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Interactions between Medicine and the Arts

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Wiener klinische Wochenschrift 132(Suppl 1):1-65

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wiener

klinische

wochenschrift

The Central European Journal of Medicine

132. Jahrgang 2020, Supplement 1

Interactions between Medicine and the Arts

International Conference of the Medical University and Vienna and the

Austrian Academy of Sciences (Commission for History and Philosophy of

Sciences), held in Vienna on 11th and 12th October 2019.

Journal Editors: Wolfgang Schütz, Katrin Pilz

With contributions from: Wolfgang Schütz, Dietrich von Engelhardt, Jane Macnaughton,

Barbara Putz-Plecko, Barbara Graf, Georg Vasold, Stella Bolaki, Leslie Schrage-Leitner,

Thomas Stegemann, Klaus-Felix Laczika, Jacomien

Prins, James Kennaway, Christiane Vogel, Anna

Magdalena Elsner, Patrizia Giampieri-Deutsch,

Tomoyo Kaba, Irmela Marei Krüger-Fürhoff, Eva

Katharina Masel, Andrea Praschinger, Tomoyo Kaba,

Katrin Pilz, Florian Steger.

Correspondence: Wolfgang Schütz

Cover Picture: Gustav Klimt—“Medicine” Faculty

Painting. Section showing “Hygieia”, goddess of

health, ceiling panel for the Grand Festival Hall of the

University of Vienna, 4.3 × 3 m, oil on canvas, around

1907; 1945 destroyed by ﬁre in Immendorf Castle.

Public domain, source: https://de.wikipedia.org/wiki/

Datei:Klimt_hygeia.jpg (30 March 2020)

Wien Klin Wochenschr (2020) 132:S1–S65

https:// doi.org/ 10.1007/ s00508- 020- 01706-w

medicine and arts

medicine and arts 1 3

Table of Contents

Editorial

S3 Wolfgang Schütz: Arts as a power in “humanizing” doctors

Keynote I

S4 Dietrich von Engelhardt: Medical humanities or therapy as art—art as therapy

Keynote II

S8 Jane Macnaughton: Symptoms and sensations in breathlessness: medical humanities meets clinical neuroscience

Medicine and Visual/Applied Arts

S11 Barbara Putz-Plecko, Barbara Graf: Arts and medicine: on the potentials of transdisciplinary encounters

S16 Georg Vasold: Vienna as the cradle of art therapy: a look back at the 1920s

S19 Stella Bolaki: A multi-sensory medical humanities: artists’ books and illness experience

Medicine and Music

S22 Leslie Schrage-Leitner, Thomas Stegemann: Music therapy in neonatology—an introduction to clinical practice and

research

S25

Klaus-Felix Laczika, Gerhard Tucek, Walter Thomas Werzowa: “Every illness is a musical problem, healing a musical

resolution” (Novalis)

S29

Jacomien Prins: Tempering the mind—humanist conceptions of music and mental health

S32

James Kennaway: The value of a critical humanities perspective on music and medicine

Medicine and Literature/Media

S34 Christiane Vogel: Literature’s view on humans’ dissolution of boundary

S37 Anna Magdalena Elsner: Unsettling care in Michel Malherbe and Tahar Ben Jelloun

S40 Patrizia Giampieri-Deutsch: Dr. Dick Diver—Portrait of a psychiatrist in F. Scott Fitzgerald’s novel “Tender is the

Night”

S44

Irmela Marei Krüger-Fürhoff: Illness narratives in comics: using graphic medicine in the medical humanities

S47 Eva Katharina Masel, Andrea Praschinger: Using comics to teach medical humanities

S50 Tomoyo Kaba: Arthur Schnitzler: Spa Doctor Gräsler—the doctor-patient relationship and understanding of disease at

the beginning of the 20th century

S52

Katrin Pilz: Hearts and brains in motion: medical animated ﬁlm as a popular and controversial medium for education

and research

S56 Florian Steger: Why literature in medicine?

medicine and arts

1 3 S3

Conict of Interest: All authors declare that they have no con-

ict of interest.

Key Words: Animated Science—Breathlessness—Doctor-Pa-

tient-Relationship—Graphic Medicine—Literary Medicine—

Medical Humanities—Medicine and Arts—Medicine and Mu-

sic—Medical Comics—Music erapy—Medicine and Film.

Summary: Since ancient times, medicine has been under-

stood not only as a science but also as an art—being regard-

ed as a combination of the natural sciences and the humani-

ties in contexts that range from the understanding of illness, to

opening therapy goals, to the doctor-patient relationship. er-

apeutic power was seen as an attribute of the arts and a way of

dealing with disease. In the modern era, emphasis increasing-

ly shifted to the natural sciences and technology—with impres-

sive successes in diagnostics and therapy, in extending life, and

in improving the quality of life. However, during the modern pe-

riod, many of the anthropological and biological associations of

medicine were diminished or lost. Today’s scientic medicine

faces the challenge of connecting man’s psycho-physical and

social-cultural natures with the natural sciences and technol-

ogy. Medical humanities, the umbrella term for a eld that en-

compasses interactions of medicine and the arts, has already

undergone a steep transition from being considered an educa-

tional exercise in “humanizing” clinical practitioners. No long-

er content to serve as a “feeder service” for clinical practice,

medical humanities allow practitioners becoming increasingly

engaged in the complexities of clinical science, aiming to work

alongside medical colleagues—especially those who seek to

answer dicult questions in clinical practice. Hence, “therapy

as art” or “art as therapy” is not an issue of alternative or fringe

medicine, but a question of providing complements to science-

based medicine to benet the sick and the dying. Rather than

being contradictory, the paired terms go hand in hand.

Acknowledgements: e 2019 Conference and publication

of this issue were nanced by the Medical University of Vien-

na and the Austrian Academy of Sciences (Commission for the

History and Philosophy of Sciences). Jacqueline Beals proof-

read parts of the manuscript.

Editorial

Arts as a power in “humanizing” doctors

Wolfgang Schütz, Medical University of Vienna,

wolfgang.schuetz@meduniwien.ac.at

It is the rst time that this journal has dedicated a special

issue to the medical humanities, a eld that has devel-

oped at the interface between medicine and disciplines

categorized as the humanities, the social sciences, and—

the topic of this issue—the arts. Interactions between

medicine and the arts are understood as medicine in the

arts and the arts in medicine. How medicine is reect-

ed in visual/applied arts, music, literature, and vice ver-

sa has the potential to launch an essential movement in

treating illnesses. One should also consider, in this con-

text, that hospitals and medical consulting rooms are be-

coming increasingly global spaces in which cross-cul-

tural patients have dierent religious inuences, ways of

dealing with death, and attitudes toward the separation

of body and soul. us, subjective disease concepts need

to be kept in mind, and the inclusion of medical humani-

ties in medical study and practice merits serious consid-

eration.

e rationale for using arts and medicine in medical

education and practice is three-fold [1]: (i) reading the

stories or viewing pictures or comics of patients and—

vice versa—writing (or even drawing or painting) of doc-

tors about their experiences gives them in training the

tools they need to better understand their patients; (ii)

discussing and reecting on literature, paintings or mu-

sic brings the doctor’s biases and assumptions into focus,

heightening awareness; (iii) reading literature, viewing

paintings or listening to music requires critical thinking

and empathetic awareness about moral issues in medi-

cine.

At least two main messages can be taken home from

the 17 journal articles contributed on this topic:

e rst concerns the humanist aesthetics of mind-

body dualism. is theory, which stems from the thought

of René Descartes, implies that “mind” and “body” not

only dier in meaning but also refer to dierent kinds of

entities. e arts are able to facilitate the harmonization

of these entities. Arts, if honest and without propagan-

da, can change people and, as a consequence, inuence

their illnesses as well. For that reason, novels and po-

ems can convey insights into the etiology and pathology

of many medical conditions long before they have been

established on a scientic basis. Sigmund Freud also

suggested that psychoanalysis drew attention to phe-

nomena that had long before been “discovered” by po-

ets and writers in their literary works. Examples include

the description of transference love in F. Scott Fitzger-

ald’s novel “Tender is the Night” (Giampieri-Deutsch’s

contribution); Shakespeare’s “King Lear”, the rst literary

character with dementia; and E.

A. Homann’s “e

Nutcracker and the King of Mice”, in which symptoms

Wolfgang Schütz()

Medical University of Vienna

Spitalgasse 23, 1090, Vienna, Austria

wolfgang.schuetz@meduniwien.ac.at

medicine and arts

medicine and arts 1 3

of pedophilia are anticipated. e latter story, famously,

is the literary basis of Tchaikovsky’s musical suite com-

posed for “e Nutcracker” ballet.

e second message is drawn from the use of such

terms as “evidence-based medicine” and “precision

medicine,” neither of which represents a type of medi-

cine that considers the patient as a person, with his/her

own feelings, thoughts, and living conditions. Accord-

ing to Engelhardt’s keynote contribution, medical hu-

manities can ll this gap. According to the views of ev-

idence-based medicine, any treatment of a disease has

to be proven by clinical trials. Only clinical outcomes

data, such as reduction in mortality, modifying the con-

sequences or reducing the recurrence of a disease being

treated, are considered as evidence. Surrogate param-

eters, such as lowering the serum cholesterol or blood

sugar levels, do not apply. Evidence-based medicine is

the periodically updated gold standard for curing an ill-

ness, but not for curing the sick person, the patient, as

an individual. Similarly, following the model of precision

medicine, diagnostic testing is employed in selecting ap-

propriate therapies based on a patient’s genetic make-

up. e tools used include molecular diagnostics, im-

aging, and analytics. However, for truly comprehensive

treatment, a doctor not only needs to consider the sci-

entic point of view (i.

e., evidence-based and/or preci-

sion medicine), but also the patient’s perception that his

or her experienced symptoms may not always correlate

well with measured organ function (see Macnaughton’s

keynote contribution on the symptom of breathless-

ness). A doctor ideally needs to break down this appar-

ent conict, and medical humanities in particular—un-

derstanding the interaction between medicine and the

arts—certainly could help: stimulating empathic behav-

ior in physicians and medical students as well as sharp-

ening their clinical observation skills.

A quotation from Goethe’s “Faust” (Verse 4917,

Faust II) might be representative of this dilemma by

which a physician is often confronted:

Mephistopheles.

“Daran erkenn ich den gelehrten Herrn!

Was ihr nicht tastet, liegt euch meilenfern,

Was ihr nicht faßt, das fehlt euch ganz und gar,

Was ihr nicht rechnet, glaubt ihr, sei nicht wahr,

Was ihr nicht wägt, hat für euch kein Gewicht,

Was ihr nicht münzt, das, meint ihr, gelte nicht.”1

1 English poetry translation by Anthony S. Kline (https://www.

poetryintranslation.com/klineasfaust.php): “By this I recognize a

most learned lord!—What you can’t feel lies miles abroad.—What

you can’t grasp, you think, is done with too.—What you don’t count

on can’t be true.—What you can’t weigh won’t weigh, of old.—

What you don’t coin: that can’t be gold.” (30 March 2020).

Keynote I

Medical humanities or therapy as art—art as

therapy

Dietrich v. Engelhardt, Fichtestraße 7,

76133 Karlsruhe, v.e@imgwf.uni-luebeck.de

I. Context

From ancient times until today, there has been great di-

versity—both mutual and fundamental—in the relation-

ships between medicine and literature. Whether in di-

agnostics, therapy, or the doctor-patient relationship,

medicine connects science (scientia) and art (ars). A Hip-

pocratic aphorism from the 5th century BC is of timeless

relevance: “ars longa” (art is long), “vita brevis” (life is

short), “occasio fugax” (opportunity is fugitive), “experi-

mentum fallax” (experience is fallacious), “iudicium dif-

cile” (decision is dicult). [1].

Since ancient times, healing powers have been at-

tributed to all the arts, especially literature. Reading and

writing should provide valuable contributions to med-

icine and to the way doctors and patients deal with ill-

ness and death. Art and medicine are interrelated and

inuence each other while, at the same time, represent-

ing independent elds that dier in their language, de-

scriptions, terms and theories, and their dependence on

space and time [2–7].

e connection between medicine and the arts has

dierent dimensions, raising questions about the na-

ture of medicine and the arts. In spite of undoubted suc-

cesses, today’s scientic medicine faces an anthropolog-

ical and socio-cultural challenge: the task of integrating

the psycho-physical and social-cultural nature of human

beings with the natural sciences and technology. is is

not about alternative medicine, but about alternatives

or supplements to medicine. By combining natural sci-

ences, humanities, arts, and life—in other words, subjec-

tivity and objectivity—Medical Humanities extends, in a

double way, the Cartesian dualism of body (res extensa)

and soul (res cogitans) to individual subjectivity (= soul)

and general subjectivity (=

culture), and individual ob-

jectivity (= body) and general objectivity (= biology).

Against this background, the connection between the

concept of health and that of illness, the goal of therapy,

and the doctor-patient relationship deserves particular

attention. If illness is understood as a defective machine,

then therapy means repair, and the doctor-patient rela-

tionship is the relationship between an engineer and his

machine. However, if illness is understood as the suer-

ing of a person with consciousness, language, and social

contacts, the aim and mode of medical treatment must

be personalized and communicative.

e World Health Organization (WHO)’s 1946 def-

inition of health has attained representative validity:

“Health is a state of total physical, social, and mental

wellbeing and not merely the absence of disease and in-

medicine and arts

1 3 S5

rmity” [8]. e fact that health and illness are extend-

ed to social and mental domains supports this denition.

Its anthropological deciency lies, however, in the strict

opposition between health and illness as well as its ex-

aggerated appreciation of health. Better or in addition—

not alternatively—it should say: Human health is also the

ability to live with illness, disability, and death. Medicine

then becomes the seemingly paradoxical attempt to heal

what, ultimately, cannot be healed, and to do it again and

again with delight and only partial success.

e normative equation of “healthy

positive” and

“sick = negative” is one-sided, not convincing, and has

never been advocated consistently. In medieval times

there was the phrase: “pernicious health” (“sanitas

perniciosa”)—“salubrious disease” (“inrmitas salu-

bris”) [9]. In the Renaissance, philosopher and politician

Michel de Montaigne (1533–1592) also spoke of “salubri-

ous disease” (“maladies salutaires”) [10]. In the Roman-

tic period, the poet and naturalist Novalis (1772–1801)

was convinced that “illnesses, particularly long-lasting

ones, are years of apprenticeship in the art of life and the

shaping of the mind” [11].

e social-cultural context is fundamental to the rela-

tionship between arts and medicine. Medicine is an in-

dependent reality; but medicine, like all the arts, mirrors

society and culture. If the arts and literature were to lose

their inuence on medicine, their illustrations and imag-

es, their values and symbols could no longer play a role in

stimulation, consolation, or as healing powers.

II. Therapy as art

According to ancient Greek beliefs, Apollo was the god of

the arts as well as the art of healing. Apollo caused dis-

eases that he could heal again. Apollo also supported

artists in a non-material way by infusing them with rest-

lessness, which is expressed in their lives and creativity.

Medicine, being both science and art, is dened as doing

guided by experience and knowledge. Despite the promi-

nence of science and technology in modern medicine, the

development of medicine from ancient through medieval

to modern times has retained its original phenomenon.

As emphasized by the physician Viktor von Weizsäcker

(1886–1957), medicine unites “objective correspondence”

(= illness and medicine) with “personal correspondence”

(= people in need and people as helpers). Eective med-

ical treatment may entail “transjective understanding,”

which transcends distinctions between subjective and

objective: i. e., understanding how someone understands

himself and not how he is understood by the doctor or

others [12]. In his “General Psychopathology” (1st edition

1913, 9th edition 1973), the psychiatrist and philosopher

Karl Jaspers (1883–1969) conceptualized the methodolog-

ical dualism of scientic explanation and humanistic un-

derstanding, a duality that is basically valid for medicine

and especially psychiatry.

Rather than between non-human animals or ma-

chines medicine involves contact and communication

between people. Art plays or can play a role in all elds or

at all levels. e therapeutic task of medicine brings with

its characteristic dierences both in relation to the natu-

ral sciences and to the humanities. Medical Humanities

remains biology-bound, not understanding health and

illness only as psychical phenomena. Medical Humani-

ties necessitates dialogue between nature and culture,

not a one-sided orientation towards the objective (phy-

sique) or the subjective (psyche).

Proven by empiricism is a central tenet of modern

medicine, which psychosomatics and anthropological

medicine, acupuncture and homeopathy should ignore

no more easily than all types of art therapy. Today’s cor-

responding keyword is evidence-based medicine. Typi-

cally forgotten or overlooked, however, is the double

meaning of evidence: e term can signify an empiri-

cal-statistical proof and also immediate insight. Medical

therapy cannot disregard any evidence of ecacy, which,

however, may produce dierent results. Subjective state-

ments by doctors and patients can be objectied, and

doctor-patient relationships can be described and ana-

lyzed on a scientic basis. From the perspective of Medi-

cal Humanities, the medical concepts of science must be

guided not only by mechanics and physics. Medicine as a

discipline is grounded in empirical science, and its ther-

apeutic task—to which diagnostics also refers—makes it

an action science. But medicine is also a humane disci-

pline, related to humans and not to non-technical or life-

less artefacts.

e separation between the natural sciences and the

humanities, which has deepened since the 19th century,

originated in the Renaissance. In this separation current

criticisms and tensions are rooted, which only will nd a

solution or achieve a balance by overcoming this sepa-

ration.

One event of cultural-historical and symbolic impor-

tance is Francesco Petrarch’s (1304–1374) legendary as-

cent of Mont Ventoux in Provence on April26, 1336. At

the top of this mountain, Petrarch confronts the admon-

ishing word of Augustine (354–530) in his “Confessions”

(around 400 years AD): “And men go to admire the high

mountains, the vast oods of the sea, the huge streams

of the river, the circumference of the ocean and the rev-

olutions of the stars—and desert themselves.” Petrarch

closed his eyes, ashamed of the beauties of nature, and

henceforth devoted himself to studying the altitude of

man (altitudo hominis) [13], i.

e. the inherent values of

mankind. is separation is also established by Charles

P. Snow (1905–1980) in his much-discussed lecture and

book “e Two Cultures and the Scientic Revolution”

(1959): “Literary intellectuals at on pole—at the oth-

er scientists, and as the most representative, the physi-

cal scientists. Between the two a gulf of mutual incom-

prehension—sometimes (particularly among the young)

hostility and dislike, but most of all lack of understand-

ing” [14]. In reality, however, there are not two, but four

cultures: e culture of natural sciences, humanities, the

arts, and life. e goal of Medical Humanities is to elimi-

nate or mitigate their opposition or conicts in the eld

of medicine as well.

medicine and arts

medicine and arts 1 3

e arts can be addressed in medicine early in medi-

cal education. e physician omas Sydenham (1624–

1689) is said not to have given a scientic text to Richard

Blackmore (1654–1729), a medical student requesting

reading material, but, instead, recommended the novel

“Don Quixote” (1605/15) by Miguel de Cervantes (1547–

1616). However, the student reacted too seriously to this

recommendation: He became a poet, and was lost to

medicine.

Communication between doctor and patient, above

all, is not just science but also art. Several dimensions

can be distinguished: (1) empathy and a friendly at-

mosphere, (2) authenticity and self-criticism, (3) verbal

and non-verbal skills, (4) factual and situational knowl-

edge, (5) knowledge of human nature, (6) cultural edu-

cation, (7) imagination, and (8) paying attention to the

patient’s language. Empathy not only projects the pa-

tient’s feelings, but also his thoughts and desires, diers

from sympathy and antipathy, must result in a partial but

not a complete identication with the patient and, -

nally, should relate to a patient’s actual (=

present), past

retrospective), and future (=

prospective) situations.

