Chapter III: Introduction (2)

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

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

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

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

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

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

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

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

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

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

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

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

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

In an unnamed manual the following statements occur:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

* * * * *

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

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

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

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

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

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

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

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

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

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

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

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

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

III

OTHER CONDITIONING FACTORS

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

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

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

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

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

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

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

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

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

LISTENING

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

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

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

a. Reflex or physiological; soothing or stimulating.

b. General euphoria.

c. Stimulation of thought and wandering of attention.

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

e. Dramatic visual images of day-dreams.

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

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

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

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

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

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

IV

MUSICAL TASTE

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

V

SUMMARY

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

_CHAPTER THREE_

MUSIC AS OCCUPATIONAL THERAPY

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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