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Brain and Art
From Aesthetics to Therapeutics
Bruno Colombo
Editor

123
Brain and Art
Bruno Colombo
Editor

Brain and Art

From Aesthetics to Therapeutics
Editor
Bruno Colombo
San Raffaele Hospital
University Vita-Salute, Neurological Department
Milano
Italy

ISBN 978-3-030-23579-6    ISBN 978-3-030-23580-2 (eBook)

https://doi.org/10.1007/978-3-030-23580-2

© Springer Nature Switzerland AG 2020

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
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To Paola, my wife
To Lorenzo, Francesco and Stefano, my children
To my parents
The life so short, the art so long to learn, opportunity fleeting,
experience treacherous, judgement difficult. “Ars longa, vita
brevis”
Hippocrates 460–357 b.c.
Art does not reproduce what we see; rather, it makes us see.
Paul Klee 1879–1940
Contents

1 The Art of Being a Doctor ��������������������������������������������������������������   1

Bruno Colombo
2 Is There an Artistic Treatment for Neurological Diseases?
The Paradigm of Music Therapy����������������������������������������������������   5
Bruno Colombo
3 Beauty and the Brain: Neuroaesthetics������������������������������������������ 19
Enrico Grassi and Marco Aguggia
4 Neurodegenerative Diseases and Changes in Artistic
Expression���������������������������������������������������������������������������������������� 27
Massimo Filippi, Noemi Piramide, Sarasso Elisabetta,
and Federica Agosta
5 Painting in Neurology���������������������������������������������������������������������� 41
Bartlomiej Piechowski-Jozwiak and Julien Bogousslavsky
6 Art and Neurologists������������������������������������������������������������������������ 53
Nicholas J. Wade
7 Music and Mirror Neuron System ������������������������������������������������ 67
Arturo Nuara
8 Opera and Neuroscience: A Historical Approach
and Its Relevance Today������������������������������������������������������������������ 81
Lorenzo Lorusso and Alessandro Porro
9 Cinema and Neurology: From History to Therapy���������������������� 95
Lorenzo Lorusso and Simone Venturini
10 A Neuroscience of Dance: Potential for Therapeusis
in Neurology������������������������������������������������������������������������������������� 121
Gerry Leisman and Vered Aviv
11 Literature and Neurosciences: The temps perdu, Between
Hermann von Helmholtz and Marcel Proust�������������������������������� 139
Marco Piccolino