In principle, there are four types of social relationships

of the sick: (1) the healthy to the sick, (2) the sick to the

healthy, (3) the sick to another sick, and (4) the healthy to

another healthy with regard to sick and illness.

Overcoming disease and establishing health may be

compared to an act of creativity. Aesthetics and therapy

are connected in particular ways with surgery, especially

plastic surgery. Organ transplantation is not just body al-

teration but body metamorphosis, raising various ques-

tions: Do personality, identity, and continuity change

with reception of a foreign organ? Are dierent types of

changes associated with dierent transplanted organs—

whether kidney, liver, heart, or hands? What alterations

occur if transplanted organs are rejected as foreign tissue

and require explantation?

Medical publications, lectures, and discussions can

also have literary value. e so-called teaching poem of

the past used the connection between science and art in

classroom lessons. In the widely read poem “Syphilis sive

de morbo gallico” (1530), by doctor and writer Girolamo

Fracastoro (1477–1533), Apollo, the god of muses and the

art of healing, is held responsible for the plague.

In medicine, art is also manifested in the names of

diseases. A line can be drawn from Oedipus-, Electra-,

and Cassandra-complexes to the Munchausen-, Rapun-

zel-, and Oblomov-syndromes. e Rapunzel syndrome

denotes the swallowing of hairs (trichophagia) and for-

mation of gastric hairballs (trichobezoar). e Oblomov

syndrome refers to the novel “Oblomov” (1859) by Rus-

sian writer Ivan A. Goncharov (1812–1891), in which a

person is described as losing all interests and sinking into

a puzzling hallucinatory state of paralysis—a syndrome

diering from depression, but not unlike it.

III. Art as therapy

Since ancient times, a therapeutic function has been as-

cribed to the arts. e term ‘bibliotherapy’ was coined

early in the 20th century, but the concept is an old one.

Aristotle (384–322 BC) anticipated a cathartic eect for

those attending the performance of tragedies, due to

confronting terror (φοβος) and pity (ελεος). Similarly,

writing letters should help not only the recipient, but

also the writer (scribendo solari). David playing his harp

supported Saul during his times of melancholy (1 Samuel

16:23). Painting and the viewing of pictures should also

be salutary.

e arts dier in their applicability to various medi-

cal domains—diagnosis, therapy, prevention, rehabili-

tation, doctor-patient relationship, hospital, therapeu-

tic milieu—all are domains in which arts can be eective.

However, despite numerous strong individual studies,

a comparative or historical-systematic study of various

types of arts therapy is still awaited.

By their very nature, dierent diseases have distinc-

tive inuences on the production and, conversely, the

reception of art works. Yet, even more important than

the etiology and patho-phenomenology of diseases is

their anthropology. Anthropology in medicine deals with

six types of relationships: to the body, to space, to time,

to the social environment, to oneself, and to the world.

e impact of the arts should be examined not in gener-

al, but specically in each of these areas. As cultural re-

sponses to illness and therapy, to patients and doctors or

therapists, art and literature simultaneously surpass any

treatment in its biological sense, reveal an earthly time-

lessness or immanent transcendence, as one might say,

contributing to medicine as Humanities: humane and for

human beings.

e various forms of therapy also carry implications

for art therapy: somatic, psychological, conservative, op-

erative, drug, and dietary processes each involves a par-

ticular approach to or way of dealing with the arts. is

specicity also applies to various diagnostic and thera-

peutic situations or special medical institutions. Prac-

tice, inpatient clinic, rehabilitation center, sanatorium,

admission, discharge, time before or after surgery—each

entails specic options and limits.

e condition of being ill is inuenced by the char-

acteristics and types of disease. Rheumatism, multiple

sclerosis, cancer, skin diseases, loss of sight or hearing,

depression, post-traumatic stress disorder, amputation,

organ transplantation, all have a characteristic inuence

on the body, space and time relationships, social rela-

tionships, self-relationships and world relationships of

the patient, inuences which art therapy has to respect.

As pointed out by the psychiatrist Hubertus Tellen-

bach (1914–1994), melancholy brings about a special

relationship to time and space, namely “remanence”

as “staying behind oneself” (change of the time mode)

and “includence” as “being locked or locking oneself”

(change of the space mode) [15]. Art works are able to

counteract these changes in time and space perception.

medicine and arts

1 3 S7

Other diseases are associated with other modications of

the aforementioned anthropological sextet of diseases or

being sick.

Literary texts mean world gain and are stimulating im-

pulses for the thinking, feeling and wanting of the sick

person, who is usually put into a passive and restricted

state by his illness.

Literary texts can enrich the life and worldview, stimu-

lating thinking, feeling and willing of a patient who, due

to illness, often is put in a passive and restricted state. Lit-

erature can free up spaces for plans, thoughts, and de-

sires that neither have to agree with the immediate reality

nor are required to justify themselves to meet the expec-

tations of a neighborhood, friends, or relatives. Like any

form of therapy, bibliotherapy is not devoid of possible

side eects or dangers: Literature can also lead to self-

deception and escapism, reinforce neurotic tendencies,

and give rise to the creation of illusory worlds.

After all, there is no doubt that art therapy essentially

depends on the personality and interests of the patient.

e sick person—not least during his hospital stay—may

even be won over to previously unknown or neglected

cultural opportunities and activities. Illness oers an op-

portunity for culture.

e process of communicating the artwork is essen-

tial. Distributing catalogues and favored pictures, books,

or pieces of music cannot suce: Art works cannot be

prescribed and taken like medication, and watching and

counseling are crucial. e eects of art on the sick must

be monitored in order to balance them, to go deeper and,

nally, to recommend other art works. Ideally, art thera-

pists should have three areas of expertise: knowledge of

the anthropology of disease and healing, knowledge of

the arts and their inuences, and psychological skills—

especially empathy and communication.

Arts, especially literature, can undoubtedly contribute

to diagnostics and therapy but, clearly, are not an alter-

native to established medical procedures and cannot re-

place surgery or drug therapy. Yet, art and literature are

going far beyond therapy, which is essential to the con-

cept of Medical Humanities as well. Franz Kafka (1883–

1924) expressed this view: “A book must be the ax for the

frozen sea inside us” [16].

e world of medicine constitutes a central literary

topic. Its description and interpretation can meaningful-

ly be dierentiated into eight dimensions: (1) pathophe-

nomenology, (2) etiology, (3) diagnostics and therapy,

(4) subjectivity of the patient, (5) image of the physician,

(6) medical institution, (7) social reactions, (8) symbol-

ism. ree perspectives are prominent in the dialogue

between medicine and literature: (a) literary function of

medicine, (b) medical function of literature, and (c) func-

tion of literature for a general understanding of medicine

(the genuine function of literary medicine).

Health and illness are as basic to human life as birth

and death: Both refer to nature and culture, involve bi-

ology and spirit, simultaneously represent descriptive

as well as normative terms, are descriptions and judge-

ments. e meaning of health and illness is found not

only through life science and medical perspectives, but

is also widely characterized by the arts and literature,

by philosophy and theology. ose disciplines, in addi-

tion to the patient’s subjectivity, remind medicine of its

anthropological character, of the mental and social di-

mensions of health and illness, of therapy and hospital.

IV. Perspectives

“erapy as Art—Art as erapy” is a multi-faceted topic,

closely linked to the essence and roles of both medicine

and art. rough representations and interpretations,

the arts as a whole remind one of the holistic nature of

human life, and relativize common or one-sided assess-

ments of health and illness such as traditional role mod-

els of doctors and patients. Recovering from illness and

disability can be more impressive than living in unbro-

ken health. Doctors can also become sick, patients on the

other hand can support medical diagnostics and therapy.

Art and literature inuence public and general aware-

ness and shape people’s attitudes and behavior, improv-

ing and humanizing them; but they may also suggest

mistaken ideas and raise illusionary hopes. Many images

and concepts of suering and healing, of people in need

and people as helpers, stem from works of art and litera-

ture—hence, these works document and determine the

level of a culture, and provide guidance for individuals as

well as society and the state. Karl Jaspers was deeply con-

vinced of the high value of description and interpretation

of medicine in literature: “It is not mere chance therefore

that poets have used symbols and gures of madness for

the essence of human life in its highest and most horrible

possibilities, in its greatness and decline. us, Cervantes

in Don Quixote, Ibsen in Peer Gynt, Dostoevsky in e

Idiot, Shakespeare in Lear and Hamlet” [17].

Reality, art, and medicine, although diering in many

ways are, at the same time, interconnected in a special

way. Medicine is not only science but is art a well; it

should be understood as a culture of healing and recog-

nized as such. Medical Humanities represents this con-

nection between the natural sciences, the humanities,

and the arts: Illness is always understood as a physical,

psychological, social, and mental phenomenon, as—

in other words or a with a new concept—’spiritual-so-

cio-psycho-somatics’. e doctor is not only engineer or

scientist, but—taking into account the necessary pro-

fessional distance and balance—a personal and commu-

nicative companion of the patient.

Personalized medicine should not only mean biolog-

ical and genetic individuality, but should consider the

patient as a person with feelings, thoughts, and living

conditions. Evidence-based medicine cannot be limited

to empirical-statistical evidence, but must also include

immediate insights. Precision medicine should not only

mean objective accuracy, but must include subjective

accuracy of the doctor as well as the patient. Medicine

as Medical Humanities is human and humane—for the

benet and dignity of suering, sick, and dying men and

women.

medicine and arts

medicine and arts 1 3

Keynote II

Critical medical humanities in action: symptom

and sensation in breathlessness

Jane Macnaughton, Institute for

Medical Humanities, Durham University,

jane.macnaughton@durham.ac.uk

Some of the material is published elsewhere [18]. Much

of the work of this paper was funded through the Life of

Breath project funded by the Wellcome Trust 2015-2020,

grant number: 103339/ Z/13/ Z; 103340/ Z/13/ Z. Ethical

permission for work with Breathe Easy group partici-

pants was granted by Durham University’s Department

of Anthropology Ethics Committee. Furthermore, this

paper draws upon work undertaken by members of the

Life of Breath project team: Havi Carel, Krzysztof Bier-

ski, Kate Binnie, Jordan Collver, James Dodd, David Full-

er, Alice Malpass, Coreen McGuire, Sarah McLusky, Re-

becca Oxley, Kyle Pattinson, Mary Robson, Arthur Rose,

Andrew Russell, Corinne Saunders, Jade Westerman and

Sian Williams. I am very grateful to them all for the gener-

osity of their input which made this interdisciplinary pro-

ject a success.

Introduction

It was a huge honor for me to open the Internation-

al Conference, “Medical Humanities—Interactions be-

tween Medicine and the Arts”, in Vienna in October

2019. My introductory presentation proposed a more

ambitious role for medical humanities than has histori-

cally been the case and intended to provide a challenge

and stimulus for further development of the eld. In this

short article I will set out that new agenda for medical

humanities and make a case for its importance. I will il-

lustrate how such an approach might work with refer-

ence to my project, the Life of Breath, which is a ve year,

Wellcome Trust-funded project investigating the experi-

ence of breathlessness and intended to show how med-

ical humanities research might inuence clinical man-

agement.

Critical medical humanities: a new concept

At Durham we have led on the development of a new con-

cept of medical humanities which we call “critical med-

ical humanities” [19] to distinguish it from the original

concept which focused on clinical (mostly medical) ed-

2 e Life of Breath is a ve-year interdisciplinary project led by

the author and Professor Havi Carel of the University of Bristol

and funded by the Wellcome Trust (2015–2020, grant number:

103339/ Z/13/ Z; 103340/ Z/13/Z) to explore the phenomenological,

cultural, historical and clinical understandings of breathlessness.

Ethical permission for work with Breathe Easy group participants

was granted by Durham University’s Department of Anthropology

Ethics Committee.

ucation. is approach to medical humanities emerged

in the 1970s in the USA as a result of a growing concern

about “depersonalization”, the “centrality of molecular

biology” and the “teaching of mechanistic medicine” in

medical schools [20]. e suggestion was that with in-

creasing technology and more in-depth biomolecular

knowledge, students were losing a sense of how wider

human lives inuenced health and illness. e result was

the establishment of programs in medical humanities in

US medical schools, and also in the UK, that broadly con-

formed to the two educational narratives later outlined

by Howard Brody [21].

It became clear, however, in the early 2000s that this

approach was not breaking through in part because nei-

ther sought to or succeeded in getting engaged in chang-

ing biomedical culture nor have played any part in chal-

lenging epistemological divisions or power structures

within biomedicine. is is important because there are

clear shifts in the challenges for health in the 21st Cen-

tury that recognize the need to see health in medicine

within wider critical frameworks and contexts and that

therefore call for a more interdisciplinary approach to re-

search and understanding [22].

In response to this, writing in the 2015 special issue

of the journal Medical Humanities, my colleagues Will

Viney, Felicity Callard and Angela Woods open out a

new concept of this eld that seeks not to dene medi-

cal humanities but rather “to consider what it is capable

of doing”. ey ask [23]: “Can the medical humanities in-

tervene more explicitly in ontological questions—in par-

ticular, of aetiolology, pathogenesis, intervention and

cure—rather than, as has commonly been the case, leav-

ing such questions largely to the domains of the life sci-

ences and biomedicine?”

is approach to medical humanities, which we call

“critical medical humanities”, is characterized by a be-

lief that the important task is not one of educating the

practitioner but of shaping the evidence base in order

to contribute to improvements in health. is concep-

tion maintains that to address the health challenges of

the 21st century and beyond requires an expanded vision

of what is allowed within the rather narrow connes of

the health care evidence base. at evidence base needs

to include knowledge from the arts, humanities and so-

cial sciences as well as seeking understanding through

their methods. We will not achieve that working in iso-

lation from biomedical understanding—we need to get

engaged [23]:

“So that… a framework in which the ‘perspectives’ of

the humanities are pitted against those of the ‘science’

or ‘social sciences’ … give[s] way to a much richer and

more entangled investigation of bio-psycho-social-phys-

ical events that underpin the life, and death, of any or-

ganism”.

In the Research InstituteI lead in Durham and in oth-

er Centers in the UK, Europe and the US, this is the char-

acter of medical humanities that is now emerging strong-

ly. Its key features are interdisciplinary research that is in

engaged with themes of critical interest to health, med-

medicine and arts

1 3 S9

icine, healthcare and biomedical research. In concord-

ance with that vision, the research mission of the Insti-

tute for Medial Humanities at Durham is to transform

research in health through the study of human experi-

ence.

is is a very exciting moment in the eld of medi-

cal humanities, but it is also a moment where we have to

prove our claims to making a dierence in health through

this approach. But how do we do this in practice? How do

we engage and make it meaningful? What are the chal-

lenges and pitfalls involved in this?

Life of breath: engaging clinical science

e Life of Breath research project illustrates this criti-

cal medical humanities approach. It is a ve-year pro-

ject funded by the Wellcome Trust that aims to investi-

gate the cultural, experiential, and historical origins of

our understanding of breathing and breathlessness and

to bring that into dialogue with clinical understanding.

Its ultimate aim is to make a dierence to the lives of

breathless people through taking seriously our claim that

this dialogue is critically important to ensure that what

clinicians do to help patients actually addresses what is

wrong.

Interdisciplinarity

Our approach to this project was from the outset pro-

foundly interdisciplinary. Our research group, which

is called ‘Breathing Space’ (BS), meets regularly across

the two sites of the project bringing together everyone

involved, including philosophers, clinicians, a medi-

cal historian, literary scholars, anthropologists, clinical

scientists and artists, and experts by experience (those

with breathlessness). e process of generating research

questions within BS is critical, because the success of in-

terdisciplinary engagement is dependent upon think-

ing dierently about a subject through the collusion of

new insights and methods in a collaborative space [24].

emes and research questions have therefore been

emergent. One important theme has been that of investi-

gating the dierence between experience and sensation

in relation to breathlessness and how this informs neuro-

scientic investigation.

Clinical relevance

is emergent theme speaks to the important issue of

clinical relevance. If our aim in critical medical humani-

ties is to generate research that will lead to real changes

in health care practice we have to engage with clinicians

and clinical science. In order to do that, it is our responsi-

bility to explain why anyone working in health care prac-

tice or research would want to engage with us. From the

outset of Life of Breath, therefore, I wanted to nd out

what it was that clinicians felt was dicult about their

management of breathlessness and where they might be

needing new insights and evidence.

Breathlessness is important symptom in a number of

common and chronic diseases, most commonly chronic

obstructive pulmonary disease (COPD) which is strongly

associated with smoking. Currently the WHO rank COPD

as the fourth most common cause of death in developed

countries and it is estimated to become the 3rd by 2030

[20]. As chronic breathlessness frequently results from

incurable, often long-term progressive conditions, the

symptom often persists despite maximal treatment of

the condition. Palliative care physicians such as Miriam

Johnson and colleagues have termed such breathless-

ness “refractory”, and the attitude of clinicians and pa-

tients themselves towards it is one of “nothing more can

be done”, with all that implies in terms of hopelessness,

and lack of attention to the problem by either party [25].

Patients may no longer report increasing distress to their

doctors and clinicians may fail to ask about the problem

as they feel unable to help.

Breathlessness is, therefore, a potentially very fruitful

symptom for a medical humanities approach. It is impor-

tant in global health terms and clinicians are struggling

to manage patients eectively. It also presents clini-

cians with a conundrum: that measured breathlessness

(through spirometry in the clinic) does not often equate

with the actual experience: a problem known as “symp-

tom discordance”. Physicians are struggling with this

problem and are at the very early stages of seeking an-

swers. A major focus in clinical research has therefore

been on trying to understand the sensation of breathless-

ness through neuroscientic investigation.

Clinical engagement—neuroscience

is takes me back to our emerging theme of investigat-

ing the dierence between experience and sensation in

relation to breathlessness and how this informs neuro-

scientic investigation. Addressing this involves impor-

tant insights that the humanities and social science can

provide. In order to bring those insights into play it was

important for us rst to explore the nature of clinical un-

derstanding.

In 1999 the American oracic Society published an

inuential denition of breathlessness as “a subjective

experience of breathing discomfort that consists of qual-

itatively distinct sensations that vary in intensity” [26].

What struck me about this from a medical humanities

perspective was the merging of “experience” and “sen-

sation”. It seems apparent in this denition that experi-

ence is regarded as consisting purely of sensory experi-

ence. e ATS further modied their denition in their

2012 update referring to emerging evidence that de-

scribes three distinct sensory experiences associated

with breathlessness (air hunger, tightness and the work

of breathing) and that such sensations can vary in un-

pleasantness and in their “emotional and behavioral sig-

nicance” [27].

For me this concentrated, clinical focus on sensory

mechanisms seemed to carry with it the potential to miss

what else might be understood by and inform the full pa-

medicine and arts

medicine and arts 1 3

S10

tient experience of breathlessness. One of the fascinating

things about breathing is that it is under both voluntary

and involuntary control, and this means there is a com-

plex set of mechanisms that come into play, including

the involvement of the brain stem to override voluntary

breath-holding. But it also enables us to examine poten-

tial relationships between aect (emotions) and breath-

lessness, and the arts and humanities have expertise to

oer here.

Lansing, Gracely, and Banzett in an important paper

in 2009 propose a multidimensional model of breath-

lessness taking its lead from pain studies [28]. ey de-

scribe the three sensory qualities and link them to dis-

tinct physiological mechanisms. ey draw a distinction

between sensory intensity (i.

e. how breathless do you

feel) and aective intensity (i. e. how unpleasant does

that breathlessness feel, or how upsetting is it). A further

distinction is also made between two time-distinct stages

in this sensory process: the immediate experience of un-

pleasantness and a later stage of cognitive evaluation and

emotional response. is later stage mirrors the model of

chronic pain where (as with chronic breathlessness) it is

recognized that negative emotions such as depression,

anxiety and fear are common consequences.

