Chapter IV: Introduction (3)

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.