ix
x Contents

12 Wax Anatomical Models and Neuroscience: From Artistic

Italian Creation to Therapeutic Approach������������������������������������ 153
Alessandro Porro and Lorenzo Lorusso
13 The Significance of Art Therapy���������������������������������������������������� 169
Emanuela Galbiati
 The Art of Being a Doctor
Bruno Colombo
Where do art and neurology meet?
What is the link between music, painting,
dance and our brain?
And, above all, how can artistic expressions
have a healing effect on pathologies affecting the
nervous system?
Furthermore, what should be the new cultural
role of a physician, and particularly a neurologist,
so as to use these means of expression compe-
tently and safely?
In my opinion, everything stems from the
need to train a new kind of doctor providing,
within the university curriculum, the means to
develop the humanistic side of the profession.
The majority of medical faculties all over the
world aim at training specialists with an accurate
and modern scientific preparation, but with little
knowledge of general human culture. This may
be a mistake, since someone who loves literature,
music and art probably has a better introspection
and open-mindedness compared to someone who
does not share such interests.
The benefits of art and literature relate to three
qualities which I believe to be necessary, even
essential, to a good doctor: empathy, wisdom and
a tolerance for ambiguity (i.e. being able to
calmly deal with complex and ambiguous situa-
B. Colombo (*)
Neurological Department, University Vita-Salute,
San Raffaele Hospital, Milan, Italy
e-mail: colombo.bruno@hsr.it
© Springer Nature Switzerland AG 2020
B. Colombo (ed.), Brain and Art, https://doi.org/10.1007/978-3-030-23580-2_1
1
tions, devising creative solutions to existing
difficulties).
If we consider the medical entrance exams, or
frequently even the exams taken during the
degree course, we realise that multiple choice
tests imply an explicit and definitive train of
thought. The danger is that the student, when
later relating to a patient, may look upon the
diagnosis as the result of algorithms, of steps
from symptom to symptom only linked by a ‘yes’
or a ‘no’.
But this is not medicine, this is not a person. A
doctor must face the deep discomfort caused by
disease and, above all, has to relate to a fellow
human being, a patient whose integrity has been
disrupted by the pathology and who has lost
some physical and psychological boundaries.
If, liberally quoting J. Monod, we acknowl-
edge that every living being is an object with a
project [1], then we have to look at health as the
ability of the body to carry out the project of the
human species and consider disease a temporary
or permanent loss of this ability. There are clearly
different objective and subjective aspects of a
disease. These have an effect on the core of the
single individual touching social, emotional and
working visions.
Disease must therefore be seen as a time when
the need of the suffering patient must be met by a
curing and caring doctor with a special human
understanding.
Therefore, a good physician has to know
how to connect with the sufferer to create a
1
2 B. Colombo
trusting relationship. This is an essential part of
the healing effort. Medical practice should be
considered an art that makes use of science,
these two are intrinsically linked. If it is true
that without science we would probably still
rely on sorcerers and witch doctors, it is also
true that in the absence of a humanistic culture
medical practice would merely be a sterile
technicality.
The new doctor, who believes in caring for a
person, is an artist when he carries out an objec-
tive examination, when he looks for clinical
signs, when he shares the data regarding the
patient’s history and uses them to work out a his-
tory that may help to define a diagnosis. This also
means acknowledging that time is a fundamental
tool when relating to a patient.
Scientific progress has allowed medicine to
identify the chronological development of dis-
eases, the differing clinical courses of different
patients and the duration of the treatments that, in
most cases, can help to improve the prognosis.
However, scientific medicine, having given doc-
tors increasingly powerful diagnostical and ther-
apeutic implements, has created a time factor
totally new to the doctor/patient relationship.
Prior to this technological turn, a doctor took
the time and care to collect the data relating to
medical records and to question patients about
their history. In past centuries physicians would
use all their five senses to get an experience of
what the disease was. Later, with the arrival of
the anatomical–clinical method and the imple-
mentation of sophisticated diagnostical technolo-
gies, doctors have developed an increasingly
impatient and speedy style of medical examina-
tion, spending less time studying the medical his-
tory of the patients and relying more and more on
laboratory and test data.