From a medical humanities perspective it is possible

to discern a number of problems with this model. First,

there is the language: the humanities and social scienc-

es are sensitive to the nuances, variations and implica-

tions of language in a way that medical science does not

tend to be. In this case, the basis the authors use to con-

nect people’s sensory experience to physiological mech-

anisms is by oering word descriptors of breathless-

ness sensations to subjects and asking them to choose

the best t, rather than allowing a range of possible de-

scriptors to emerge unbidden from their respondents,

as might happen in qualitative research [18].

Research

in our Life of Breath “Breath Lab”, which brought togeth-

er researchers in the project with clinicians, people with

breathlessness and their families and carers, revealed

that some of the clinical language was not understood.

Patients in particular found the words used for “pulmo-

nary rehabilitation (PR)” o-putting because “pulmo-

nary” did not mean much to them, and “rehabilitation”

had connotations of drug rehab [29]. is is important,

as PR is the main evidence-based management on oer

for such patients.

Second, there is a lack of acknowledgement of how a

life lived with breathlessness impacts upon perception of

the sensation in the moment. What is striking about Lan-

sing’s model is that the emotional response is described

as deriving from the sensation of breathlessness. But what

is abundantly clear from a range of studies, including our

own emerging research, is that people’s experience of

their chronic breathlessness profoundly colors how the

sensation is perceived [18]. e problem with the labo-

ratory-based approach is that this experimental work is

largely carried out on normal subjects whose bodies and

minds have not be subjected to years of chronic breath-

lessness and the eects that may have on physiology and

neural mechanisms. As our neuroscientist collaborator

Pattison and colleagues acknowledge [30]:

“Replicating the emotional component of dyspnea in

a laboratory environment is dicult as laboratory dysp-

nea does not cause the existential fears dyspnea suerers

encounter in daily life, hence patient studies will be nec-

essary in order fully to comprehend all aspects of dysp-

nea”.

And those patient studies are challenging for people

whose condition does not enable them to spend time ly-

ing at in the enclosed tunnel of an fMRI scanner. MRI

by the constraints of its physical demands is not suited to

imaging people with chronic breathlessness.

Medical humanities, therefore, has a role in terms of

critique of the clinical approach but can also point to a

number of potential productive ways to work with the

clinical scientists.

Interdisciplinary insights: dynamism of the brain and

body in response to experience

What our interdisciplinary discussions, especially in-

volving anthropologists and research with people with

breathlessness, reveal is that lived experience is a dy-

namic thing and human beings need to be conceptual-

ized as in constant conversation with their social and en-

vironmental surroundings. Anthropologist Tim Ingold

strongly asserts this dynamism in his book Biosocial Be-

comings [31]. He reects on the kind of “impasse” cre-

ated by regarding human beings in the traditional medi-

cal machine-like way initiated at the Enlightenment, and

suggests we think dierently, “to think of ourselves not

as beings but as becomings—that is not as discrete and

pre-formed entities but as trajectories of movement and

growth”. It is in this space of thinking about the nature of

human being that creative engagement with clinical sci-

ence can occur and we can see connections between ex-

perience, sensory bodily awareness and an approach to

neuroscience that takes this dynamism into account.

In their 2013 paper, “Understanding dyspnea as a com-

plex individual experience”, our collaborator Kyle Pattin-

son and colleagues note the importance of the emotions

as powerful moderators of the perception of breathless-

ness [30]. is is further conrmed by the American o-

racic Society who quote research that shows the “high

prevalence of anxiety and depression in patients with

chronic breathlessness” [27] and that this is also relat-

ed to the problem of poor interoceptive awareness [32].

Interoception is the sensation of the internal workings

of the body, such as heart beat, digestion and breath-

ing, and it seems clear that it is suppressed in chronic

breathlessness. is idea may lie at the heart of the prob-

lem of symptom discordance in breathlessness. rough

the idea of a mind/brain in dynamic interaction with the

ever-changing world we connect neuroscience with the

philosophical social science of Ingold and others indi-

cating the power of human becomings (not beings) to

change and adapt to new circumstances confounding

sometimes the power of clinical technology, reliant as it

medicine and arts

1 3 S11

is on its static modes of measurement, to uncover symp-

tom experience.

I think that this insight, rather than making clinicians

despair because of the inconstancy of the lived body in

response to clinical measurement, should provide hope

about new possibilities to support those with chronic

breathlessness.

New approaches: dance

A key challenge in managing chronic breathlessness is

poor uptake of the major evidence-based treatment: pul-

monary rehabilitation [29]. Our medical humanities ap-

proach has provided insights into why that might be, in-

cluding problems of language and culture, but key to this

is the evidence that interoceptive awareness is reduced in

people with chronic breathlessness.

ese insights are now taking us in the direction of

exploring the possibility of dance movement for people

with chronic breathlessness. We are now working in col-

laboration with our experts by experience partners (who

are the participants) and a dance teacher to deliver this

dance program in the community. During this pilot we

have been collecting both qualitative and quantitative

information about participants including information

about their interoceptive awareness to try to test out our

hypothesis that engagement with dance movement im-

proves interoception, and may therefore improve per-

ception of breathlessness and avoid inaccurate assess-

ment of symptoms. So far, it is clear that the group are

very much enjoying themselves, that the group dynamic

is supporting them through dicult times with their con-

ditions; and initial assessments of strength and balance

and very positive [33].

Conclusion

Work on the Life of Breath illustrates the potential for a

critical medical humanities approach that is determined

to engage and collaborate across disciplines and meth-

ods with the aim of inuencing clinical science and mak-

ing a dierence to people’s health. It is important that this

process is a two-way street: each step taken must make

sense not only to humanities scholars but also the clini-

cians. In this interdisciplinary and collaborative context,

we both have the opportunity mutually to correct mis-

conceptions and to inuence ideas, develop new ones

and plan collaborative research. is new approach to

medical humanities opens out a practical approach that

enables humanities and social science scholars to be ac-

tively engaged in constituting the clinical evidence base

as well as enlivening our own home disciplines.

Medicine and Visual/Applied Arts

Arts and medicine: on the potentials of

transdisciplinary encounters

Barbara Putz-Plecko, University of Applied Arts

Vienna, barbara.putz-plecko@uni-ak.ac.at

Barbara Graf, University of Applied Arts Vienna,

barbara.graf@uni-ak.ac.at

ere are many points of contact and intersection be-

tween medicine and art, many points of departure for

fruitful cooperation that can be enlightening for both

elds of endeavor. Part one (I) of this contribution will

briey outline various aspects of this interrelationship,

with particular emphasis on:

• the role played by creative processes, aesthetic prac-

tices, and aesthetic objects, in an eort to nd a reori-

entation and ways to cope with suering and daily life;

• art in its function as a “transitory body”;

• forms of cross-disciplinary cooperation, as well as

the relevance and potential of this boundary-opening

joint exploration of approaches to problems and ques-

tions related to research.

Part two (II) will present the research project “Stitches

and Sutures,” which deals with representing the percep-

tion of the body. e author of the project asks herself

how subjective sensations can be made visible and artis-

tically explores her own sensory disturbances caused by

multiple sclerosis.

I. On the potential of artistic processes with regard to

medical and therapeutic tasks

Cooperation involving scientic and artistic perspectives

and methods is meaningful on various levels. e current

spectrum of diverse interfaces includes, to name only a

few examples: image-generating processes for the pur-

pose of presenting medical facts in visual form to sup-

port communication with experts or laypersons; artistic

expertise brought in for the purpose of designing clinical

areas to support recovery processes; the targeted use of

artistic processes for diverse forms of therapy.

In artistic works, physical and psychological disposi-

tions, as well as psychodynamic processes and mental

images, can be made visual in condensed form. Artistic

works possess communicative potential: With regard to

therapeutic decision-making, for example, these works

can reveal possible points of contact, possible synaps-

es. For the trained observer, this opens the possibility of

perceiving creatively articulate individuals from multiple

perspectives:

• the perspective of their specic make-up, background,

and the various contingencies that aect them;

• the perspective of the problems, crises, and illnesses

with which they have to cope;

medicine and arts

medicine and arts 1 3

S12

• the perspective of the resources that they—perhaps

without realizing it—have at their disposal.

Along with this possibility, however, goes the obligation

for the observer to constantly maintain a critical self-re-

gard and to reect on the systemic and disciplinary con-

text in which he or she works, to avoid reaching oversim-

plied or false conclusions.

Like the art of healing and psychotherapeutic activ-

ity, personality development is fundamentally connect-

ed with creativity. e doctor who helps people to gath-

er their strengths in order to restore not just the healthy

functioning of their body (restitutio in sano) but their

original healthy condition (restitutio ad integrum) [34]

must, on the basis of his knowledge and skill, be able to

act creatively. Similarly, mental development is impos-

sible without the ability to become creative. Creativity is

an attitude and an activity in which perception, imagina-

tion, memory, and artistic activity fuse. It allows new ide-

as or insights to take form. Personality development re-

quires this “structure-forming internalization” [35].

Furthermore, creativity requires direct encounter.

Whether in art or in science, direct encounter with the

object of interest, the person, or the eld of knowledge is

essential: Creativity is inuenced by the degree or depth

of this encounter. However, despite possible overlaps,

art and science use dierent processes and methods in

approaching a subject. ese dierences can potential-

ly be fruitful and productive for both areas; for example,

in various forms of therapy and art therapy in particular.

Art therapy centers on an intra-psychic process of form

construction and design that aects the senses as well as

psychomotor processes. ese processes are reected in

the artistic dynamics of form of an aesthetic medium [36].

e aesthetic object becomes a “transitory body” [37] that

provides an image of inner and outer life circumstances

and renders them processable. By applying this artistic

approach, the therapeutic process aims at rearranging

patterns of perception, thought, and behavior into a con-

stellation that makes it possible to cope with everyday life.

At the same time, in this therapeutic process, atten-

tion is consistently focused on the person’s resources,

which are reected in the aesthetic process and in the

object itself. ese resources thereby become manifest.

“Placing the aesthetic object in the therapeutic frame-

work, in a protected, non-judgmental context, makes it

possible for a genuinely visual language to emerge” [37].

In the eld of artistic production, this visual language is

labeled “Outsider Art,” as exemplied in the artistic work

produced by the Gugging Artists3. However, the direction

of intensity in the artistic process diers, depending on

whether it is within or outside the therapeutic context.

In the context of therapy, this intensity must be main-

tained in the therapeutic situation itself. Here, the gradu-

al development of a visual language leads to the creation

of a “potential place” in which an individual’s own expe-

3 https://www.museumgugging.at/de/gugginger-kunst/die-kuen-

stler-aus-gugging/kuenstler_innen (30 March 2020).

rience and a rst objectication can coexist. In the ther-

apeutic relationship, the patient, little by little, comes to

recognize himself or herself in the images generated; the

artistic process unfolding within secure boundaries stim-

ulates and nurtures the joy of experimentation and the

discovery of new forms of expression and action. Clear,

dynamically structured frameworks enable patients to

perceive the interrelationship therapy–object–patient–

group, a perception that is also protected by these struc-

tured frameworks and can thus be given shape.

Over the past 15 years, an equally diverse and enrich-

ing form of collaboration has emerged in the eld of re-

search, namely, vigorous collaboration between the eld

of art and design and the elds of medicine and social

science. e incorporation of artistic processes and per-

spectives provides new impulses for a broader under-

standing of medical facts in such contexts as: precise and

empathetic communication; therapy; enhancement of

self-healing capacities; as well as new support tools in

the context of treatment.

In this regard, it is worth drawing attention to the ex-

amples of at least three projects:

• Firstly, the Peek project “D.A.S.—Dementia. Art. Sci-

ence”, which, by tapping the potentials of art and de-

sign, aims at meeting the challenges to our society

posed by dementia;4

• Secondly, the FFG project “INTERACCT”—a project

that aims at designing and developing an e-health

platform and supportive tools especially focusing on

juvenile patients with chronic diseases in aftercare;5

• irdly, the Peek project “Features: Vienna Face Pro-

ject/Laboratory of the Senses”, which aims at increas-

ing sensitivity to facial paralysis in children—a project

in which experts from the elds of sociology, plastic

surgery, and art collaborate.6

e latter example allows, at this point, a transition to

part two (II) of this contribution, in which the artist

Barbara Graf will present her current research project,

“Stitches and Sutures,” which gives deeper insight into

the artistic research process itself. First, however, a de-

nition of artistic research might be in order.

In the words of Henk Borgdor [38], a key person in

this eld, art practice qualies as research when its pur-

pose is to broaden our knowledge and understanding

through an original investigation. is means that, in ar-

tistic research, insights are gained and knowledge is gen-

erated in artistic practices that are reexive. e combi-

nation of artistic, practical approaches with prescientic

modes of action and thinking, as well as scientically ori-

ented methods, leads to other and new forms of knowl-

edge; these can be both rational and pre-rational, as well

as both subjective and general. eory and practice, sub-

4 https://www.dementiaartssociety.com/ (30 March 2020).

5 http://www.interacct.at/project/default.aspx (30 March 2020).

6 http://www.corporealities.org/features-2010-2014/ (30 March

2020).

medicine and arts

1 3 S13

jectivity and objectivity, scientic methods and art are

not considered as oppositions, nor as dichotomies; rath-

er, they are to be approached openly and negotiated in

the work and thought processes.

e following presentation of the rst research phase

of the PhD project, “Stitches and Sutures,” should make

the potentials of artistic research strikingly apparent.

II. From bodily manifestations to the representation of

physical sensations, Barbara Graf

In my artistic research, I am concerned with the body. In

my earlier work, I focused on anatomical structures, both

inner and outer aspects of the body. Body identity and

bodily expression were my primary interests. My current

investigation centers on what is experienced physical-

ly. My aim throughout is to comprehend what is taking

place in my body and to understand myself by under-

standing my body (Fig.1).

„Vertebral Column Garment (Anatomical Garment

V)“, dated 1996, describes a movement from the inside to

the outside. e solid inner skeleton becomes a protec-

tive textile outer covering (Fig.2).

In the installation “Contours”, dated 2005, we are no

longer dealing with a compact outer covering but with

a body that breaks up into parts. A gure detaches itself

from a canvas-like surface. Leaving a gap behind, it ex-

pands into space (Fig.3).

In the “Hand Breast Layers (Anatomical Garment

XVI”), multiple layers create a kind of relief, extending

the person’s body in space. Embroidered topographies of

the body cover the body and can be folded back or turned

like pages. is shifts the body’s spatial limits. Manipu-

lating the body’s covering becomes a form of palpation,

a means of reassuring oneself with respect to one’s body

(Fig.4).

For the past fteen years, I have been working on artis-

tic research projects concerned with the eld of medicine.

From 2009 to 2013, in the project “Surgical Wrappings”7,

my colleague, Christina Lammer, and I explored various

7 Supported by the Vienna Science and Technology Fund (WWTF)

and based at the University of Applied Arts Vienna and the Medical

University of Vienna; project leader Christina Lammer.

Fig. 1 Barbara Graf, „Vertebral Column Garment“, 1996, cot-

ton, 175 cm (© Barbara Graf, Vienna. Reprint by courtesy.)

Fig. 2. Barbara Graf, „Contours – Installation“, 2005, cotton,

170 × 200 × 120 cm (© Barbara Graf, Vienna. Reprint by

courtesy.)

Fig. 3 Barbara Graf, „Hand Breast Layers“, 2008, cotton,

life-size (© Barbara Graf, Vienna. Reprint by courtesy.)

Fig. 4 Barbara Graf, „Cloth 6“, 2013, photograph (© Barbara

Graf, Vienna. Reprint by courtesy.)

medicine and arts

medicine and arts 1 3

S14

aspects of surgical activity. One of our goals was to exam-

ine surgical wrapping cloths—which both separate pa-

tient from surgeon and form a transition from one to the

other—and to develop a vocabulary for the hand gestures

in a surgical context. ese are hands that have a ne

touch and at the same time hands that carry out deep in-

terventions. I created textile works that reect a vision of

the operating eld as being a picture and represent hand

movements involved in surgical operations (Fig.5). For

this purpose, I used surgical drapes and medical gauze.

In staged photographs, my attention shifts from the body

in the operating room to my own body. Indeed, my body

could also be another body, one that serves as an example.

In my current work connected with my artistic PhD8,

my goal is not so much to represent ways in which the

body expresses itself as it is to make the life of the body

visual. How can perceptions of the body be made visual?

My research is based on personal experience. At the heart

of my artistic investigation are the sensory disturbances

I experience as a result of multiple sclerosis (MS). Sen-

8 Artistic Research PhD: “Stitches and Sutures” in progress since

2018 at the University of Applied Arts Vienna.

sory disturbances are among frequent complaints made

in connection with the chronic disease MS. ey are in-

visible, irritating, disturbing, and can even be debilitat-

ing. Some of these symptoms create the impression of a

sensory stimulus triggered by an external object (Fig.6).

For example, one sensation is that my feet are cov-

ered with something resembling socks. I perceive many

of these sensations as having a textile character. At rst,

I suspected that my professional work was providing

me with the vocabulary I was using here. However, ac-

counts given by persons aected by MS show that the

sensory impressions caused by this nervous disorder

are frequently compared to the structures of textile fab-

rics or to pieces of clothing. is suggests that basic per-

ceptual experiences involving the sense of touch make

themselves immediately available when the need aris-

es to describe these sensations. Often, people also de-

scribe the feeling of having painfully constrictive band-

ages wrapped around parts of their bodies (Fig.7).

e sensation of being touched without anything ma-

terial actually touching me makes me ask myself wheth-

er I perceive what I am feeling as being my own body or

something foreign to my body (Fig.8).

Fig. 5 Barbara Graf, „Cloth 5“, 2013, photograph (© Barbara

Graf, Vienna. Reprint by courtesy.)

Fig. 6 Barbara Graf, „Drawing 193“, 2017, pencil on paper,

29.7 × 42 cm (© Barbara Graf, Vienna. Reprint by courtesy.)

Fig. 7 Barbara Graf, „Drawing 189“, 2017, pencil on paper,

29.7 × 42 cm (© Barbara Graf, Vienna. Reprint by courtesy.)

Fig. 8 Barbara Graf, „Drawing 190“, 2017, pencil on paper,

29.7 × 42 cm (© Barbara Graf, Vienna. Reprint by courtesy.)

medicine and arts

1 3 S15

Phenomena occur that seem convincingly real, such

as the feeling of balls of textile material gathered under

the soles of my feet (Fig.9). Does sketching these irritat-

ing sensations make it easier for me to accept them as be-

ing part of my body?

e paresthesia can also distort perception of the

body’s physical expansion. In a drawing that shows the

feeling of “largeness,” I attempt to represent what I feel

are the dimensions of my body in relation to the body

that I actually see. Discordance between the body that

one feels and the body’s visible outer aspect is a phenom-

enon that is caused not only by illness; but illness makes

it more striking (Fig.10).

WhenI attempt to draw feelings of tension, do I sense

the body’s spatial limits? Or do I sense the places where

my perceived sensations extend beyond my actual body?

We perceive our body distinctly when something forces

itself upon us, when something exceptional takes place;

we perceive it by experiencing disturbances and pain but,

of course, also by experiencing alterations and events of a

pleasant nature.

In the drawings, I try to represent sensory input just

as I perceive it. However, a simple, almost seismographic

record is not possible, because if I consider perception to

be sensory recognition, then stored experience is neces-

sarily a part of the process (Fig.11).

And how does drawing aect my physical perception?

e sensation that a delicate, almost immaterial mem-

brane is touching my knees evolves, as I draw it, into that

of a fabric laying itself over my body (Fig.12). So is the

drawing that results in exaggeration? Or does the way I

have drawn it help me perceive the strange phenomenon

more distinctly?

