis, 64

  Mealtime music, 82

  Medical direction, 119

  Medicine man, 3, 4

  Melancholy, involutional, 64

  Melody, effect of, 19

  Mendelssohn, F., 30

  Mental deficiency, 71

  Mental disease, 9

  Mental disease classification, 62

  Mode, effect of, 20

  Mood effects, 17, 22, 32, 40

  Morale, effect on, 7

  Mozart, W., 11

  Mursell, James, 18

  Music aide, training for, 123

  Musical therapy, ix, xviii, 57, 61


  National Music Council, xiv

  Nearchus, 6

  Newton, Isaac, 28

  Noyes, A. P., 61


  Occupational Therapy, 44

  _Orenda_, 3

  Orpheus, 2

  Ortmann, Otto, 17

  Operating room, music in, 75

  Opponens action, 52


  Paget, V., 36

  Painful level of sound, 41

  Palmer House Ensemble, 86

  Paresis, general, 63

  Parlor organ as foot exercise, 54

  Patient band, 70

  Pediatric ward, music in, 90

  Percussion instruments, 55

  Persian use of music, 5

  Philip V of Spain, 10

  Photoism in music, 28

  Phrygian mode, xi, 6

  Physical therapy, 45

  Physiologic effects of music, 34

  Piano; analysis of motions, 52

  Piano playing for exercise, 50

  Pianola, value of, 52

  Pierce, A., 70

  Pinel, P., 11, 44

  Pitch, effect of, 17

  Plato, 5, 76

  Plectrum instruments, 53

  Plutarch, 6

  Pocket instruments, 54

  Porta, J. B., 11

  Primitive people, music among, xi, 2

  Production, effects of music on, 80

  Program distribution system, 93

  Program notes, effect of, 33

  Psychiatry, value in, 72

  Psychologic effects of music, 36

  Psychosis, alcoholic, 63

  Psychosis, arteriosclerotic, 64

  Psychosis, manic-depressive, 64

  Public address system, 93

  Pythagoras, xi


  Quarin, 8

  Quintillian, 76


  Radio, bedside, 91

  Rameau, J. P., 18, 20

  Reade, W., 19

  Record library, 115

  Remedial exercise, 78

  Renaissance of art forms, xii

  Response to music, 36

  Rhythm, effect of, 18

  Room, listening, 111

  Rose, D., 86

  Rubinstein, A., 30


  Sauvages, G., 12

  St. Chrysostome, 9

  St. Patrick’s Day music, 114

  St. Thomas Aquinas, 42

  Schizophrenia, 65

  Schoen, M., 32, 37

  Schönberg, A., 41

  Schumann, R., 30

  Scorpion bites, music for, 7

  Seashore, C., 107

  Secret remedies, xiii

  Selinsky String Ensemble, 86

  Shakespeare, W., 9, 13, 59

  Shaw, G. B., 84

  Shopwork, music in, 79

  Sickert, W., 42

  Sioux Indian practice, 3

  Slumber music, 90

  Sonorous fluid, 12

  Stravinsky, Igor, 42

  Surgery, music in, 75


  Tarantula bites, music in, 7

  Tarchanoff, I., 76

  Taste, musical, 38

  Templeton, Alec, 91

  Tempo, effect of, 25

  Thalamus, role of, 68

  Thaletas, 6

  Timbre, effect of, 18

  Toneless instruments, 95

  Tuberculosis ward, music in, 92


  Ulysses’ wound, 5

  Upper extremity exercise, 51


  Valentine, C., 21

  Vernon, P. E., 36

  Vescelius, Eva, xix, 12

  Vibration, effect of, 7

  Victor Salon Orchestra, 86

  Violin as exercise, 52

  Viper bite, music in, 7

  Vocal music, 32, 35

  Voice, human, 35

  Voltaire, 82

  Volume, effect of, 80

  Volunteers, hospital, 97, 99


  Wallaschek, R., 4

  Wallawalla practice, 4

  Waltzes, effects of, 81

  War, music in, 7

  War songs, 7

  Ward sings, 96

  Wasambara practice, 4

  Weber, Marek, 86

  Willis, T., 10

  Words, effect of, 35

  Working songs, 79




Transcriber’s Notes

In a few cases, obvious errors or omissions in punctuation have been
fixed.

Page ii: “nervous insistance,” changed to “nervous insistence,”

Table of Contents and Index: “Eurthymics” changed to “Eurhythmics”

Page xvi: “of human ature” changed to “of human nature”

Page xix: “forget his preconcieved” changed to “forget his preconceived”

Page 8: “delerium, melancholy and mania” changed to “delirium,
melancholy and mania”

Page 12: “she admitted after after having” changed to “she admitted
after having”

Page 25: “in every singly key” changed to “in every single key”

Page 31: “Largo al Factotem” changed to “Largo al Factotum”

Page 41: “Most people have been conditioned” changed to “Most people
who have been conditioned”

Page 44: “sooner those who remained” changed to “sooner than those who
remained”

Page 53: “are readily adpatable” changed to “are readily adaptable”

Page 60: “which has lead some musicians” changed to “which has led some
musicians”

Page 65: “may appear quiet normal” changed to “may appear quite normal”

Page 68: “more powerful subconcious” changed to “more powerful
subconscious”

Page 69: “for heterogenious groups” changed to “for heterogeneous
groups”

Page 77: “preferable the piano” changed to “preferably the piano”

Page 78: “places of assemble” changed to “places of assembly”

Page 84: “barbershop and other public” changed to “barbershops and
other public”

Page 92: “alloting certain periods” changed to “allotting certain
periods”

Page 94: “musical programs and hospital announcement,” changed to
“musical programs and hospital announcements,”

Page 110: “age range of the patient” changed to “age range of the
patients”

Page 115: “with continuous acession” changed to “with continuous
accession”

Page 120: “the appelation “music aide”” changed to “the appellation
“music aide””

Page 122: “programing for concerts” changed to “programming for
concerts”

In the bibliography, “Electrophsiology of Mental Activities” was
changed to “Electrophysiology of Mental Activities”; there is no
anchor for reference [6] Barker. L., in the text.

In the index, “Mental disease classication” changed to “Mental disease
classification” and “Cavotte from Mignon” changed to “Gavotte from
Mignon”

The original index had T located after W. This has been fixed.

There are numerous probable mistakes in the French and German
references in the footnotes; these have been intentionally left as per
the original.

The spellings of “Philippe Pinel” and “Richard Wallaschek” have been
corrected.