Nowadays we doubtlessly train doctors who
are more efficient in treating diseases and who
are able to develop appropriate diversified diag-
noses. But they seem to be further and further
removed from the sufferer in front of them, with
whom they spend an ever shorter time. It seems
therefore that we are progressively confronted
with doctors who are less able to deal with
people.
In this context one should not underestimate
the dissatisfaction of the patient due to the lack of
communication. The practice of a hurried and
defensive treatment can induce the patient to fall
back on a superstition based pseudomedicine
which does not cure but offers the individual
more time and attention. We know that the length
of a medical is in itself a factor to predict a
patient’s satisfaction, especially if the time is
spent listening and clarifying. In countries where
examinations are longer, the perceived quality of
the medical service is higher. In Sweden the aver-
age length of an examination is 22 min, whereas
in Italy a medical lasts about 9 min. It has been
calculated that the minimum time that is needed
for the patient to be satisfied with an examination
is just under 15 min. Although medicine is now
based on experimentally tested knowledge and
procedures, social dissatisfaction with doctors
and health welfare is probably similar to that
sketched some centuries ago by Moliere in his
caricatures.
What can we do to rebalance the system?
Surely, we should rediscover the values of
empathy, re-establish therapeutic alliances, but
more importantly we should enhance doctors
who know how not only to employ technical
devices but also to approach human beings, both
the patients and those who look after them,
through a highly emotional process of
integration.
In this respect, the humanistic education of the
doctor needs to surface as a key value in a kind of
medicine where art has a creative and active role,
both in practice and culturally.
The bond between scientific and humanistic
culture should be a distinguishing feature of a
physician. The clinical procedure and medicine
itself are the contact point between human and
natural science. The person who taught me to be
a doctor used to say that, given an equal level of
scientific training, between a doctor who has read
Flaubert or Dostoevsky and one who has not,
probably the former would be a better clinician.
This is because the great classics of literature
portray those aspects of human nature one should
be familiar with to be a good doctor, or perhaps
those who have a passion for literature and a
1 The Art of Being a Doctor
sound knowledge of the classics also have a pre-
disposition to understand human events [2]. This
attitude is a prerogative to be a good doctor.
Humanistic doctors have a vision of the ther-
apy that will allow them to take into consider-
ation every tool that may enable the patient to
comprehensively take part in the healing effort.
Following that logic any intervention linked to art
can be crucial in turning a generic therapy into a
cure meant for an individual.
How can we define a therapy that adopts art as
part of a cure, and particularly, how can we qual-
ify it and make it acceptable to the scientific
community?
Art-based therapy (music, dance, and paint-
ing) can be described as a form of treatment
which employs artistic expression to strengthen
some of the patient’s personal characteristic such
as the ability to express oneself, the handling of
emotions, and the skill to improve interpersonal
relationships and self-esteem (Fig. 1.1).
To be in a position to implement this non-­
standardised healing approach, and above all to
validate and make it “scientifically” significant as
a therapy, we need to prove its value and
effectiveness.
Fig. 1.1 ‘Waiting for
emotions’ courtesy
of Lorenzo Colombo
3
The scientific method continues to be the
starting point to substantiate that an artistic
approach can affect cerebral functions and struc-
tures, providing the basis to guarantee the person
being treated more flexibility and adaptability
when facing pathological developments. Art-­
based therapy is beginning to show evidence of
its potential and the possibility to be accepted
and acknowledged as credible by the scientific
community and to be seen as a part of the healing
method. In this respect studies which are directed
at evaluating changes brought about on cerebral
activities seem to be the most modern and rea-
sonable. Neurophysiological approaches or
Magnetic Resonance Imaging are effective
means to provide evidence of how an artistic
involvement can produce shifts and functionality
changes in the brain. And neurological patholo-
gies are the best gymnasium to perform this kind
of research.
It seems to me that we have reached a moment
when we must reflect on the role of doctors, who
often are cooped up in an activity that impover-
ishes their primary humanistic capacities. The
interaction between science, medical practice,
and art can bring about a cultural renaissance,
4 B. Colombo