In an eort to concentrate more on the specic nature

of these disturbances, I try, in a drawing of the soles of

my feet, to represent only what I nd striking and to leave

aside anything that does not seem essential. Why, then,

does the drawing nevertheless show what are recogniz-

ably my feet? Does this have to do with a kind of visu-

al foreknowledge? Or do I actually feel the structures in

this topographic conguration? Aside from what I feel at

the moment of perception, what guides me in this eort

is the inner image that I have of my body, an image that

consists of the body I have experienced spatially and the

body I have perceived visually (Fig.13). Perhaps that is

an explanation.

Drawing my whole body exclusively on the basis of

sensations inicted on me by the disturbances of my

Fig. 9 Barbara Graf, „Drawing 212“, 2019, pencil on paper,

29.7 × 42 cm (© Barbara Graf, Vienna. Reprint by courtesy.)

Fig. 10 Barbara Graf, „Drawing 203“, 2019, pencil on paper,

29.7 × 42 cm (© Barbara Graf, Vienna. Reprint by courtesy.)

Fig. 11 Barbara Graf, „Drawing 200“, 2019, pencil on paper,

29.7 × 42 cm (© Barbara Graf, Vienna. Reprint by courtesy.)

Fig. 12 Barbara Graf, „Drawing 208“, 2019, pencil on paper,

29.7 × 42 cm (© Barbara Graf, Vienna. Reprint by courtesy.)

medicine and arts

medicine and arts 1 3

S16

nervous system makes my undertaking even more ex-

plicit. Perhaps this kind of representation comes closer

to expressing what I actually feel as being my body; nev-

ertheless, it lends itself less to being generally compre-

hensible. Is this introspective work an attempt to under-

stand the “disturbed” perception I have of my body and,

by transferring what I feel to the body that I draw, to take

distance from it? In some cases, the paresthesia is very

subtle; in other cases, much more intense or painful. In

all cases, it is evidence of the chronic illness (Fig.14). Can

representing it ward o my fear or be a means of provid-

ing an outer locus for what is threatening me? As if, by

representing it, I had control over something without ac-

tually being able to change it?

It is inherently dicult to convey what one experiences

subjectively. e wording commonly used in descriptions

of the specic nature of sensory disturbances is based on

accounts given by persons aected by the disease. Over

and above fundamental questions related to the very

possibility of representing body perception, a catalog of

drawings of these symptoms could serve as a supplement

to verbal descriptions that already exist. Insights gained

by means of graphic representation reveal other aspects

of the disease and could potentially stimulate discourse

with other aected persons as well as with various disci-

plines—especially those that are therapeutic.

Artistic processes and artistic research, by reason of

the great variety of their experimental, sensuous, and de-

scriptive methods and practices, can, therefore, lead to a

broader understanding of illness as well. Moreover, they

possess a potential that is, to a certain extent, emancipa-

tory. is potential allows new contexts for action to be

opened up; in addition, thanks to the boundary-cross-

ing impetus provided by artistic processes and artistic

research, completely original links to the scientic and

technical disciplines can be created. In this process, the-

ory and practice, subjectivity and objectivity, art and sci-

ence are no longer to be perceived as dichotomies. It is

precisely from the combination of artistic practices—

along with prescientic modes of thought and action—

and scientically oriented methods that a great innova-

tive force is generated.

Vienna as the cradle of art therapy: a look back at

the 1920s

Georg Vasold, Institut für Kunstgeschichte,

Universität Wien, georg.vasold@univie.ac.at

Acknowledgement: the author is grateful to Jonathan

Blower for help in preparing the manuscript.

Looking at the relationship between visual art and med-

icine it soon becomes clear that it is a relationship that

takes many forms and has a long history. e desire to

make visual records of diseases and illnesses is evident-

ly as old as art itself. Surviving artefacts from some of the

earliest human civilizations include numerous images

of sick people and the measures taken to alleviate their

suering [39]. Our fascination for this subject is old and

its motivic bandwidth correspondingly broad. Although

it may be dicult to organize and classify the countless

images of disease and illness that have accumulated over

the millennia, we can at least identify a few themes that

have come up time and again and have thus drawn the

attention of art historical scholarship.

Of course, the main theme in this iconography of ill-

ness is the visualization of illness itself, that is, the depic-

tion of sick people, or, more specically, of bodies which

evidence the visible traces of sickness. Stone tablets from

ancient Egypt depict polio suerers and the crutches

they used as indispensable walking aids. Extant pre-Co-

lumbian art, particularly that of the Peruvian Moche civi-

lization, includes sculptures showing people with facial

paralysis, leishmaniasis and nasal or oral mutilations. In

Europe, too, there is widespread evidence that the visual

representation of physical illness was a signicant source

of interest. One could cite Raphael’s Transguration in

the Vatican Museum in Rome as a typical example of this

tendency: the lower half of the image features a boy suf-

fering an epileptic seizure.

Fig. 13 Barbara Graf, „Drawing 210“, 2019, pencil on paper,

29.7 × 42 cm (© Barbara Graf, Vienna. Reprint by courtesy.)

Fig. 14 Barbara Graf, „Drawings“, 2017-19, pencil on paper,

each 29.7 × 42 cm (© Barbara Graf, Vienna. Reprint by cour-

tesy.)

medicine and arts

1 3 S17

But representations of the sick are just one aspect in

this iconography of illness, albeit the most spectacular

one. Another is the evident desire to depict the people

who cure illnesses: the doctors. Here, too, there are ex-

amples from every age and from all around the world,

though such depictions were especially popular in sev-

enteenth-century Holland, where often dubious meth-

ods of doctors and quacks provided plenty of scope for

satire. But the intrinsic interest of such imagery goes well

beyond merely formal and aesthetic concerns; it actually

provides us with insights into the social history of medi-

cine and the status of the medical profession. Moreover,

such images often point to very specic historical cir-

cumstances which, if we read them correctly, can some-

times seem incredibly modern and up-to-date. For in-

stance: archaeologists and historians have been able to

show that the number of doctors per capita in Pompeii

was actually higher than that in modern-day Turkey; that

their medical instruments—bone saws, forceps and so

on—were of such high quality that they were exported

throughout the Roman Empire and used in places such

as Mainz and Trier; nally, that general healthcare pro-

vision in ancient Rome was precarious because doctors

were expected to cut costs. is much we know from an

edict of Emperor Antoninus Pius (reign 138–161 AD), ac-

cording to which the number of publicly funded posi-

tions for local doctors was to be reduced. In other words,

cuts to public health budgets were being made as early as

the second century AD [40].

Besides the iconography of the sick and representa-

tions of the medical profession there is one more area

that is of particular interest to art historians; namely art

therapy, which will be my focus in what follows. is eld

also has a long history, particularly in the iconography of

therapeutic methods. But systematic research on the sub-

ject soon brings us to a rather paradoxical position. On

the one hand art therapy is currently very popular. One

could even say it has now arrived at the heart of modern

society. To substantiate this claim we need only look at

the homepage of the Austrian Association of Art era-

pists (Österreichischer Berufsverband für Kunsttherapie),

which lists some three thousand members in Austria.9

at is comparatively high; in Switzerland it is more like

ve hundred. On the other hand, we still know very lit-

tle about the history of art therapy, however widespread

it might happen to be today. True, there are more than a

few German-speaking scholars who have spent years ad-

dressing this knowledge decit. Among them are Karl-

Heinz Menzen (an editor of the journal Kunst & era-

pie, which existed from 1982 to 2005), Flora von Spreti,

Karin Dannecker and, in Vienna, primarily Barbara Putz-

Plecko and the recently deceased Peter Gorsen. But de-

spite their best eorts our knowledge of the history of art

therapy remains fragmentary. Essentially, we still know

very little about it.

9 https://berufsverbandkunsttherapie.com/mitglieder/ (30 March

2020).

e purpose of science must be to reduce these gaps

in our knowledge so as to increase awareness, particular-

ly of the beginnings of art therapy. is is absolutely cru-

cial because every eld of activity, whether scientic or

artistic, needs to know about its origins if it is to develop

a critical attitude to what it does in the present.

We shall begin with the early history of art therapy in

Vienna, which is an obvious starting point in some re-

spects. After all, Vienna was the native city of ‘the major

art therapy pioneer’ Edith Kramer, who was able to leave

Austria just in time in 1938 and went on to become the

doyenne of her discipline in the USA after the war [41].

We now know a great deal about Kramer. ere are a cou-

ple of informative works about her personal and profes-

sional life, and she will no doubt nd a prominent place

in the as-yet unwritten history of the origins of art ther-

apy [42, 43].

But that history goes well beyond Kramer. She would

be a starting point for further questions and investiga-

tions, and that research would have to consider the en-

vironment in which she operated, the historical, political

and artistic parameters that shaped her work, the tradi-

tions she was able to subscribe to and those she could

not; that is, the predecessors and threads of tradition

from which she distanced and detached herself.

Delineating this context is not all that dicult to be-

gin with. Kramer herself often mentioned the people who

inuenced her development. Among them, perhaps un-

surprisingly, is Sigmund Freud, whose theories—chiey

that of sublimation—she was able to subscribe to. Anoth-

er inuential gure was the painter and designer Friedl

Dicker-Brandeis, under whom Kramer studied and

whom she supported as a teaching assistant in art class-

es for traumatized children whose families had ed from

Nazi Germany to Prague. Another inuence was Franz

Čižek, an art pedagogue who ran the so-called Youth Art

Classes (Jugendkunstklasse) in Vienna, a position from

which he pioneered nothing less than a fundamentally

new conception of art teaching. With the support of Otto

Glöckel, the longstanding president of the Municipal

Schools Council, Čižek sought to bring out the innate but

often hidden creative potential of the children he taught,

and in a variety of ways. Under Čižek’s nurturing direc-

tion, every possible form of artistic expression was exer-

cised: the children in his classes made music, sang and

played sports together. Most importantly, though, they

worked with as many dierent materials as possible. is

involved more than just drawing and painting; the chil-

dren were encouraged to experiment with clay, plaster,

textiles and glass beads; they cut shapes from colored

papers to make collages; they sawed, carved and ham-

mered. And all this, it seems, involved using the whole

body, which was quite new at the time: the children were

allowed to get up, walk around and interact with one an-

other “using all their senses”, as one contemporary put

it [44].

Ideas like these were integral to municipal educa-

tion policy in Vienna during the interwar years, which

was when they were theorized for the rst time, though

medicine and arts

medicine and arts 1 3

S18

they had been put into practice in isolated cases even

earlier. We nd the same links between pedagogical and

therapeutic purposes in nineteenth-century Vienna. e

main example of this was the Levana Institute for Health

and Education (Heilpege- und Erziehungsanstalt Lev-

ana) in Baden, just south of Vienna. Directed by author

Jeanne Marie von Gayette and reform pedagogues Jan-

Daniel Georgens and Heinrich Marianus Deinhardt from

1856, this institution for children with mental illnesses is

noteworthy for various reasons, not least because it was

the rst place to employ the term ‘therapeutic pedago-

gy’ (Heilpädagogik). e Levana Institute may only have

lasted ten years, but it was a huge success; there was sig-

nicant demand for places and an increasing number

of parents sent their sick children there. Indeed, the di-

rectors were compelled to look for larger premises due

to lack of space, which explains the move from Baden to

Schloss Liesing. ankfully we are quite well informed

about the activities of the Levana Institute, which pub-

lished its own in-house journals. Looking through these

publications we learn that the directors pursued a very

wide-ranging and essentially holistic concept of ther-

apy. One thing they regarded as particularly important

was regular exposure to the natural environment, which

is why the institute was always located on premises with

large gardens—something we can certainly appreciate

today given the current discourse on ‘healing architec-

ture’. Also, the directors were clearly convinced that craft

activities and visual art could expedite the healing pro-

cess.

“For our part we want to create a twofold training

school: one for gardening and one for certain groups of

creative work; namely for wood turning and pot throw-

ing, for clay sculpting and wood carving. […] Here we

note that progression through the classes must proceed

incrementally, according to the particular ability shown

by each pupil in this or that task, and that, where aptitude

allows, the transition from craft to art is to be facilitated

by our teaching sta [45] .”

We do not yet know whether people such as Edith

Kramer were aware of the Levana Institute in the inter-

war years. What we do know is that ideas that were de-

veloped in the nineteenth century, however sporadical-

ly, were widely discussed later on, after the First World

War, and became one of the foundations of education

and health policy in the changed political conditions in

Vienna. And the crucial thing here is that these elds—

art, education, health—were not divided and compart-

mentalized but connected to one another. Indeed, there

were several places in ‘Red Vienna’ where art was being

opened up in various directions at once and linked to

pedagogical and therapeutic methods. is interdiscipli-

nary tendency, a desire to probe and transcend discipli-

nary boundaries, is a consistent feature of the self-con-

ception of the scientic community in Vienna. One could

cite several other examples, most prominently the Vien-

na Psychological Institute (Wiener Psychologisches Insti-

tut), where Karl Bühler regularly lectured from 1928 and

where the psychology of art rst became an area of study

[46]. ese lectures were well attended, often by art his-

torians, and many students from eastern Europe and the

USA were enlisted—proof positive, if it were needed, of

the international orientation of the Vienna Psychological

Institute.

is internationalism was also typical of the gures

I have mentioned above. Čižek’s work was reviewed

with particular interest by foreign scholars [47]. As for

Dicker-Brandeis, she was part of an open network of

central-European artists who kept well abreast not only

of art and design but also of new developments in medi-

cine. Research has shown that she was familiar with the

writings of Viktor von Weizsäcker [48]. Still, it is hard-

ly surprising that such artists followed Weizsäcker, the

founder of medical anthropology and pioneer of psycho-

somatic medicine, for his work very often comes back to

a subject that was of particular interest to sculptors and

designers; namely the importance of haptics, the “sense

of touch” (Tastwahrnehmung) or “haptic form” (Tast-

gestalt), as Weizsäcker called it [49]. Indeed, during the

1920s there was much discussion of tactile qualities in

art and perception, and since the doctors had evident-

ly started to show interest in such things, it was really

only a matter of time before that discourse took on an

explicitly therapeutic dimension. So too in the Austrian

capital.

In 1923, on the Hohe Warte in Vienna, artist Viktor

Löwenfeld and art historian Ludwig Münz started work-

ing with blind children at the Israeli Institute for the

Blind (Israelitisches Blindeninstitut), which had been

in existence since the 1870s. ey encouraged them to

make clay gures in their lessons. e purpose of these

classes was to study the expressive capabilities of the

children and to investigate how blind and partially sight-

ed people conceive of forms and spaces. To determine

this the children were asked “to express their feelings,

the things that preoccupy [and] concern [them]” [50].

Although Münz and Löwenfeld’s work has never been

analyzed in much detail, we can be certain that their ex-

periments were of crucial signicance to the emerging

eld of art therapy, and so it will come as no surprise

that Edith Kramer only ever spoke of Löwenfeld with the

greatest of admiration.

To summarize the above, then: having run through the

beginnings of art therapy in interwar Vienna there are a

few striking peculiarities. First, there was clearly a denite

transdisciplinary tendency. Despite the historical back-

drop of an acutely perceived and general sense of crisis,

people started to expand and transcend the boundaries

of their disciplines. Second, this happened alongside a

clearly internationalizing tendency and in opposition to

a narrow national understanding of the scientic com-

munity. ird, the scientic conventions of the day also

shifted; the new eld of art therapy (though the term was

never actually used until the 1940s) was no longer domi-

nated by men; increasingly, women were given a say. At

the very least it is striking that the proportion of women

in art therapy, unlike most other areas of cultural and sci-

entic life at the time, was very high.

medicine and arts

1 3 S19

All this needs to be borne in mind. When we talk about

the structures and aspirations of the medical humani-

ties today, we would do well not to forget their prehisto-

ry. For it teaches us that art does not exist purely for the

sake of aesthetic pleasure; it serves other purposes, too.

Or, in the words of Austrian sculptor Karl Prantl [51], “Art

is therapy. I don’t know what more to say. Perhaps that’s

enough.”

Multisensory medical humanities: artists’ books

and illness experience

Stella Bolaki, School of English, Rutherford

Extension, University of Kent, S.Bolaki@kent.ac.uk

Portions of this essay have been previously published

elsewhere [52].

e artist’s book is a versatile medium that combines

text, image and various methods of production, for ex-

ample photography, painting, drawing, stitching, col-

lage and others. What dierentiates it from conventional

books is that it integrates its themes or aesthetic concerns

with its formal means of realization and engages read-

ers physically through its tactility and materiality. Be-

ing able to look closely and handle artists’ books makes

them uniquely accessible compared to other art objects

(for instance, an untouchable painting or print hanging

on a gallery wall). Johanna Drucker, one of the most pas-

sionate advocates of the artist’s book, has suggested that

the appeal of this medium for artists is its “intimate au-

thority” [52]. In my own research on lived experiences of

illness, I have found this concept productive to put in di-

alogue with illness narrative scholarship (Fig.15).

In the rst “wave” of the medical humanities, authori-

tative expressions of illness by patients are often synony-

mous with narrative. ese are inadequate when repre-

senting experiences that seem to resist representation or

elude closure, such as chronic pain or mental distress. My

own contribution to recent debates in the eld surround-

ing the functions and limits of narrative [53, 54] has been

to broaden approaches to illness narrative study. Turn-

ing to art forms that move beyond merely verbal modes

of expression by engaging the senses, in “Illness as Many

Narratives: Arts, Medicine and Culture”, I examined pho-

tography, artists’ books, performance art, lm, thea-

tre, animation and digital media. rough that research

I emphasized the aesthetic and imaginative elements

of illness communication that are often neglected in ill-

ness narrative study, while arguing for a more inclusive

medical humanities canon that encompasses not only

“high” literature and art, but also more experimental and

mixed-media modes [55]. My specic research on artists’

books, on which this essay focuses, attends to the distinc-

tive strategies through which this multisensory medium

can help artists/people living with illness to craft an “in-

timate authority”. is authority moves beyond narrative

legitimacy and is not reduced to merely a form of struggle

against the medical gaze. More importantly, it allows the

maker to represent lived experiences of illness in more

palpable ways than verbal or written accounts.

In the 1970s, artists’ books proliferated in the context

of the cultural revolution of the 1960s that was rebelling

against the elitism of the art world. Not situated within pro-

fessional networks of publishing or the art gallery space,

these books circulated freely in small editions thanks to

inexpensive methods of print production that were availa-

ble, cementing the idea of the book as a “democratic mul-

tiple” [56]. Among them were some books that addressed

experiences of trauma, illness and death. ey consisted

of photos, medical records, diary entries, and personal

objects, and used unusual bindings and textures. Exam-

ples include: Matthew Geller’s “Diculty Swallowing”

(1981) about the death from leukemia of the artist’s part-

ner; Scott McCarney’s “Memory Loss” (1988), inspired

by a traumatic brain injury suered by the artist’s broth-

er; Joan Lyons’s “e Gynecologist” (1989), which criti-

cizes the authority of patriarchal medical culture; and Su-

san King’s “Treading the Maze: An Artist’s Book of Daze”

(1993) that charts the artist’s experience of breast cancer.

However, even though these books confronted directly

the experience of diagnosis and treatment, and had the

capacity to spark wider debate about the changing mean-

ings of health and illness, there was little direct engage-

ment with medical humanities literary/cultural frame-

works in the 1970s and 1980s. Such engagement is now

possible because the methodologies of the medical hu-

manities in its second, more critical “wave”, have taken

a “visual turn” [57, 58]. e visual, as “an embodied per-

ceptual experience that also involves the other senses”,

such as touch, has been “welcomed as one possible al-

ternative to narrative’s longstanding dominance” in this

eld [58]. e study of a highly expressive and innova-

tive medium of bringing art to a wider public, such as the

artist’s book, therefore has the potential to contribute to

visual medical humanities that attends to the aective,

communicative and radical pedagogical possibilities of

visual and material culture.

