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.