where the patient goes back to being at the centre References

of a new way of thinking.
Those who suffer from a disease will benefit, 1. Monod J, editor. Chance and necessity. New York:
AA Knopf; 1970. p. 13–4.
but also the doctor—and especially the neurolo- 2. Rugarli C, editor. Medici a metà. Milano: R. Cortina;
gist—who will be in a position to humanise and 2017. p. 169.
bring to life the special and unique relationship
which is created between a doctor and a patient.
 Is There an Artistic Treatment
for Neurological Diseases?
The Paradigm of Music Therapy
Bruno Colombo
2.1 Introduction
If we consider art, and particularly music, as a spe-
cial tool able to provide and provoke a universal
response leading to significant changes in emo-
tions and movement, we can state that both art and
music are direct ways to stimulate the brain. Music
can evoke changes in the most important reac-
tion’s components of emotions, such as motor
expression of emotion (i.e. triggering zygomatic
muscle activity or corrugator muscle in case of
happy or sad music), action tendency (dancing,
rhythmic beating) or physiological arousal in
terms of endocrine and autonomic activity [1].
Listening to music and playing a musical instru-
ment ameliorate neuronal connectivity in specific
brain regions. Music can promote neural plasticity
to support growing neuritis to connect new syn-
apses in order to remodel previously disturbed
networks [2]. From this point of view, music pro-
vides a non-invasive technique with a therapeutic
value, partly because of its cultural role in facili-
tating emotional well-being and social learning.
Admittedly, music has the prerogative of involv-
ing a lot of social functions, and the emotions
linked to music include deep experiences on fun,
joy and happiness. Music enhances social contact,
social cognition, communication and (considering
B. Colombo (*)
Neurological Department, University Vita-Salute,
San Raffaele Hospital, Milan, Italy
e-mail: colombo.bruno@hsr.it
© Springer Nature Switzerland AG 2020
B. Colombo (ed.), Brain and Art, https://doi.org/10.1007/978-3-030-23580-2_2
2
the activity of music playing and singing) coordi-
nation of actions, cooperation and social cohesion.
From a sociological perspective, music is a univer-
sal feature of human societies and humans in all
cultures in every part of the world make and per-
form music. Somewhere along evolution, our
ancestors, full of emotional expressions but poor
in language, probably began to gesticulate and
articulate inner feelings. Quoting the philosopher
Langer, the most highly developed kind of such
purely connotational semantic is music [3]. The
first musical instrument used by our progenitors
was the voice: being more variable than drums,
voices soon made patterns and the long endearing
melodies of primitive songs became a part of com-
munal celebration [3]. Other authors supporting
this concept argued that spoken language and
music evolved from a proto-language, a music-
language (emotional but without words) which
stemmed from primate calls and was probably
used by Neanderthal men [4]. So, it is possible that
our language emerged from this proto-language,
accompanied by a rich gesticulation and framed
by basic musicality. This proto-language was per-
formed with the continuous increasing flexibility
which accrued with both expanded anatomical
developments of brain structures and connections
(primary and association auditory cortices, cere-
bellum, prefrontal cortex and basal ganglia) and
the refined coordination of facial and pharyngeal/
laryngeal small muscles [5].
‘Where words can’t get, music speaks’ (L. van
Beethoven)
5
6 B. Colombo
Etymologically the term music derives from
the Greek ‘mousikos’, with a clear reference to
the Muses. Originally, however, the term didn’t
indicate one specific art form but all nine arts of
the Muses, referring to something perfect and
ideal. The therapeutical impact of sound and
music have been known for millennia: some his-
torical examples have been found on Egyptian
medical papyruses, some are present in shaman
practices of tribal medicine, others are well out-
lined in Plato’s third book of the ‘Republic’
(where the impact of different kinds of music on
the human soul are mentioned) and others still
can be identified in the Arab–Hebrew medical
tradition [6]. Looking at the Hellenistic period
we find how Plato and Aristotle observed that
music had a distinct power on people’s behav-
iour, especially regarding their reactions and
emotions, finding the reason for this in the modal
organization of music itself. Relating to this
observation, music types were catalogued and
used according to their respective powers:
lamenting for the Mixolydian mode, energetic,
active and sober for the Doric and Phrygian
modes, effeminate, dissolute and voluptuous for
the Ionic and Lydian modes. Many are the anec-
dotes in the Greek tradition of how music was
used to calm the rage of those probably affected
by the neurological consequences of alcohol
abuse. Iamblichus, for example, relates that
Pythagoras was able to mitigate the psychic
excitement of a youth in the grip of alcoholic
excess while Phrygian music was played, chang-
ing this to a slow and solemn Doric music [7].
Another example is Empedocles who assuages
the fury of a young man shifting the tone of his
instrument, the lyre, and starting a chant fitted to
soften and sooth. In ancient Greece we find a
close reciprocal relation between temperament
and musical harmony. A later example is that of
the doctor and musician Marsilio Ficino at the
end of the fifteenth century. In his letter ‘De
Musica’ to his friend Antonio Canisiano, he urges
him to mix medical and musical studies to find
the virtue and therapeutical proprieties of sound,
building on the new musical theories of counter-