Fig. 15 Display of artists’ books, British Academy Summer

Showcase, London, June 2019 (© Stella Bolaki. Reprint by

courtesy.)

medicine and arts

medicine and arts 1 3

S20

A variety of art forms are continuing to inform art ther-

apy, medical education and the medical/health human-

ities. However, artists’ books have been rarely explored

in relation to these elds and as distinct types of illness

narrative. Historians of medicine and medical humani-

ties scholars have concentrated on more established art

forms such as painting and sculpture when mapping the

histories of art and medicine. However, when we look to

the past, we see that Renaissance anatomical textbooks

were the products of close collaborations between anat-

omists, artists and printmakers. eir rich imagery and

theological context anticipate contemporary artists’

books that depict bodies and illness beyond strictly clini-

cal frameworks [59]. In particular, ap books, a form of

anatomy books that engage the senses, draw on many of

the formal techniques used by artists’ books. Casebooks

used by early modern medical practitioners in England

have been recently researched as artefacts of the medi-

cal encounter [60], and attention has been given to medi-

cal paratexts, ranging from the medieval to the modern

period [61]. However, this scholarship has not been con-

nected to the form and function of artists’ books in con-

temporary culture or to their role in redressing the lack

of patients’ voices in the visual culture of medicine. Even

the burgeoning area of “graphic medicine” has so far con-

centrated on graphic narratives/comic books rather than

considering some of the aesthetic and political anities

that these more popular genres share with artists’ books.

In the following sections I will elaborate on the distinc-

tive characteristics and communicative power of artists’

books by drawing on examples from an ongoing research

and public engagement project that I have been leading

at the University of Kent. e project hosted one inter-

disciplinary symposium in the United Kingdom on art-

ists’ books and the medical humanities in 2016 and an-

other in the Unites States on storytelling and the healing

arts in 2018, co-sponsored by the Maine Women Writers

Collection, University of New England. I also curated an

exhibition of contemporary artists’ books entitled Pre-

scriptions with book artist Egidija Ciricaite (Beaney Art

Museum, Canterbury, UK, 22 April–25 September 2016).

Some of the Prescriptions books were included in a dis-

play that was part of the British Academy’s 2019 Summer

Showcase in London. In addition, we organized sever-

al book-making workshops as part of the project, aimed

at patients, health professionals, artists and members of

the public. rough this project we created a new col-

lection of around 70 books, which was acquired by the

Special Collections of the University of Kent’s Library

(Templeman Library). is collection has been fully cat-

alogued and has enriched various taught programs tak-

en by our medical humanities and creative writing stu-

dents at Kent. I will discuss examples of books exhibited

and made by our workshop participants as part of this re-

search project to illustrate my reections below on the

potential of artists’ books for the medical humanities.10

How readers experience the artist’s book is a ques-

tion that remains central to their study. Breon Mitchell

characterizes the reading of an artist’s book as “a perfor-

mance”; the “ideal” reader is someone who “plays” the

book, “actualizing” the various elements the artist has

built into it, as if it were a “musical score” [62]. But this

question of how readers interact with such an intimate

medium gets complicated with books that focus on ill-

ness. As book artist/cancer patient Martha Hall has writ-

ten, “people may not want to touch the topics I explore in

my books. Yet the books invite handling, touching, inter-

action” [63]. Expanding understandings of the visual by

involving the other senses, the artist’s book mediates em-

bodied experiences of illness more directly than literary

narratives. In integrating their themes with their physical

means of production, artists’ books not only incorporate

the patient/artist’s own perspective, but show how an ex-

perience, especially those that are dicult to articulate

in words, can be made visible or tangible. e advantage

of artists’ books over literary narratives of illness then is

that they invite a participatory touch that makes them in-

teractive and sensuous forms of exchange. is has im-

portant implications for representations of illness expe-

rience and medical humanities pedagogy.

rough their expressive richness and versatility art-

ists’ books can enhance the ways in which we think

about, and experience, our bodies. e book as a form

and idea has rich cultural, spiritual and metaphorical

associations, including with the body. Words like skin,

spine and joints may refer to both the body of the book

and the human body. Books used to be bound with vel-

lum, and there are even cases where human esh has

been used, such as the pocketbook that is bound in the

skin of 19th-century murderer William Burke that vis-

itors can see in e Surgeons’ Hall Museum, in Edin-

burgh. Drawing on these associations, many of the works

that were included in the exhibition Prescriptions use the

book and its elements as a metaphor for the body or as

metaphors for particular kinds of illness. For example, an

open, yet “frozen” book corporealizes a rare condition of

the nervous system in Ashley Fitzgerald’s altered book

“G.B.S.” (the title standing for Guillain-Barré Syndrome).

rough its form, including its static pages, the book cap-

tures the artist’s bodily experience better than any narra-

tive. Similarly, Lizanne van Essen’s sculptural book “Os-

teoporosis” exhibits the characteristic holey appearance

of osteoporotic bone to display rather than inform about

this condition [64] .11

Inspired by books like these, I collaborated with Amer-

ican artist Darian Goldin Stahl with whom I organized

10 More information about the ‘Artists’ Books and Medical Hu-

manities’ project can be found at: https://research.kent.ac.uk/

artistsbooks/ (30 March 2020).

11 Images of most artists’ books discussed in this essay can be

viewed from our exhibition catalogue Prescriptions, https://

research.kent.ac.uk/artistsbooks/catalogue-preview/ (30 March

2020), an Index contains all book titles.

medicine and arts

1 3 S21

a series of hands-on workshops that Stahl has named

“Book as Body” workshops (Fig.16). As a book artist and

medical humanities researcher, Stahl is interested in

guiding medical professionals (as well as other partici-

pants) to use the artist’s book format as a bodily proxy,

that is, to employ it to sensorially materialize a symptom

or experience outside of the body so that it may become a

shareable and tacit form of communication. 12

One of the “Book and Body” workshop participants

transformed his book in a very imaginative way to de-

pict the pressure felt within his body. As Stahl has written

about this book [65]:

“For this sculptural book, balloons (representing his

mind) are being contained and kept in check by paper

and thread (his body)–but just barely. Taking inspiration

from the harmonious, geometric, and primary colored

paintings of Mondrian, this participant turns that order

on its head to evoke the chaotic opposition between his

mind and body. Although the lopsided pages bend under

the pressure of the balloons, there is nevertheless a com-

positional balance in his book’s tension, because he is

‘still trying to nd some sort of order within that chaos’.”13

“Illness as journey” is a dominant way of represent-

ing illness experience, but non-linear or open-ended

narratives are better suited to some experiences, such as

chronic illness. Anne Partt’s “Diary of an Illness” which

featured in the Prescriptions exhibition captures this dif-

ference in a palpable way. Her concertina book consists

of repeated black and white sequential drawings of an or-

namental bottle, each drawing “an imitation of the previ-

ous, yet never identical… mirroring the indistinguisha-

ble yet unique nature of each moment” [64]. In retaining

sequence, one of the main structural features of the book

form, but refusing closure, works like Partt’s expand

awareness of the complexity of illness experiences that

resist established forms of narration. e focus on the

12 For the workshop methodology, watch the following video by

Darian Goldin Stahl: https://research.kent.ac.uk/artistsbooks/

darian-goldin-stahl-book-as-body-workshop/ (30 March 2020).

13 An image of this book can be seen at: https://medicalhealth-

humanities.com/2019/05/01/the-artists-book-as-body/ (30 March

2020).

ever-present or enduring nature of illness experience, as

Partt waits for diagnosis and treatment, also reveals that

patients rarely perceive the temporality of illness in the

same way as their physicians.

Clinicians, scholars and members of the public have

privileged particular types of evidence and ways of pre-

senting or sharing knowledge about health. ese include

third person reports, medical data, and illness represen-

tations that emphasize linearity, coherence and closure.

Such emphasis generates “epistemic injustice” [66] and

leads to stigma, silence and sometimes poor treatment.

It also ignores the aesthetic achievements of illness nar-

ratives, in other words creative responses to illness that

are not reduced to representing a clinical encounter. Art-

ists’ books counter epistemic injustice through their “in-

timate authority”, even when they address the invisibility

of being a patient. For example, for her book “Unknown”,

also part of a live performance, Carole Cluer considered

the number of people diagnosed with breast cancer in

the same year as her (45, 704 in 2004). Her book consists

of pages and pages of identical looking hand-drawn gold-

threaded grids of blue dots (based on the measurements

grids and tattoos used when one has radiotherapy), each

dot representing one person, anonymous like her. “Un-

known” makes us feel beyond what we can merely see; as

we turn the pages of her book, we experience viscerally

the artist’s attempt to connect with other cancer patients

through this creative aesthetic intervention. A similar

book that relies on repetition is “Prescriptions”: a set of

embossed white prints inside a white box that represents

the amount of pills Lizzie Brewer took during ve years

of cancer treatment. ere is no personal narrative, and

the choice of white color throughout conveys the clinical

world inhabited by the artist. However, through the tac-

tile reading it invites, the book still manages to draw us in

to witness not only the artist’s vulnerability but also the

agency involved in making that particular work.

Dominant metaphors in medical education, such as

the ‘body as machine’, perpetuate the dehumanizing and

objectifying aspects of medical care [67]. Artists’ books

can disperse the medical gaze by opening up the idea of

the body as traditionally understood by medicine. ey

can help reignite a sense of “wonder” and mystery when

it comes to confronting our bodies’ materiality that re-

veals its importance “in other ways than as the contest-

ed or reductive objects of the biomedical gaze” [68]. One

example from the Prescriptions exhibition is Véronique

Chance’s “In the Absence of Running”. Removed from

its original context of technically advanced medical vis-

ualization, the oversized image Chance created by put-

ting together her knee scans taken during surgery (and

later turned into a ip book) resemble a wondrous lunar

landscape. Similarly, “On Innards”, a collaboration be-

tween Amanda Couch, Andrew Hladky, Mindy Lee and

Richard Nash, cleverly embodies through its multitude of

folds, the intestines. e book is held together by a mes-

enteric binding, which when unwound allows the book

to be fully experienced by the reader. Another example

is Julie Brixey-Williams’s “Rosebud”, an original book-

Fig. 16 Image from „Book as Body“ workshop led by Darian

Goldin Stahl, Canterbury, March 2019 (© Emma Bainbridge.

Reprint by courtesy.)

medicine and arts

medicine and arts 1 3

S22

work that reimagines the breathing patterns of a subject

under general anesthetic as a series of ow-loop wave-

forms. ese calligraphic traces were created by an anes-

thetic machine as the artist performed an extended read-

ing of the fairy tale “e Sleeping Beauty” (whose words

are printed on the book’s voluminous ribbon). Finally,

the body is mapped dierently in Lise Melhorn-Boe’s

meander book “Body Map” that consists of square pag-

es, each with a section of the artist’s photographed body.

Hand-printed text on top of the photos contains person-

al references (written directly on each part of the body)

and researched information about environmental haz-

ards (written around the body). In all these ways, artists’

books can “re-enchant” [69] illness narratives as they in-

vest in alternative images that fall outside strictly clinical

frameworks.

It is clear through these examples that rather than

merely serving an illustrative role, the visual and other

formal aspects of artists’ books have a defamiliarizing

function that can be very productive, especially for med-

ical professionals who are traditionally resistant to am-

biguity. e value of visual culture for the medical hu-

manities is however not merely instrumental, that is,

educational or humanizing. With regards to her artist’s

book “On Innards” that establishes connections across

elds such as gastroenterology, virology, cultural theo-

ry, poetic practice and yoga, Couch has written: diges-

tion “stems from the word ‘digest’, which can both refer

to an arrangement of written work; and to the processing

or making sense of knowledge and experience, as well as

to break down and absorb food” [64]. Similarly, Brixey-

Williams’ “Rosebud” (2004) that emerged from the art-

ist’s residency at e Association of Anesthetists of Great

Britain and Ireland is an example of an interdisciplinary

experiment that attests to the “shared set of interests”

[58] between the histories of medicine and art.

In addition to becoming a metaphor for the kind of

gentle care a patient may want, the slow movement that

artists’ books often require during handling create “a

space for a contemplative experience” [64]. is ritual-

istic and meditative dimension of artists’ books was ex-

plored in “No Mind” by Gaby Berglund Cardenas that

contains 1.65-meter-long ink calligraphy script repeat-

ing the words “no mind”, a Zen expression equivalent to

being present. “Like Weather” by Amanda Watson-Will,

a ag book that highlights the changeable nature of our

moods by drawing on the Buddhist idea of the mind as a

cloudy sky, also developed from the use of mindfulness

as technique. In the specic context of healthcare, where

routine and impersonal interactions frequently turn pro-

fessionals into automatons, a space, often silent, where

awareness and presence can be restored, is essential.

Even though this gap is being addressed through an em-

phasis on reection, as some medical humanities critics

have noted [70], reection tends to become synonymous

with narrative or with writing within medical education.

In contrast, making or reading artists’ books can facilitate

an alternative kind of reection that engages both body

and mind [64].

Finally, as a multisensory space the artist’s book can

renew modern healthcare’s faith in human touch. One

of our workshop participants who educates nursing stu-

dents constructed a book of pages, each with an outline

of an identical human hand, cut from dierent materi-

als. e nal few pages are stamped with progressively

fading ink prints of her own hand. “Hands”, she told us,

“are such an important part of nursing care” [64]. e -

nal pages of her book are emblematic of current nursing

trends which put technology between carer and patient,

thus reducing physical contact to a bare minimum. Such

lack of physical contact has potentially serious implica-

tions: for example, there is concern that health profes-

sionals such as surgeons don’t acquire sucient dexter-

ity skills in a digital world, and that crafts and arts might

help redress this phenomenon [71]. But it also illumi-

nates how technology, as many of the books that were in-

cluded in the Prescriptions exhibition powerfully show,

has dramatically changed how health professionals in-

teract with their patients.

In conclusion, as experimental and multimodal forms,

artists’ books encourage us to reect on, and experience

in practice, the importance of not merely what we read

but also how we read. I hope this essay’s examples and

accompanying reections have illustrated the value of a

multisensory medical humanities for patients and health

professionals, as well as for how we conceptualize knowl-

edge more broadly, especially in an increasingly digital

world. I am planning to develop this research in the fu-

ture in relation to specic healthcare contexts, enhanc-

ing the communal and participatory elements of the pro-

ject through additional workshops and exhibitions. My

aim is not only to study the history of artists’ books and

medicine for scholarly goals, but also to examine how

this innovative art form can support people living with

illness in their struggle for recognition and legitimacy by

making their experiences more palpable and shareable.

Medicine and Music

Music therapy in neonatology—an introduction to

clinical practice and research

Leslie Schrage-Leitner, University of Music and

Performing Arts Vienna, schrage-leitner@mdw.ac.at

Thomas Stegemann, University of Music and

Performing Arts Vienna, stegemann@mdw.ac.at

Supported by the University of Music and Performing

Arts Vienna, mdw-initiative “Kunst & Gesundheit”

Introduction

Due to highly promising research ndings in the eld,

music therapy in neonatology has gained worldwide rec-

ognition during the last two decades. It has proven to be

especially eective in neonatal care—both in babies and

medicine and arts

1 3 S23

parents [72–79]. We will present a brief overview of the

clinical application of music therapy in neonatology, in-

cluding an overview of current research in the eld. In

addition, we will describe a study taking place in the De-

partment of Neonatology of the Medical University of Vi-

enna/Vienna General Hospital. is randomized con-

trolled trial (RCT) comparing music therapy intervention

with treatment as usual is a cooperation between the

University of Music and Performing Arts Vienna and the

Medical University of Vienna.

Music therapy in Austria

Ten years ago, in 2009, the Austrian Music erapy Act

came into eect. According to this law, music therapy

(MT) by Austrian law is dened as an “independent, sci-

entic, artistic, creative and expressive form of therapy.”

Currently (i. e., November 2019), 424 music therapists

are registered on the Austrian Federal list of music ther-

apists.14 Approximately one in four music therapy work

places (23.2%) are located in hospitals [80]. While mu-

sic therapy with children and adolescents having devel-

opmental or behavioral problems represents the largest

sector of the eld (22.5%), music therapeutic work in ne-

onatology (0.5%) is still expanding.

Music therapy in Neonatology

In cases of premature birth, the challenges for the child

and his family are numerous—the dicult intensive care

situation (e. g., lack of intimacy, noisy environment); in-

vasive, painful interventions; and isolation of the incuba-

tor to be endured. Mothers and fathers (each in their own

way) are often traumatized by the overwhelming experi-

ences, are constantly worried about their child’s surviv-

al, and have diculties establishing a relationship with

their newborn. Many parents, afraid of the fragility of the

child, experience their own isolation and alienation out-

side of the incubator. is may have potential long-term

consequences for the relationship between mother, fa-

ther, and child: e fears between them remain unpro-

cessed and limit the child’s developmental space.

Basic principles that guide the therapeutic approach

e child’s sense of hearing is usually mature, even if

a child is born prematurely. is ability, together with

their special responsiveness to musical stimuli [81], the

sense of touch, and the child’s search for contact, form

the neurophysiological basis for therapeutic interven-

tions. e following principles—based on personal expe-

riences and (music-)therapeutic approaches [82–86]—

form a scaold for the music therapy work described in

this overview:

14 www.musiktherapeutenliste.at (30 March 2020).

• Immediately after birth, babies show an interest in au-

ditory stimuli. e sonic level oers the opportunity

to come into direct pre-verbal contact with the child.

• Musical parameters of infant-directed speech, infant-

directed singing (humming), and music in the form of

lullabies, for example, are a traditional and global part

of communicating with newborns [87].

• e therapist’s voice establishes a direct connection to

the child, enabling basal communication and rst ex-

periences of infantile self-ecacy [82].

• e child’s general state of health is inseparably linked

to its condition. Physical and emotional well-being

form a unity.

• For involving the parents, it is important for a music

therapist to “hit the right tone.” e parents’ own mu-

sical experiences can point the way to nding a re-

laxed form of communication [88].

Aims of music therapy in Neonatology

As a non-invasive form of therapy for newborns, prema-

ture babies, and their parents, the music therapist focus-

es on the following:

Short-term aims with these babies and their families

are relaxation, stress reduction, support of the child’s

self-regulation, stabilization of vital signs and sleep be-

havior, and improved stimulus processing; short-term

aims concerning the parents are coping, bonding, and

empowerment. Long-term goals can be dened as: a) de-

velopmental support of the premature child, b) support

of the abruptly interrupted attachment process between

parents and child, and c) individual support of maternal

(and paternal) coping with the perinatal traumatization.

Music therapy methods and techniques

e music therapy takes place 2–3 times a week next to

the child’s bed (incubator, neonatal warming system),

ideally takes 20–30 minutes, if possible with the partici-

pation of the mother, but also of the father and/or other

close relatives (siblings, grandparents). e initial con-

tact oer is made via sound: vocal and/or instrumental;

using her or his voice, the therapist is mainly humming.

Instruments used are typically therapeutic string instru-

ments, played by plucking the strings [87]. e music

therapist tries to respond directly to the child’s expres-

sions: its gestures and facial expressions, breath, and vo-

cal utterances can be integrated into the music and thus

carefully modied.

If a child reacts positively, it gets further support of

self-regulation, and the musical oer is gently extended,

e. g., shaping individual notes into a melody (see case vi-

gnette below). If a child shows signs of rejection, it will

receive a prompt reaction in the form of a break. A fur-

ther attempt with a modied intervention will possibly

follow, or sometimes the session will be cancelled for this

time. If possible, the mothers (and fathers) are included

in the session, and receive support and reinforcement

for getting involved by observation, by personal vocal

medicine and arts

medicine and arts 1 3

S24

expression, or by basic communication with their baby.

If mother or father needs to have a verbal exchange and

counseling, there is also room for this. Fig.17 oers in-

sight into music therapy in the NICU with an infant born

preterm.

Case vignette

B., born in the 27th week of gestation, is lying in the incu-

bator due to instability (respiration, thermoregulation);

the child’s parents are present, observing intently, and

involved. e music therapist perceives the high arous-

al of the child, which is evident from the clenched sts,

stressed facial expressions, and motor restlessness, and

can be read on the monitor in the form of increased res-

piratory and heart rates, and uctuating oxygen satura-

tion.

e music therapist begins to very softly hum single

notes. e child pauses, turns to the “source of noise,”

and relaxes a little. e music therapist interprets this

reaction as a sign of approval and shapes the individu-

al notes into a melody. In this moment, the child turns

away, and the tension rises again. e music therapist

takes this reaction as a sign of irritation, withdraws a lit-

tle, and invites the child’s father to turn to his child and

hum for him. After a brief moment of uncertainty, the fa-

ther joins in. e child relaxes, drops his hands, closes

his eyes, and falls asleep with a deep sigh.

In this vignette we can see how the father loses his in-

hibition to actively communicate with his child: e fa-

ther-child bonding process is encouraged. Furthermore,

the father can observe the positive consequences of his

involvement, as his child relaxes and falls asleep. is

positive experience supports the father’s coping and em-

powerment.

In addition to medical therapies, music therapy oers

relationship in a tense atmosphere. e medium of laid-

back musical communication supports the self-regula-

tion of the immature newborn and facilitates—in exten-

sion to the verbal level—the encounter between parent

and child, the opening to one another, and the parental

perception of their child’s resources. is process can be

initiated and supported at a time when the diculties

confronting the child’s parents often cannot yet be ver-

balized, verbally processed, and/or integrated. Based on

the strengthened individual resources, the formation of

the parent-child relationship can be promoted. Space for

development and growth will be opened and expanded.

Research

According to a recent literature overview of music ther-

apy and other music-based interventions in pediatric

health care [89], the highest quality of evidence for posi-

tive eects of music therapy is available in the elds of

autism spectrum disorder and neonatal care. e main

ndings of this overview reveal that music therapy and

other music-based interventions in neonatal care lead

to a reduction in heart and respiratory rate, improve the

infant’s sleep and food intake, and reduce the anxiety of

mothers. In addition, it has been found that the length of

stay in NICU can be signicantly reduced through music

therapy interventions.

In summary, there is growing evidence from RCTs and

meta-analyses that music therapy in infants born pre-

term has signicant, clinically relevant positive eects

on arousal, general state of health, and well-being of the

baby as well as on psychological outcomes (e. g. anxiety)

of the mothers. However, more well-designed and high-

quality research—such as taking account of short- and

long-term eects of music interventions on brain func-

tion and development—are needed [90].

“Music therapy as an accompanying intervention in

inpatient preterms at risk” (PhD project)

As a cooperative project between the University of Mu-

sic and Performing Arts Vienna and the Medical Univer-

sity of Vienna/General Hospital Vienna, the rst author

is currently carrying out a study within the scope of her

doctoral research within the Division of Neonatology at

the University Children’s Hospital Vienna, Medical Uni-

versity of Vienna/Vienna General Hospital. is study

aims to investigate the eects of music therapy as a sup-

portive measure on a) the general condition of the child

during inpatient stay, b) the contact between parent(s)

and child, c) the development of the babies after 12

months, and d) changes in parental condition during the

inpatient stay of their child.

In a prospective Randomized Controlled Trial (RCT),

120 preterm neonates (<32 weeks of gestation) are divid-

ed 1:1 into neonates receiving music therapy plus stand-

ard treatment and a control group receiving only stand-

ard treatment. If possible the mother, but also the father,

could be present. Beginning during the rst 21 day after

birth (this time span constitutes a small fraction of the

neonates’ overall hospital stay), the treatment continues

for the entire hospital stay, with two 30-minute music

therapy units applied weekly.

Fig. 17 An insight into the music therapy in the NICU with

an infant born preterm (© Leslie Schrage-Leitner. Reprint by

courtesy.)

medicine and arts

1 3 S25

e child’s behavior is observed and documented be-

fore and after the intervention, based on observational

criteria. In addition, the child’s vital functions (heart rate,

oxygen saturation) are documented. When the mother

(also the father) is present, the parent-child interaction is

observed, supported as needed, and subsequently doc-

umented (qualitative research). Developmental control

(with corrected 12 months) and comparison of the exper-

imental and control groups is carried out at their follow-

up examinations in the context of neonatal follow-up by

the Outpatient Department of the Vienna General Hospi-

tal (quantitative research).

e following areas are investigated with the specied

assessment tools:

a) Outcome data from children born before the 32nd

week of pregnancy are routinely examined, docu-

mented, and evaluated as part of the Newborn Af-

tercare Program of the Vienna General Hospital. e

entire assessment includes a standardized review of

neurological and cognitive development. Of particu-

lar concern is the cognitive assessment of our cohort

at the age of one year based on the “Bayley Scales of

Infant Development”, third edition (BSID III).

b) Parental condition is assessed during inpatient treat-

ment by means of questionnaires (pre-post design)15,

and are incorporated into the music therapy study.

ese questionnaires must be completed by the par-

ents within the rst two weeks of their child’s hospi-

tal stay (pre-) and within two weeks before discharge

(post-).

e following preliminary results have been obtained:

To date, 23 follow-up examinations have been car-

ried out. Due to the small sample size, quantitative re-

sults have to be handled with care. Measuring the vital

signs of all 23 children in a total of 192 music therapy ses-

sions revealed signicant improvements in oxygen sat-

uration and heart rate regulation. All23 mothers in the

music therapy group (the fathers of only two of the chil-

dren were constantly present and taking part) intensied

the contact with their child and were encouraged to have

vocal interactions with him. Nineteen mothers and one

father began to hum with their babies, seeing their child

responding to it and enjoying it, which increased their

willingness and motivation to communicate with their

baby. e children were able to relax through the mu-

sic-based interventions and showed positive reactions to

their parent’s activities (for example, turning their eyes

towards the parent, relaxing, smiling). In three of the pre-

mature children, the nurses reported prolonged sleep di-

rectly after music therapy.

Of the women, 20 out of 23 took the oer for therapeu-

tic discussion several times. Typical discussion topics

were the strain of unexpected events, the great concern

for the child’s life, and the diculty of doing the right

Dür M, Brückner V, Fuiko R et al. Fragebogen zur Betätigungs-

balance bei pe genden An gehörigen, 2019.

thing in the current situation (for example, dealing with

the child’s siblings at home).

Conclusion

From my personal experience (LSL), among hundreds

of children, there was not one that could not be touched

and regulated by music-based interventions, none that

was totally unable to come into contact through sound.

To help ensure the quality of music therapy in NICU,

and also to prevent the unprofessional use of “music

stimulation” in neonatology, the “Fachkreis Musikthera-

pie Neonatologie”, a group of music therapists from Ger-

man-speaking countries, has compiled its many years of

expertise. In the form of a framework, they worked out

general requirements, indications, and contra-indica-

tions as well as therapeutic goals and methods, to share

their experiences with interested professionals and mu-

sic therapists-to-be in this important and growing area

of work [86].

“Every illness is a musical problem, healing a

musical resolution.” (Novalis)

Klaus Felix Laczika, Medical University of Vienna,

Department of Medicine I, Division of Palliative

Care, klaus-felix.laczika@meduniwien.ac.at.

Gerhard Tucek, Institute Therapeutic

Sciences, IMC University of Applied Sciences,

gerhard.tucek@fh-krems.ac.at

Walter Thomas Werzowa, HealthTunes,

The MusicMedicine Consultancy,

walter@musikvergnuegen.com

e authors are gratefully indebted to Oliver Peter Graber

as well as to Adrian Krois, Jan Vagedes and Ludwig Traby.

is paper is dedicated to Klaus Felix Laczika’s parents

as well as to Augustinus Franz Kropfreiter, Karl Werzowa,

Prof. Franz Wall, Friedrich Gulda, Sergiu Celibidache,

Irene Gernert and Liina Leijala.

Novalis: A starting point

Novalis (Georg Philipp Friedrich Freiherr von Harden-

berg (1772–1801, poet and philosopher) was a vision-

ary, but his important message remains widely unheard

in our days. His statement: “Every illness is a musical

problem, healing a musical resolution,” contains enough

compelling force to create another medicine, another so-

ciety. Has it happened? Instead of setting music at the top

of the list in the eld of medicine, we still face a socie-

ty that mostly lacks any insights into the benets of seri-

ous music therapy. Normal people, as well as medical ex-

perts, often do not know how music therapy really works

and therefore fall prey to proteers: Buying a “therapy

CD” at any health food store does not guarantee feeling

better after listening—often it may have the opposite ef-

fect. ere are many dierent ”-ists” in medicine nowa-

medicine and arts

medicine and arts 1 3

S26

days, but there is still not a single “music-medicine”-ist

on this planet. Our society and medical system are still

waiting for this subject area and specialization—what

must happen to improve this unsatisfactory situation?

Novalis: Poetry

First, please let us face the music! Since we really want

to make multi-sensory understanding possible, we have

linked this paper with short clips16 in order to acoustical-

ly illustrate our explanations. You can nd all the videos

there; or just follow the upcoming links step by step while

continuing to read this paper.

People often start to confuse the term “music” with

the general term “song” [91], which becomes a problem

in the medical sciences, too. Instrumental music is al-

most absent from the elds of Pop, Rock, Country, Hip-

Hop, or R&B. As a result, students of music therapy—as

well as other younger people who are used to streaming,

“playlists,” and popular music styles—tend to apply the

term “song” to every type of music, whether it be a song

or a sonata, a fugue or a symphony.

Of course, music and language are deeply interwo-

ven in many dierent ways. “Sunny,”17 for example, is a

jazz song written by Bobby Hebb in 1963. He wrote the

song after the assassination of John F. Kennedy and also

in the wake of a personal tragedy: Hebb’s older brother

Harold had been killed in a ght outside a nightclub. e

lyrics and the theme word “sunny” show Hebb opting for

a sunny outlook on life rather than a depressed or dark

view. Returning to our original starting point of Novalis,

we want to think more here about the “rules” of poetry:

especially its metrical structure, or versication.

Ludwig van Beethoven (we are celebrating his 250th

birthday in 2020) had a lifelong obsessive interest in

prosody—the “rules” that guide the combination of lan-

guage with music when composers plan to write a vocal

score. Beyond vocal applications, he also implemented

these rules in instrumental music. For example, the dac-

tyl is like a nger, having one long syllable followed by

two short syllables. We see this in the second movement

of Beethoven’s 7th symphony18, which is based on a “dac-

tylic tetrameter” (Fig. 18); when you become aware of

the accents of the music, you can hear this easily. Do you

need more examples? Beatles fans could think of the lyr-

ics: “Pic—ture your—self—in—a—boat—on—a—riv—

er—with” (double-dactyl, accents given in bold) used in

their song “Lucy in the Sky with Diamonds” or say the

trochaic “Peter, Peter, pumpkin-eater.

Versication takes place in many languages, but we

want to highlight some examples from a very dierent

language: Finnish.

16 vimeo.com/user/77123650/folder/1141439 (30 March 2020).

17 vimeo.com/healthtunes/review/372552581/5638414b81?sort=la

stUserActionEventDate&direction=desc (30 March 2020).

18 vimeo.com/healthtunes/review/372551598/14a2d456a1?sort=la

stUserActionEventDate&direction=desc (30 March 2020).

e Finnish national epic Kalevala, like much old

Finnish poetry (e. g., “Kalevipoeg” as well as Balto-Finn-

ic—Estonian, Finnish, Karelian, etc.—folk poetry), not

only inspired the great Finnish composer Sibelius but is

written in a variation of trochaic tetrameter that has been

called the “Kalevala meter.” Its main rules are: Syllables

fall into three types—strong, weak, and neutral. A long

syllable (one that contains a long vowel, or a diphthong,

or ends in a consonant) with a main stress is metrically

strong, and a short syllable with a main stress is metrical-

ly weak. All syllables without a main stress are metrically

neutral. A strong syllable can only occur in the rising part

of the second, third, and fourth foot of a line: Veli/kul-

ta,/veikko/seni (“Brother dear, little brother”); accents

are indicated in bold, and all examples are from the Ka-

levala. A weak syllable can only occur in the falling part

of these feet: Miele/ni mi/nun te/kevi (“I have a mind

to”). Neutral syllables can occur at any position. e rst

foot has a freer structure, allowing strong syllables in a

falling position and weak syllables in a rising position:

Niit’ en/nen i/soni/lauloi (“My father used to sing them”)

and: vesois/ta ve/tele/miä (“Others taken from the sap-

lings”). e Kalevala meter is very old and is thought to

have originated during the Proto-Finnic period. Can we

still nd it today? Ever heard that Donna Hightower’s

most successful record, “is world today is a mess”19

(which she co-wrote) is based on a trochaic rhythm fol-

lowing the pattern “Ne—ver—do—to oth—ers what—

they—do—to (you)”?

e ancient rules of versication—i. e., ancient rules

of rhythm and meter, two central musical parameters—

still “rule” today! To nd our way back to Beethoven’s

epoch, we’ll give a nal example, this time in German:

An iamb (or iambus) is a metrical foot used in vari-

ous types of poetry. Originally the term referred to one

of the feet of the quantitative meter of classical Greek

prosody: a short syllable followed by a long syllable (as

in the word “above”). is terminology became part of

the description of accentual-syllabic verse in English,

where it refers to a foot comprising an unstressed syl-

lable followed by a stressed syllable (as in “a-bove”).

“Wanderers Nachtlied” (“Wanderer’s Nightsong”)20

is the title of a poem by Johann Wolfgang von Goethe,

written in 1776, and is among Goethe’s most famous

works. e poem was set to music by Franz Schubert.

19 vimeo.com/healthtunes/review/372552224/9e32c3f18d?sort=la

stUserActionEventDate&direction=desc (30March 2020).

20 vimeo.com/healthtunes/review/372553342/6e6c9da262?sort=la

stUserActionEventDate&direction=desc (30March 2020).

Fig. 18 Dactylic Tetrameter“, the basis of the 2nd move-

ment of Beethoven’s 7th symphony (from https://imslp.org/

wiki/Main_Page, the freely accessible musical score library,

accessed on 30 March 2020. Content is available under the

Creative Commons Attribution-ShareAlike 4.0 License.)

medicine and arts

1 3 S27

Some of its rhymes follow the iambic pattern: “Ü—ber

all—en Gipfeln—ist—Ruh. In all—en Wipf—eln spür—

est—Du kaum einen Hauch.”

To one familiar with the background of versica-

tion, it becomes evident that Novalis, a poet and phi-

losopher who had to deal with many dierent as-

pects of language daily, gained deep insight into music

as well as the interconnections of music, language,

and physiology: eir common core is—breathing!21

at is also why he once stated: “Poetry is the great art of

constructing transcendental health. e poet is the tran-

scendental doctor.”

Novalis: Philosophy

To repeat: Music and language are well connected, but

please don’t talk only about “songs.” Don’t forget that

purely instrumental music oers, in addition, countless

possibilities for music therapy that transcend the lim-

itations of knowing a specic language. People are fas-

cinated to learn about “phrasing”—the hidden rules of

breathing in instrumental music.

Seldom has any composer created more “transcen-

dental poetry,” more “philosophy,” and more breathing

within his scores than Novalis’ contemporary, Wolfgang

Amadeus Mozart. Based on the assumption that music

breathes and Mozart’s music represents the phrasing (in

other words, the musical breathing) in an ideal way, the

score of his Piano Concerto KV 449 makes this breathing

appreciable and apparent. On top of that, breathing pat-

terns become the focus of attention for the musicians as

well as the audience. Based upon such a collective, sen-

sorily perceptible “ventilography,” the coupling of music

and physiology takes shape.

Back in 2008, in the course of the “St. Florian Bruck-

ner Days,”22 one of us (KFL) conducted a very special in-

vestigation into the interaction between musicians, the

audience, and a musical masterpiece: He performed

Mozart’s Piano Concerto No. 3 in E-at major, KV 449,23

together with string players who were members of the Vi-

enna Philharmonic Orchestra. Before the performance,

20 healthy and willing members of the audience, as well

as the 11 musicians including the piano soloist/conduc-

tor, were wired with a heart rate variability (HRV) record-

ing system (Schiller: Medilog® AR12). During the per-

formance, this device recorded the HRV and breathing

patterns of all the participants. A synchronized high-de-

nition video/audio recording was made at the same time.

Later, an overlay of all these data onto the musical score

was done by hand, using music notation software (FINA-

LE 2011) and the GIMP 2.0 graphics program. In paral-

lel with the medical/technical analysis, a formal musical

21 vimeo.com/healthtunes/review/381053058/cd3197754d?sort=la

stUserActionEventDate&direction=desc (30March 2020).

22 www.brucknertage.at (30 March 2020).

23 vimeo.com/healthtunes/review/372553706/e36f1aaea6?sort=las

tUserActionEventDate&direction=desc (30March 2020).

analysis of the score created insights into the style and

structure of the composition.

e results of this study [92] increased our under-

standing of two archetypes of breathing and breath tech-

nique by professional musicians: e rst (“driving”)

archetype serves the technical playing and interpreta-

tional requirements and, with them, the compositional

structure of the movements; the second (“driven”) can

be considered an expression of the adaptive experience

of the mutual music making. It became clear that such

correlations only become visible when there is a detailed

consideration of the musical text and a corresponding

graphic appraisal that takes into account the music theo-

retic analysis. In addition, the correlations elude statisti-

cal capture because, in relation to the very same “musi-

cal stimulus,” they tend to exhibit highly signicant but

contrary patterns.

For a better understanding of these essential elements,

we will discuss selected highlights from this study’s re-

sults. Unfortunately, almost no other studies published

in the last decade [93] were able to add more insight to

this phenomenon—a concrete sign that the eld of mu-

sic-medicine is highly underrated and under-researched!

is is becoming especially evident during the “Beethov-

en year 2020”: Everyone is talking about the First Vien-

nese School (consisting of Joseph Haydn, Wolfgang Am-

adeus Mozart, and Ludwig van Beethoven), but society

still ignores the medical potential of this cultural treasure

as well as its implication for medical humanities.

Breathing behaviour in professional musicians pro-

pels musical creation, performance, and experience,

which in turn are propelled by the musical structure it-

self. ese archetypes also enable various levels of syn-

chronicity and coordination between the performers, the

audience, and the musical structure. is threefold com-

munication is manifested in a statement by Joseph Haydn

who, as a guest of Count Esterhazy, wrote that “my Count

was happy with all my work, I was applauded, I could ex-

periment as the conductor of an orchestra, I could ob-

serve what creates an impression and what weakens it,

and thus improve, add, take away, dare. I was cut o from

the world, nobody could confuse and torment me, and

so I had to become original.” In a direct comparison be-

tween the musical structure and the breathing activity,

typical patterns appear to be in accordance with a direct

“bilateral interaction” between music and physiology.

e example of two viola players playing at one desk

demonstrates that their breathing correlates with the

activity of the instrument (and responds to its require-

ments). is physical response related to the instrument

can also be subject to interference from other musicians

and forms a “foreign stimulus” (with regard to resonance

and synchronization).

Musicians also possess profound knowledge re-

garding the central role of the musical upbeat, which

acts as a clear and well-dened inspiration(!). Due to

their education process, musicians can use their in-

spiration as an aid to mastering metrical dicul-

ties (so-called “counting music with the body”). Typi-

medicine and arts

medicine and arts 1 3

S28

cal breathing is on display in the following example24

of the second violins (bars 46/47, treble clef ). is upbeat

represents a “dialogue”/responsorial event in the sense

of question and answer breathing (see bars 42, 44, and

46.) ere is another “question and answer” situation

in the “breathing dialogue” between the solo piano and

the upper strings in bars 41–44 (upper piano sta, treble

clef; lower sta, bass clef; strings: both staves are treble

clef). e accented notes for producing the grace notes

are clearly discernible.