point. Specifically, being rhythm part of our
organism (‘the harmonious rhythm of the pulse
and the harmonious rhythm of fever’) and also
part of the global rhythm of the universe, music is
able to reflect human moods and to cure their
effect, keeping in balance the inner faculties of
the soul and the health of the body [8].
Later, among the best-established norms
regarding the relation between treatment and
music, we can detect some key principles: ‘music
is good for the human body only if the exposure
to it is unobtrusive’, ‘music intervenes on human
behavior according to its nature, genre and mode,
for better or for worst’ and again ‘music is a com-
fort because of its primary analgesic character,
music is a tranquilizer, a mild sedative’ [9]. In his
text ‘Il Tesoro della Sanità’ of 1590 Castor
Durante Gualdo includes in his rules of hygiene
for a good health the combination of three ‘back-
grounds’: admiring nature, conversing with
cheerful friends and being accompanied by sound
and singing [10]. This was reiterated about
50 years later by Isbrand van Diemerbroeck who,
though living through an extremely problematic
historical medical period due to the fear of the
plague, confirms that ‘a happy and joyful soul’ is
that which profits from a musical accompaniment
[11]. Therefore, for many centuries, music was
perceived in the medical context as a good,
benign and comforting remedy, even for longer
periods. This always respecting some principles
such as ‘dosing’ it (hence spacing it out with
times of silence) and ‘devoting it to alleviate the
consciousness of the dissolution of existence’
thus using it to help the sufferer to peacefully tol-
erate the finite nature of life.
A further example of the use of music as ther-
apy, from the Middle Age to the twentieth cen-
tury in some regions of South Italy, is that of
tarantism. Music and a dance called tarantella
were used to fight the delirium prompted by the,
true or alleges, bite of a tarantula spider
(Latrodectus tredecimguttatus) which lives in
underground dens in Apulia and moves jumping
very fast. During their crisis patients were
extremely agitated and the therapeutical control
consisted of a home ritual where players of fi­ ddle,
guitar, tambourine and barrel organ performed
various pieces of music—the so-called musical
exploration—then expanding on the kind of
2 Is There an Artistic Treatment for Neurological Diseases? The Paradigm of Music Therapy
music to which the tarantism sufferer responded
starting to dance. The behaviour of the sufferers
and the ritual varied according to the type of
tarantula which was believed to have bitten them.
The bite, associated to the size and colour of the
tarantula itself, provoked behaviours to which the
musical therapy was adapted. Some tarantulas
named ‘dancers or singers’, for example, seemed
to react to singing, dance and music which were
rhythmic, syncopated and obsessive. The ‘sad
and muted’ tarantulas required melancholic
chants or funeral dirges. Lastly, ‘stormy and lib-
ertine’ tarantulas, which lead the patient to eroti-
cized behaviours, needed dances that continued
until the tarantula itself died. The ‘tarantulate’
patient started to dance to the music suitable to
the type of bite, alternatively moving on the
ground, so imitating the tarantula and becoming a
kind of dancing beast, then rhythmically hopping
and skipping for 15 min, the feet always beating
the ground 50 times every 10 s [12]. The music
was highly rhythmical, with cries, lamentations
and harmonic structures that we still find today in
two dances typical of the South of Italy: the ‘piz-
zica’ and the ‘tarantella’. When tiredness pre-
vailed music stopped, and the sufferers laid their
heads on a cushion to rest for 10 min. And then
all the cycle started again. Hours later, often the
next day, the sufferers interrupted their dance,
told the players to stop the music and went to bed
amazed and smiling. One can ask oneself if tar-
antism, with time, has not become a symbolic
ritual, culturally accepted by the people to exor-
cise the patient’s also symbolic poisoning (trau-
mas, unresolved conflicts and psychic
frustrations). In this context, music, and dance,
creates a conceptual idea of the entity which is
the object of the cult (the spider) making it mate-
rial through the music and visual through the
dance. What’s more the ceremony has a social
importance as music is community bonding. In
any case, music and dance have a therapeutical
role as they trigger the ritual trance and resolve
the crisis of the patients who have been bitten by
the tarantula.
It was only in the last century, though, that ini-
tial scientific basis came to support the use of
music as a credible therapy for the cure of neuro-
7
logical disorders. The important advancement of
medical science in Europe and the industrialized
countries during the twentieth century, allowed
the birth of schools of scientific thought focused
on understanding the causes and effects of music
on certain diseases. We should mention the work
done by Chomet who in 1875 investigated the
impact of music on mental and physical health
and its usefulness in preventing epileptic seizures
[13], and note that in 1891, in Great Britain,
music was first utilized in hospital wards to calm
the patients during their recovery [14].
Throughout these early trials the therapeutical
implications of music were still quite vague, even
though an attempt was made to provide a scien-
tific justification to the impact of music on the
human body. The early research works looking
into the predictable and measurable effects of
music, sound and vibrations on cerebral physiol-
ogy had a seminal value as they pioneered what
later became a medical model of a music therapy
based on a rigorous scientific method. With the
birth of psychoanalysis came the concept of non-­