At bar 44, the players at the leader’s desk change their

breathing from active breathing (“driving”) shaped by

the music to passive breathing (“driven”) while, at the

same time, their breathing line adapts to the events in

the solo piano part. us far, the “synchronization” be-

tween elements that appear in the score and the pat-

terns of breathing correlated with them represents in-

strumental professionalism on the part of the performers

and is therefore neither surprising nor accidental. is il-

lustrates how closely physiological parameters are con-

nected with musical elements and musical structure. We

want to point out that this is also of signicance for shap-

ing the composition, as well as for the eectiveness of

Mozart’s music in the eld of music therapy.25

In the area of instrumentation, questions of funda-

mental signicance are: How much breath does a specif-

ic instrument need in order to execute tone groups; and

how much time, for example, may slurs require as a result,

in relation to the stipulated sound volume and register. A

brief aside: In the summer of 1784, Mozart interrupted

the score at precisely this point, namely at bar 41, in order

to study Joseph Haydn’s new string voicing technique as

exemplied in Haydn’s string quartets. is interruption

lasted a full four months; then Mozart resumed his com-

position. is moment is visible in the score in the demi-

semiquavers of the violas. ese bars, therefore, might

arguably include the composer’s predominant inuence

(Joseph Haydn) and depict “a volcanic eruption of tran-

scendence.” In other words, this strange oscillating mo-

ment in the composition, free of any signicant melo dic

characteristic, forms a signicant moment in Mozart’s

personal musical development. Physiological data made

it clear that this outstanding moment still “moved” the

musicians, and even the audience, in 2008!

Novalis: Romanticism

Synchronization of the breathing activity of listeners of-

ten presents itself as “integer valour” (whole-bar-breath-

ing), in accordance with the ndings of Haas etal. [94],

which can be attributed to the basic compositional struc-

ture of Mozart’s piano concerto and the musical shap-

ing. In the course of breathing in the “pulse” of the com-

position, there is a corresponding increase in listeners’

24 vimeo.com/healthtunes/review/374085966/cec8ba41ec?sort=la

stUserActionEventDate&direction=desc (30March 2020).

25 vimeo.com/healthtunes/review/372581329/920686a225?sort=la

stUserActionEventDate&direction=desc (30 March 2020).

HRV involving increased activity or excitability of the va-

gus nerve. In relation to the special position of bar 41 as

described above, signicant alterations in the HRV arise

which, in accordance with musical analysis, correlate

directly with musical expectations and the formal and

structural course of the movement.

According to Haas, human respiration is ennobled

as the “royal pathway to the autonomic nervous system

(ANS)”—the ANS being not only an “inammatory path-

way” [95]. Haas’ groundbreaking paper, a milestone in

1986, revealed how listening to the second movement of

Ludwig van Beethoven’s Symphony No. 7 can improve

respiratory patterns.

e interaction of music and the human organism

covers the interaction between two “biological systems,”

the system of the human body and the system of human

music. e phrasing of a musical piece can produce a

distinct impact on a listener’s lung activity: Instrumental

music “sings” the tale of humans, too.

If music constitutes a structured gear in the transmis-

sion of autonomic rhythms, music can support biological

resynchronization. is medico-musical rhythmic inter-

action, in which disturbed pathophysiological processes

can benet from restructuring by musical drive, is called

“entrainment” by modern researchers. Boost learning

with music: “at is Entrainment” is a song written by

the Northern Irish singer-songwriter van Morrison and

included on his 2008 album, Keep It Simple. Morrison

describes the meaning of the word entrainment and the

music on the album: “Entrainment is when you connect

with the music… Entrainment is key to what I am getting

at in the music… It is kind of when someone is in the pre-

sent moment—right here—with no past or future.”

It’s characteristic of biological rhythms for similar ef-

fects to occur in similar sequences rather than identi-

cal eects in identical sequences. is recalls another

famous quotation, from a classic work of Chinese pulse

diagnostics, Mai Jing (“e Pulse Classic”) by Wang

Shue (physician, 265–317 after Christ): “If the pattern

of the heartbeat becomes as regular as the tapping of a

woodpecker or the dripping of rain from the roof, the

patient will be dead in four days.” Biorhythms and mu-

sical structures are inseparably related. As chronobio-

logy and chronomedicine teach us, all biorhythms in a

healthy organism resonate in harmony. Diseases, on the

other hand, have pathophysiological eects that cause

“biorhythmic chaos.” In order to animate HRV in a syn-

esthetic way, we suggest listening to another example

by Mozart: the “Roses Aria” from Le Nozze di Figaro.

Please listen to the rigid, computer-generated MIDI le26

rst and, after this, an arrangement by Friedrich Gulda

played by himself.27

26 vimeo.com/healthtunes/review/372550090/a43200aa?sort=las

tUserActionEventDate&direction=desc (30 March 2020).

27 vimeo.com/healthtunes/review/372550830/64b6b3a6e9?sort=la

stUserActionEventDate&direction=desc (30 March 2020).

medicine and arts

1 3 S29

Conclusion

Medicine and the arts have walked hand in hand through

millennia of human culture. Mozart’s drug still exerts its

healing eect after more than two centuries. Using No-

valis as a starting point, we wanted to oer a brief com-

mentary in 2020—the 250th year since Beethoven’s

birth—that would also generate increased interest in the

interactions of physiology and music, the importance

of music therapy, and the immeasurable importance of

music for our society. In this paper, several highlights

and examples of well-known ndings serve as a tanta-

lizing “appetizer”—while the musical heritage of centu-

ries invites scientists to a rich musical buet. Not every

piece of music is a “song,” so we need to step back and

ask: “What will it take to improve medicine’s acceptance

and appreciation of music therapy?” But rst, recogniz-

ing that biorhythms and musical structures are insepara-

bly related, let’s take a few moments to just face the mu-

sic and dance!28

Tempering the mind: humanist conceptions of

music and mental health

Jacomien Prins, Department of Philosophy and

Cultural Heritage, Ca’ Foscari University of Venice,

jacoba.prins@unive.it

“e Arts are not drugs. ey are not guaranteed to act

when taken. Something as mysterious and capricious as

the creative impulse has to be released before they can

act.” ― E. M. Forster

Introduction

Music has close connections to our emotions and mem-

ories. Precisely for this reason, it can lift us out of the

deepest states of melancholia, depression and madness,

sometimes even when nothing else can. But, according

to the famous British neurologist and humanist Oliver

Sacks (1933–2015), the power of music goes much fur-

ther, because music occupies more areas of our brain

than language does. His “Musicophilia” (2007) is built

on the axiom that humans are a musical species [96].

e compassionate tales in the book of patients trying

to adapt to dierent neurological conditions have fun-

damentally changed the way we think of the inuence of

music on the human brain. But why are so many of his

readers, including highly educated doctors and scien-

tists, prepared to believe his stories about the power of

music, for example, the miraculous tale about a man who

is struck by lightning and suddenly inspired to become

a pianist at the age of forty-two? Moreover, why is mu-

sic therapy so popular, while the scientic evidence of its

eectiveness is scarce? is article argues that the mod-

28 vimeo.com/healthtunes/review/373594423/884ea9808c?sort=la

stUserActionEventDate&direction=desc (30 March 2020).

ern belief in the healing and ethical power of music is the

product of a long tradition of humanist views on the sub-

ject. Indeed, among the deep-rooted but hardly explain-

able beliefs in our Western culture is the idea that music

has deep connections to our emotional life, and that it

is capable of making us healthier and morally stronger

people. But at the same time, this view presents us with a

puzzle and sometimes strains our credulity. Could music

really have been thought, we wonder, to form and con-

trol the character and behavior of the individual, not to

mention his state of health, and indeed the health of so-

ciety as well, as has been argued, for example by Plato in

his “Republic”?

Music, mental health and happiness have indeed

been the focus of many philosophical theories and de-

bates throughout history. Since health and well-be-

ing have been among the most important concerns and

quests of human beings throughout history, they are

contested concepts, that is, experts in dierent disci-

plines and people in dierent cultures and period of his-

tory have dierent views on the natures, values, and best

practices of music therapy and music education. In “e

Routledge Companion to Music, Mind and Well-being”

(2018) my co-editors and I argued that common medi-

cal terms and concepts are not absolute but contingent:

health-disease, normal-abnormal, diagnosis-treatment

are all terms with historical, cultural and normative di-

mensions [97]. Moreover, we highlighted in the book that

in our time with a tendency to science worship, that is,

an over-reverential attitude towards modern science, it is

very important to stress that science is not the only valid

form of intellectual endeavor and not the only way of un-

derstanding music’s connections to our health and well-

being. If we want to take music therapy seriously, we ar-

gued, it must be seen as a value-laden practice guided by

the values of its practitioners and users. Indeed, in addi-

tion to details of individual physiology and medical con-

dition, concepts of music, health and well-being that are

related to time, place, culture, age, gender, social status,

ethnicity, and self-ecacy must be taken into account if

one aims at curing a person’s illness or improving some-

one’s health and happiness by music. In line with this

view, rather than discussing the scientic evidence for

Oliver Sack’s claim about the benecial inuence of mu-

sic on depression, this article investigates the historical

conceptions that determined his view to a large extent,

and that have the potential of rening our modern con-

ceptions of music therapy.

The historical roots of Oliver Sack’s belief in music as

an antidepressant

Sacks’ ideas about the healing and ethical power of mu-

sic are rmly based on the Western tradition of the “phi-

losophy of life”, in which philosophy has a strong con-

nection to issues of health and well-being. Indeed, many

philosophers from antiquity until far into the 17th cen-

tury conceived philosophy as a way of life, that is, as a

personal philosophy, whose focus was on resolving exis-

medicine and arts

medicine and arts 1 3

S30

tential questions about the human condition and on for-

mulating a view of the art of the good life [98, 99]. Some

of the most important philosophers of the Western tra-

dition communicated their ideas and teachings not only

through their theoretical writings, but also through creat-

ing inspiring ways of life in the pursuit of self-knowledge

and ways to further the health and happiness of them-

selves and their fellow humans.

In the ancient Greek world music was integrated with

ceremonies, celebrations, entertainments, feasts, ritu-

als, education, and therapy. In the context of the musical

practice of their time, Plato and Aristotle argued that mu-

sic had a unique ethical and healing power: music was

capable of imitating and arousing specic passions (or,

emotions) in listeners, so much so that the state should

limit the use of modes and rhythms to those that had a

positive ethical inuence. us, Plato argued in his “Re-

public” (book III) that the Lydian mode should be avoid-

ed because it makes people “drunk, and soft and idle”

and certain rhythms are dangerous because they en-

courage “meanness and promiscuity or derangement”.

In contrast, Aristotle was more positive about music’s ef-

fects in his “Politics” (1340a), where he explained that it

is possible to “experience change in our soul” when we

hear certain “rhythms and melodies that are close imi-

tations of gentleness, courage and moderation” [100,

101]. Moreover, in his “Poetics” (1449b 21–28), Aristotle

founded the theory of catharsis, that is, the purication

or purgation of the emotions (especially pity and fear)

primarily through art. e use of the term is derived from

the medical term katharsis (Greek: “purgation” or “puri-

cation”). Aristotle stated that the purpose of tragedy is

to arouse terror and pity and thereby eect the catharsis

of these emotions.

e exact meaning of catharsis has been the subject

of critical debate over the centuries that started already

in the Renaissance, where it was used in the context of

music therapy. e famous scholar, physician and musi-

cus Girolamo Cardano (1501–1576), for example, sought

to revive the wonderful music of the ancients with its eth-

ical and healing power as part of his search for the art of

living well. He saw melancholy, an early modern kind

of depression, as one of the main dangers for the health

and happiness of humans, especially of intelligent per-

sons [102, 103]. In his book “On Subtlety”, Cardano starts

his discussion of therapy for melancholy with a diagno-

sis of the illness [104] (translation by Fierz [105] slightly

modied):

“Among those with very warm and moist bodies, in-

telligent people have the worst disposition, unless they

devote themselves to the study of philosophy. One of the

eects of diligent study is melancholy. It is caused by the

decomposition of the fatty uid [black bile] due to exces-

sive study and waking. If intelligent people will nonethe-

less persist in their evil and malicious ways, all one can

say is that they are behaving true to their nature, and that

for them the study of philosophy has been to no avail”.

Cardano portrays here a naturalistic and realistic pic-

ture of a sixteenth-century melancholic scholar, who in

the process of deep thinking, consumes a great part of his

spirits (energy), as a result of which his blood becomes

thicker and full of noxious fatty uids. is would ulti-

mately disturb the balance between the four humors, or

bodily uids, and consequently hamper the circulation

of spirits and the soul. Behind this view, was an ideal of

human nature in which the soul circulated unhampered

by disturbing emotions or mental and physical weak-

nesses through the body in imitation of the planetary

spheres. As a simple, but eective remedy subsequently

he recommends his melancholic patients to ll up their

supply of spirit in the following way [104] (translation by

Fierz [105] slightly modied):

“Due to their intellectual activities, intelligent men

are less enslaved to Venus, because study dissipates the

animal spirits and redirects them away from the heart to

the brain, that is, in the opposite direction of the genital

organs. For this reason, these men beget weak children

who bear no resemblance to them. ey will greatly ben-

et from associating with beautiful women, reading love

stories, and putting up pictures of beautiful maidens in

their bedroom”.

e solution for melancholy presented here is sim-

ple: contact with all exciting, stimulating, and suggestive

things stirs the emotions, which in turn leads to an in-

crease of the pulse, a better blood circulation and, as a

consequence a sense of increased well-being. Moreover,

as a more rened and eective form of therapy, Carda-

no recommends catharsis through the imitation of strong

emotion in music. To illustrate his point, he gives a spe-

cic example [106]:

“A mood of compassion proceeds in music in slow and

serious notes by dropping downward suddenly from a

high range. is imitates the manner of those who weep;

for at rst they wail in a very high and clear voice, and

then they end by dropping into a very low and rather

mued groan.”

e musical imitation of this kind of physical manifes-

tations of the emotions seen in a person was supposed to

have a very powerful cathartic eect on the listener. In-

deed, Cardano was very positive about the possibilities

of self-regulation, that is, attempts to control emotional

reactions, by listening to or making music. He wrote, for

example, a “Lament” for the death of his son to come to

terms with his grief [107]. In so doing, he applied Aristo-

tle’s theory of catharsis in musical practice, and theorized

about a process of releasing strong emotions through a

musical activity or experience in a way that could help the

grieving, melancholic or depressed listener to understand

or come to term with harmful and painful emotions.

Oliver Sacks’s revival of the ancient doctrine that

music can form and control the character and health

of a person

Till the end of the last century, in mainstream medicine

there was almost no place for practices associated with

the concept of philosophy as the life-long contemplation

and practice of “artful living”. Subjective views about vir-

medicine and arts

1 3 S31

tuous and healthy living for oneself, for the health and

happiness of others, and for society as a whole were

banned from regular medicine and were often labelled

in a pejorative way as ‘alternative medicine’. However,

recently they have made a come-back, which is reect-

ed in the emerging eld of the “medical humanities”

and in Oliver Sacks’s attempt to combine a philosophy

of life and music with neurology. In his “Musicophilia”,

he demonstrates that what physicians and patients as-

sume and believe about music’s healing power substan-

tially aects not only what music therapists envision and

seek to do rightly for others but also the eects of these

interventions. Moreover, music for health and well-being

is always discussed, imagined and applied in his book in

relation to human beings considered holistically as per-

sons, not simply as diseased individuals. In so doing, he

opens up an enormous potential for improving the qual-

ity of human life through music.

At rst sight, Sacks seems miles removed from the

world of Cardano. In contrast with his predecessor, in his

“Musicophilia” he examines the powers of music through

the individual experiences of patients, musicians, and

everyday people and uses the modern science of neurol-

ogy to explain the phenomena he describes. But just like

Cardano, Sacks takes the Platonic doctrine of the power

of music to change and control the human mind as point

of departure of his overall argument [96]:

“For virtually all of us, music has great power, wheth-

er or not we seek it out or think of ourselves as particu-

larly ‘musical’. is propensity to music, this ‘musico-

philia’, shows itself in infancy, is manifest and central in

every culture, and probably goes back to the very begin-

nings of our species. It may be developed or shaped by

the cultures we live in, by the circumstances of life, or by

the particular gifts or weaknesses we have as individuals

but it lies so deep in human nature that one is tempted to

think of it as innate…”.

In this belief, Sack’s book is clearly inuenced by the

same stories of the marvelous power of music that haunt-

ed Cardano. From this normative point of departure,

Sacks describes how music can animate people with Par-

kinson’s disease who cannot otherwise move, give words

to stroke patients who cannot otherwise speak, and calm

and organize people whose memories are ravaged by

Alzheimer’s or amnesia. ese are all quite plausible

stories about the power of music, but the story of a man

who is struck by lightning and suddenly inspired to be-

come a pianist at the age of forty-two, in my view, can-

not otherwise be interpreted than as a modern musical

miracle that has nothing to do with science or neurology.

Moreover, Sacks is deeply inuenced by the creative mu-

sic therapy of Paul Nordo and Clive Robbins, who were

inuenced at their turn by the ideas of Rudolf Steiner and

the anthroposophic movement in humanistic psycholo-

gy [108]. From these inuences emerged Sack’s idea that

within every human being an innate responsiveness to

music can be found, but he often presents this belief as a

fact pertaining to mainstream neuroscience and neuro-

anatomy to grant his stories a kind of scientic authority.

In an autobiographic passage in chapter 25 titled “Mu-

sic, Madness, and Melancholia” Sacks gives an expla-

nation of why music can lift us out of depression that is

remarkably similar to Cardano’s account of a musical ca-

tharsis [96]:

I [Sacks] was passionately fond of my mother’s sis-

ter… Her death left a sudden huge hole in my life, but,

for some reason, I had diculty mourning. I went about

my work, my daily life, functioning in a mechanical way,

but inside I was in a state of anhedonia, numbly unre-

sponsive to all pleasure—equally, sadness. One evening

I went to a concert, hoping against hope that the music

might revive me. [WhenI listened to] Jan Dismus Zelen-

ka’s ‘e Lamentations of Jeremiah’, I found my eyes wet

with tears. My emotions, frozen for weeks, were owing

once again. Zelenka’s Lamentations had broken the dam,

letting feeling ow where it had been obstructed, immo-

bilized inside me”.

Just like Cardano before him, who wrote a “Lament”

to come to terms with the death of his son, Sacks argues

here that the imitation in music of the physical manifes-

tations of the emotions seen in a sad person, can have

a very powerful cathartic eect on the listener. But even

though the positive eect of sad music is a cornerstone

of our Western musical tradition, in modern scientic re-

search into the eects of music on the brain the accepta-

ble scientic methodology prevents scholars to research

and employ this kind of complex and value-laden con-

cepts [109].

Sacks found further evidence for his view of music as

an antidepressant in the stories told by numerous pa-

tients. A young man with bipolar disorder, for example,

wrote him: “If I sat at a piano, I could start to play, to im-

provise, and to tune into my mood. … If my mood was

depressed, I was able to bring my mood up. It is as if I

am able to use music in the same way that some people

use therapy or medications to stabilize their moods…”

[96]. e use of music as means to temper the mind, re-

ferred to in this letter, is also a cornerstone of our Western

musical tradition that often features on an unconscious

level of the modern minds of scientists, music therapists

and patients alike. In my view, in his Musicophilia Sacks

could have highlighted this tradition even more to stress

that his view is much more in line with certain histori-

cal concepts of music’s power than with modern scien-

tic research on the inuence of music on the brain and

the nerves.

Conclusion

In modern research, many benecial eects of music on

a person are conceptualized in terms of hormonal cen-

tral nervous changes. Since music can change activity

in brain structures that function abnormally in patients

suering from depression it seems plausible to assume

that music can be used to stimulate and regulate activ-

ity in these structures either by listening to or by mak-

ing music, and thus ameliorate symptoms of depression.

However, up till now the scientic evidence for eective-

medicine and arts

medicine and arts 1 3

S32

ness of music therapy on depression is surprisingly weak

[110]. In ‘Music, Brain, and Health: Exploring Biological

Foundations of Music’s Health Eects’, Eckart Altenmül-

ler and Goried Schlaug argue that this is the case main-

ly because of the lack of high-quality prospective rand-

omized controlled studies [111, 112]. In sharp contrast,

based on the analysis presented above I would argue that

this is a form of scientism. Nowadays, it is often felt that

natural sciences such as physics, chemistry, biology, but

also medicine, neuro-science and neuro-anatomy are in

a more advanced state than social sciences and the hu-

manities; the former can formulate precise laws with

great predictive power, while the latter usually cannot.

However, one could also argue that the methods of natu-

ral science are not necessarily appropriate for studying

social practices such as music therapy. Precisely because

controlled experiments usually cannot be done, I would

like to conclude that nding precise laws with predictive

power should not be the main benchmark of success in

music therapy. In line with Sacks, I believe that music

therapy practices can best be understood if we include

the viewpoint of the actor(s) responsible for them. If we

consider human beings holistically as persons with their

own musical histories, not simply as diseased individu-

als, music’s potential for improving the quality of human

life is indeed innite.

The value of a critical humanities perspective on

music and medicine

James Kennaway, Senior Research Fellow,

University of Roehampton, jgkennaway@yahoo.com

We live in an age in which thinking on the arts in gen-

eral is increasingly inuenced by theories and concepts

drawn from medical science, and, partly in consequence,

also in age of renewed attention to the role of the arts in

therapy. Music in particular has been the topic of intense

neuroscientic interest over the past thirty years, part-

ly because of the directly physical impact of music and

the inuence of brain scan technology [113, 114]. Related

elds such as the psychophysiology, psychoneuroimmu-

nology and psychoendocrinology have also taken a grow-

ing interest in music. Together they are creating a para-

digm of understanding musical experience that seems

to be quickly growing in authority. is paper seeks to

show that the Medical Humanities have a great deal to

oer in terms of showing the historical roots of such bi-

omedical approaches and incorporating their achieve-

ments into our views of the arts, and also in recognizing

the possible limits of such methodologies. As such, it is

aligned with the Critical Medical Humanities of scholars

such as Viney, Woods and Callard that rejects the restric-

tions involved in seeing the emerging discipline of Medi-

cal Humanities simply as a handmaiden to clinical medi-

cine [115]. While teaching insights from the humanities

to future doctors is clearly of great value, Critical Medical

Humanities can go beyond the clinical encounter to con-

sider the wider meaning and impact of medical thinking.

e most obvious connection between music and

medicine is of course music therapy, but the eect of

medical models of the body on our views of music has

been much broader than that. For instance, there is the

issue of music not as a cure but as a cause of disease. is

might seem surprising, but a discourse on the subject of

music as a trigger for degeneration, brainwashing and

even death has often been considerably larger than that

on music therapy, especially during much of the nine-

teenth century [116]. While this discourse generally re-

lates to fairly transparent political and cultural agendas,

if one takes the claims of music’s medical impact serious-

ly, then such ideas are not intrinsically illogical. Beyond a

few often-repeated Humanist anecdotes, the idea of mu-

sic causing illness had little traction until the late eight-

eenth century, but from discussions of the perils of play-

ing the glass armonica in the 1790s to the controversies

around Richard Wagner and Nazi policies of entartete

Musik, the moral-medical debate on music as a threat

to health via the nerves reected a wide range of social

anxieties, particularly in relation to young women [117].

Nor is such a way of thinking about music and medicine

merely a historical curiosity. Indeed, it seems that the In-

ternet has led to a Golden Age of theories about the pow-

er of music to control people and make them ill, albeit

often phrased in terms of hormones rather than nerves.

At a deeper level, it is clear that essentially medical

conceptions of music as a form of brain stimulation have

had, and continue to have, a profound eect on musical

aesthetics and general conceptions of how musical expe-

rience works. It could be argued that, of all the arts, mu-

sic is the most intimately connected to the body. In es-

sence unencumbered by “content” in terms of words or

concepts, it can have an apparently unmediated impact

on the human body, measurably aecting its physiology.

at has led many observers over the past few hundred

years to portray it as fundamentally a physical business—

with as much in common with electricity or cooking as

with other arts such as painting or literature. For this rea-

son, medical understandings of its powers have often had

considerable inuence. In order to address some of these

issues, this paper will outline some of the longue durée

history of music and medicine, in part as a corrective to

the historical myopia sometimes evident in scientic dis-

cussions of the topic. It will demonstrate that the history

of music and medicine is not a simple story of the unfold-

ing of scientic rationality, but a disputed eld in which

cultural and ideological factors have always played a key

role, involving arguments about the role of the physical

in the experience of musical listening that have by no

means necessarily been resolved.

Medical views of the role of music can be traced back

to Antiquity, but, ancient Greece’s most potent inher-

itance in this regard was not a focus on the impact of

music on the body but a Pythagorean and Neo-Platon-

ic conception of it in terms of ratio and the harmony of

the spheres. From the seventeenth century, though, mu-

medicine and arts

1 3 S33

sic gradually came to be the subject of measurement and

less a symbol of mathematical order. By the time of the

Enlightenment, a materialist model of music’s impact re-

lating to the stimulation of the nervous system had be-

come inuential. In particular, the idea of sensibility

(Empndung), drawn directly from physiology, put med-

ical thinking on the nerves front and center in ideas of

how music worked. e likes of the Swiss aesthetician Jo-

hann Georg Sulzer advocated an aesthetic of feeling (in

both a physical/medical and emotional sense), in which

music was viewed as a matter of “blows” experienced by

the “nervous system” [118]. With observers like Sulzer

one thus sees something not unlike twenty-rst-century

neuroaesthetics. e impact of this was arguably also re-

ected in composition, since conceiving of aesthetics in

terms of the nervous system became part of the basis of

a musical style based on Empndsamkeit, emphasizing

spontaneous, changing emotion and melody in the gal-

ant style, rather than counterpoint or the sense of apriori

cosmological structures and objective correspondences.

is medical model of music as nerve stimulant was

by no means universally accepted, however. e eight-

eenth century saw a real debate about the limits of nerv-

ous anatomy and physiology as explanations for musical

experience not so dierent from some of the critique of

so-called neuromania today. Already in 1749, the Eng-

lish physician Richard Brocklesby wrote with skepticism

about a purely materialist explanation of music’s eects,

stating that [119], “I must beg leave to dissent from that

opinion, which ascribes its operation merely to a me-

chanical undulatory pulsation of the air, on the extrem-

ities of the nerves”. Later the German doctor Johann Jo-

seph Kausch developed such ideas further in his 1782

Psychologische Abhandlung über den Einuß der Töne

und ins besondere der Musik auf die Seele, where he

roundly attacked adherents of what he called the “me-

chanical” model of music’s eects such as Sulzer for ne-

glecting the role of the mind via the imagination in their

support of a nerve stimulation model of musical experi-

ence [120].

It was against this background that the Idealist mu-

sical aesthetics emerged around 1800. e decline of

the old musical metaphysics of cosmic harmony in the

face of a materialist conception of musical stimulation,

by leaving music without a function and making it con-

cept-free, paradoxically set the stage for this new aes-

thetic of the transcendental subject and the free play of

abstract forms. Immanuel Kant tended to discuss music

in physiological terms, but, drawing on his broader theo-

ries, observers like Christian Friedrich Michaelis explic-

itly rejected the notion that music could be reduced to

mechanical movements in the nerves [121]. e ideology

of “Absolute Music,” implying a view of music in terms

of the autonomous musical work, the disinterested ap-

preciation of form and interiority, which developed from

this view in the work of the writers such as A.

B. Marx

and Eduard Hanslick, was thus in part a dialectical con-

sequence of the stimulation model [122]. Absolute Mu-

sic, with its basic rejection of physiological explanations

for music’s eects, was not the result of any scientif-

ic discovery. Indeed, it was relatively easily incorporat-

ed into fairly Positivist views of music later in the nine-

teenth century. Rather, its emergence can be ascribed to

much broader cultural shifts towards bourgeois art reli-

gion, Romanticism and Idealist philosophy, as well as to

disappointment with the perceived failure of physiologi-

cal aesthetics.

In many ways, that ideology of Absolute Music, in-

terested in music’s impact on the “soul” rather than the

brain, remained dominant until relatively recently, espe-

cially among students of Classical music. e recent re-

emergence of biomedical paradigms in discussions of

musical experience has arguably been just as dependent

on cultural factors as its decline was two hundred years

ago. As well as the neuroscience of music, the last cou-

ple of decades have, not coincidentally, been marked by

the development of another development in thinking on

music also focused to a great extent on the body—the

so-called New Musicology. It has rejected Absolute Mu-

sic’s denial of the body in music in favor of perspectives

from Feminism and Critical eory, directly connected

to the social transformations since the 1960s and the wid-

er crisis in traditional bourgeois high culture [123]. ese

changes, along with the technological advances behind

MRI scans and the like, were perhaps also necessary for

the current inuence of neuroscientic approaches.

Moving beyond history to look at the undoubted

achievements and possible limitations of the medically

informed neuroscience of music, Medical Humanities

can draw on other disciplines than history to inform the

debate. Because of the inuence of the idea of music as

brain stimulation, the Critical Neuroscience developed

by people such as Suparna Choudhury and Jan Slaby in

Berlin is of particular signicance [124]. eir approach

has questioned “neuromania,” raising vital issues about

the possible epistemological problems involved in sur-

mising states of mind from fMRI scans [125, 126]. Behind

much of the passion in debates on Critical Neuroscience,

including on music, is the so-called “Hard Problem” of

consciousness and the mind-body debate. Advocates of

a fundamentally materialist brain-based conception of

musical listening often appear to suspect critics of cast-

ing doubt on the mind-brain identity theory, of attempt-

ing to add essentially superstitious explanations of its im-

pact to respectable scientic approaches.

Applying a Critical Neuroscience approach does not

mean decrying the achievements of so-called “neuromu-

sic” or its materialist basis, but it does require an asser-

tion the necessity of conceptual clarity. For instance, it

seems to me that too often the term “music” itself is used

without discretion as if it were a known reied object that

could be applied in “doses,” instead of being a highly cul-

turally determined activity—whether in terms of listen-

ing or performing. As many musicologists have argued

in the last twenty years, it might be helpful to think of

“musicking” rather than “music” [127]. Likewise, the as-

sumption that music is a question of emotional impact

(a point by no means accepted by many aestheticians)

medicine and arts

medicine and arts 1 3

S34

requires an understanding of the historically contingent

ideas of what an “emotion” is and how they are catego-

rized—a rich seam in recent historiography [128]. Even

more problematic is the idea of “Classical music,” which

often seems to get used as if it were a Natural Kind and

not a fairly arbitrary and historically determined concept

of comparatively recent vintage. An aggravation of that

category error is the habit of using “Mozart” as if his mu-

sic had a specic clinical character, something that one

sees especially in popularizers of neurological approach-

es to music, notably in the case of the so-called “Mo-

zart Eect” relating to the supposed power of that par-

ticular composer’s music to improve cognitive capacity.

e idea started with an article in “Nature” in connec-

tion with adults, but soon led to a wave of public interest

and commercial exploitation in relation to making chil-

dren more intelligent by playing Mozart’s music [129].

is included the creation and marketing of devices such

as the Babypod, a speaker system designed to be inserted

in the vagina of pregnant women. Leaving aside the fact

that Mozart’s music has many dierent musical aspects

depending on the piece concerned and the context it is

heard, the cultural determinants of such an attitude to-

wards the composer as a quasi-magical child genius and

his music as associated with the habitus of the European

elite are obvious.

More generally, the biomedical approach to mu-

sic generally conceives of music’s emotional eects as a

matter of reward circuits in the brain, driven in part by

what brain scans can tell us. However, while music is cer-

tainly connected to emotion and the brain, any approach

that cannot distinguish the impact of music from that of

eating chocolate or having sex is surely missing out on

a lot, as sophisticated neuroscientists have acknowl-

edged. Disciplines such as sociology, anthropology and

psychology are invaluable to overcome such limitations,

reecting the fact that music is not just what happens

inside our brains, but always something occurring in a

context of social and cultural meanings between people.

is is particular relevant in discussions of neuroaesthet-

ics put forward by people like Semir Zeki [130]. As Bevil

Conway and Alexander Rehding have noted, neuroaes-

thetics seems caught between two traps. Some versions

search for neurological correlations to a supposedly “ob-

jective” idea of beauty that often has clear roots in the

western tradition, while others assume a subjective view

of musical experience as physical pleasure, which leaves

aesthetics merely as a branch of the physiology of corpo-

real enjoyment [131].

Bearing all this in mind, what can the Critical Medical

Humanities contribute to discussions of music therapy?

In a world where scientic respectability and institution-

al support and funding are increasingly tied to being able

to identify biological markers and quantiable impact,

music therapy has sometimes looked a little exposed,

since its benets (which I do not doubt) have often been

represented in terms of self-reported feelings of wellbe-

ing. In response, some such as Michael aut in Toron-

to have advocated so-called Neurologic Music erapy,

looking for a demonstrable physiological basis for the

practice and focused on neurological diseases—in line

with broader trends towards a biomedical conception of

music [132]. Such an attitude to music and medicine has

obvious advantages, but does perhaps run the risk of un-

dermining the use of music therapy in “softer” contexts

where quantiable biological eects might be harder to

establish. On the other hand, medical discussion of such

softer contexts itself requires a more critical edge. While

one is sympathetic to the practice and to research in the

area, some of what is written about music and medicine

takes the form of boosterism. It is surely not the task of

Medical Humanities implicitly to take for granted Hu-

manistic understandings of art’s power to ennoble the

mind and cure the body. Even if one believes this in one’s

private life, it scarcely amounts to science or Kritik. Of-

ten this boosterism takes the form of allusions to the Hu-

manities—respectable journals doing serious work still

sometimes use the language of the “magic” of music and

rather vague references to Apollo and Plato. A better ap-

proach surely would draw on the Humanities not for allu-

sions but for critical methods of thinking about the arts,

the body and human ourishing.

In conclusion, it is clear that musical experience oers

a particularly interesting case of the interaction of medi-

cal discourses with culture, partly because of its charac-

ter as both directly physical and culturally determined.

Discussion of music and the brain has become the lo-

cation of a highly signicant but often unacknowledged

interaction between cultural practices and epistemolo-

gies of scientic knowledge. is requires the attention

of a Critical Medical Humanities approach, not to reject

the real achievements of the medical/scientic approach

or to defend some kind of quasi-religious conception of

music and the soul, but to give the increasingly dominant

neuromusic approach historical depth, conceptual clari-

ty and social-cultural context. e humanities’ contribu-

tion must go beyond providing snappy quotations for bi-

omedical takes on music and provide a basis for dealing

with the profound ideological and cultural assumptions

that surround contemporary thinking on music, health

and the body.

Medicine and Literature/Media

Literature’s view on humans’ dissolution of

boundary

Christiane Vogel, Institute for History and

Ethics of Medicine, Medical Faculty of

Martin Luther University Halle-Wittenberg,

christiane.vogel@medizin.uni-halle.de

Introduction

e focus of this paper is the interdependence of liter-

ature and life science. Novelists of the 21st century in-

medicine and arts

1 3 S35

creasingly address the biological boundary crossing of

their protagonists. e literary adaptation of medico-

technical phenomena, and the overcoming of the hu-

man condition as a consequence thereof, will be central,

based on Andreas Eschbach’s 2003 novel “Der letzte sein-

er Art” [133]. Duane Fitzgerald, the protagonist, receives

expensively implanted prostheses that supply him with

superhuman powers in order to succeed as an elite sol-

dier. Due to incompatibilities between the human-ma-

chine interactions, however, he fails to go into action,

hence, reducing him to the rank of an anti-hero.

Interventions of biotechnological enhancement that

are no longer predicated on a medical indication share

a common aspect: dissolution of boundaries. Next to the

genealogical history of articial man in general, devel-

opments of medicalization and wish-fullling medicine

need contextualization. Only on rare occasions do protag-

onists not have to deal with serious repercussions. Using

the example of protagonist Fitzgerald, application of “e

International Classication of Functioning, Disability and

Health” (ICF) ought to highlight possible harmful impacts

of biotechnology on corporeality. Literature provides hy-

pothetical answers to the question: What might happen

if humans’ dissolution of boundary were surmountable?

Literature thereby encourages the readership to reect on

how the option of biotechnological solutions oered by

modern medicine impacts human existence.

Genealogical strains of the artiﬁcial man—the human

body and the machine

Since every denition of the body is a product of its his-

torical context, a changing cultural construction [134],

it is important to take a closer look at the historical and

cultural context of the man machine. First, it is impor-

tant to present the genealogical history related to arti-

cial man; these range from creation myths to mechanistic

and electronic versions.

is long historic-cultural tradition goes back to the

Greek myth of Prometheus whose work as a potter relates

to the Promethean creation of humankind. It reaches to

Jewish folklore with reference to Golem narratives—the

creation of man from clay. e biological history com-

prises the fable of the alchemically created homuncu-

lus, Victor Frankenstein’s nameless creature, as well as

genetically modied citizens as portrayed in the 1932

dystopian novel, “Brave New World”, by Aldous Huxley.

Compared to the earlier versions, the biological render-

ing comprises more threatening components that are al-

ready looming today: for example, possibilities encom-

passed by molecular and transplantation medicine. e

third category would be the mechanical—specically,

the technological development reaching from automa-

tons to computer-controlled articial intelligence. e

self-understanding of the human being in this case is

greatly reduced, since computer-assisted devices adopt

the human’s authority based on integrated circuits [135].

Being a cyborg, Andreas Eschbach’s protagonist, Du-

ane Fitzgerald, belongs to the third, although there is of-

ten no distinct boundary between biological and tech-

nological category. According to Romina Seefried, “the

demarcation line between naturally-human and arti-

cially-synthetic is not always denitely denable” [136].

It is part of the human condition to understand tech-

nological compensations as conquerors of somatic de-

ciencies. Mankind has been linked to and dependent on

tool use, since the very beginning. An important stage

in terms of man-machine history of thought is the ap-

plied anatomy of the human being (not the monkey or

other mammals). It is due to Andreas Vesalius (1514–

1564), that—according to Aram Vartanian—“[t]he mod-

ern mind… became familiarized with the image of the

human body as a neat and exact assemblage of relat-

ed structures” [135]. With his richly illustrated anatom-

ical atlas “De humani corporis fabrica” (1543), Vesalius

portrays the entire human body as an item of scientif-

ic knowledge. He opened the doors for anatomical re-

search on the human body and its inner morphology.

Also worth mentioning in this context is William Har-

vey’s (1578–1657) discovery of circulation of the blood

(around 1616), which reminded his contemporaries of

the interiors of hydraulic automatons (trick fountains

were also famous around this time). In his famous 1926

image-poster, “Man as Industrial Palace,” the German-

Jewish physician Fritz Kahn (1888–1968) depicts the epic

achievement of the functional human body with human

organs performing tasks ascribed to machinery. Ma-

chine-like, the human body is portrayed as a sequence of

production processes made visible by a cut from head to

intestine [137]. It is not an anatomical drawing like that

of Vesalius, but rather a sequence of rooms, pipes, and

assembly lines. Nor does this man-machine function on

its own terms: In all of its chambers, little humans op-

erate the electronic processes and chemical reactions in

the body by means of control panels.

Dissolution of boundary in biomedicine

It is necessary to address the dissolution of boundaries in