verbal forms of communication. This in turn gave
rise to techniques in which, as in music therapy,
the privileged relationship with the therapist is at
the base of the taking charge on the part of the
patient.
However, it is only in the last 15 years that
well planned and controlled clinical tests were
carried out. These led to a definition of the actual
benefits and possible relevant areas for the use of
musical therapies in connection with a number of
neurological pathologies.
2.2 Music for Healthy People
If music is considered as a special language, it is
the language of emotions and feeling. Music
rhythms are everyday life rhythms, and music
prosody (major and minor keys, crescendos and
diminuendos, interludes, pauses and accelera-
tions), quoting Langer ‘reveals the nature of feel-
ings with a detail and truth that language cannot
approach’ [3]. In social context, during the course
of human history, music leads to an active partici-
pation (playing an instrument, clapping, singing),
8 B. Colombo
Fig. 2.1 ‘Enchantment’
courtesy of Lorenzo
Colombo
engaging social functions such as communica-
tion and cooperation, having a shared goal and
intentionality. The same can be said for music
listeners, engaging social cognition. For this rea-
son, music is a fascinating tool to enhance quality
of life in people, young and old (Fig. 2.1).
The social and emotional impact of music in
younger age is fundamental for forming solid
interpersonal relationships, dealing with negative
emotions and stress, constructing a strong and
reliable self-identity. In adulthood music has the
same role, evoking memories, maintaining com-
petence, independence and self-esteem, reducing
feelings of isolation and loneliness. Listening to
music is a leisure activity for older people that is
linked to positive attitudes, good emotions and
contributes to psychological and mental well-­
being. The same applies to participatory group
musical activities (i.e. choir singing): this attitude
has received increasing interest as a potential
intervention to maintain and increase general
health, in particular psychological status. A large
body of literature has confirmed this idea. In par-
ticular, questionnaire and interview studies on
older adults actively participating in community
choirs have demonstrated a self-perceived benefit
on quality of life, depression and satisfaction with
health due to an increase of social interaction,
cognitive stimulation and enjoyment. The long-
term efficacy of choir singing was studied in a
randomized controlled trial in the United
Kingdom. A group of older adults (258 subjects)
was followed for 6 months, half of them were part
of a 3 months programme of choir singing. The
singing intervention had a significantly long-­term
positive effect in measures of health-related qual-
ity of live, and a shorter positive effect on depres-
sion, anxiety and mental-related quality of life.
This was more cost-effective than other activities
[15]. In a recent systematic review commissioned
by the Economic and Social research Council in
the United Kingdom, music (regular group sing-
ing or simply listening) was associated with
reduced anxiety in young adults, enhanced mood
and purpose in adults and enhanced morale and
reduce risk of depression in older people. In the
chapter, 37 quantitative studies of subjective
well-being outcomes were discussed, and the
results confirmed showing that there is a reliable
evidence of positive effects of music and singing
on adult’s well-being [16].
Music has also a positive impact on cognitive
and motor functions in older people, due to the
particular power music (especially with fast tempo
in major mode) has on stimulation. Several studies
compared the short-term effects of background
2 Is There an Artistic Treatment for Neurological Diseases? The Paradigm of Music Therapy
music versus no music in older people: results
reported a better performance on verbal fluency,
episodic memory and psychomotor speed in peo-
ple who listened to music [17–19]. In another
study, older people who had long-term musical
training in younger age have been found to have
better and faster performance and neural timing in
executive, memory and cognitive functions, atten-
tion and language [20, 21]. Furthermore, instru-
mental musical training in older age (learning to
play an instrument) has been found to significantly
improve mood and quality of live and increase
performance of executive tasks and attention [22,
23]. Taken together, these data suggest that musi-
cal leisure activities are particularly beneficial for
seniors and can serve as a practical opportunity
and an effective means to slow age-related cogni-
tive difficulties.
2.3 Music for Neurological
Diseases and Neurological
Rehabilitation
2.3.1 Stroke
Of the major neurological pathologies, the best
evidence for efficacy of music-based interven-
tions has been reported for people affected by
stroke. Music-based intervention is defined as
an experimental protocol which uses music in
various forms, to study the possible specific
therapeutic effects. According to the World
Federation for Music Therapy, music therapy is
the ‘use of music and/or musical elements
(sound, rhythm, melody and harmony) by a
qualified music therapist, with a single client or
group, in a process designed to facilitate and
promote communication, relationships, learn-
ing, mobility, expression, organization, and
other relevant therapeutic objectives, in order to
meet physical, emotional, mental, social and
cognitive needs’. Moreover, the definition of
music therapy by American Music Therapy
Association is ‘the clinical and evidence-based
use of music interventions to accomplish indi-
vidualized goals within a therapeutic relation-
ship by a credentialed professional who has
9
completed an approved music therapy program’
[24]. AMTA was created in 1988, with the pur-
pose of develop the therapeutic use of music in
rehabilitation, special education and community
settings. Focusing on stroke, in a recent pub-
lished review 16 randomized and controlled tri-
als were analysed [2]. Music was used as an
add-on therapy for stroke-related neurological
symptoms and the assessed outcomes ranged
from motor and language functions, cognitive
functions, mood and quality of life. These out-
comes were measured with numerous standard
motor tests, clinical neuropsychological assess-
ments, questionnaires and computer-based
motor analyses. In some studies, electroenceph-
alography and magnetic resonance imaging
were utilized. The number of participants in
these studies ranged from 20 to 92, the music
therapist was involved in four studies, the dura-
tion of the intervention ranged from 10 days to
15 weeks.
As far as hemiparesis is concerned, eight stud-
ies reported enhanced motor recovery when
patients who were affected by a stroke were reha-
bilitated with a music-based intervention. Four of
these scientific works studied the use of rhythmic
auditory stimulation [25–28]. This is a technique
used to ameliorate movements that are naturally
rhythmic, such as gait. A series of auditory stimuli
with a fixed rhythm are presented and movements
are entrained to the previously determined
rhythm. All four studies found the intervention to
significantly improve gait parameters (gait veloc-
ity, stride length, cadence, symmetry and length
of foot contact to surface) more than gait training
without any musical aid. In these studies, the
duration of the training was 3–6 weeks. The same
was seen when the methodology (rhythmic audi-
tory stimulation) was studied with respect to pos-
tural control and gait performance in people
affected by stabilized effects of a stroke. In a sin-
gle, not blinded study (20 participants, overall
duration of intervention 15 h in 6 weeks), there
was a significant improvement in gait velocity
and double-support period on the affected side
[25]. In another not blinded study (33 p­ articipants,
overall duration of intervention 16 h in 8 weeks)
rhythmic auditory stimulation was able to improve
10
range of ankle extension and arm flexibility (both
up and down), mood and increased frequency and
quality of interpersonal relationships [29]. The
musical technique resulted in greater improve-
ment if done by a specialist (music therapist,
compared to control) compared by a non-music
therapist (compared to control).
Music-supported therapy is a music-based
intervention developed for motor rehabilitation
on stroke. By definition, music-supported ther-
apy is not only hearing music but also singing
and playing rhythm and percussion instruments.
This approach is based on specific principles.
These are: persistent repetition and exercising of
simple finger and arm movements, auditory-­
motor coupling and integration/reinforcement of
motor effects due to immediate auditory feed-
back, shaping and adapting the training accord-
ing to individual progress and evoking
emotion-motivation effects due to the playfulness
and emotional impact of music while acquiring a
new skill. In a recent systematic review and meta-­
analysis, ten studies were analysed (358 subjects)
to investigate the use of music-supported training
in stroke-induced motor dysfunction [30]. There
was evidence of a positive effect of music-­
supported therapy on several tests (9-Hole Peg
Test, Arm paresis Score, Berg balance Scale
score and Wolf Motor Function Time). The over-
all efficacy of motor function was in favour of
music-supported therapy for upper limb motor
functions, total motor functions and executive
functions. The improvement in motor abilities
seemed to be specifically due to music rather than
motor training, considering that patients training
with mute instruments showed less improvement
than the music active group. In one not blinded
study (25 participants, overall duration of inter-
vention 10 days) an innovative protocol was
used, in particular movement sonification ther-
apy, a modern development in music-supported
therapy in which gross movement is modulated
and transformed into sound. This technique is
able to provide a continuous feedback, substitut-
ing for deficits in proprioception. Sonication sig-
nificantly reduced joint pain and improved motor
smoothness more than movement therapy with-
out a sound support [31].
B. Colombo
In one pivotal study, melodic intonation ther-
apy was tested in a group of ten patients affected
by non-fluent aphasia [32]. In melodic intonation
therapy, the intonation of speech is expressed as
high and low pitches. Production of linguistic
phrases is achieved first by singing (intoning)
them at a slow pace and steady rhythm supported
by tapping (two-syllable words at the beginning
of training), then following a series of steps that
eventually transforms communication from sing-
ing to speech. The results of this study showed an
improvement in patient’s daily life communica-
tion an object naming if compared to control
group.
Music-supported therapy for stroke motor
recovery can be categorized into two definite
fields: music making and music listening. Music
making involves the coupling of motor and
auditory systems, and may directly facilitate the
executions of movements. Music listening may
modulate the patient ability to engage in ther-
apy. A recent Cochrane review evaluated these
music interventions combined with standard
care for functional outcomes in subjects affected
by brain damage, including stroke [33]. Twenty-
nine studies including 775 adult participants
were reviewed. The studies tested the effect of
music interventions on moving, walking, think-
ing and communicating. Although the majority
of studies included presented a high risk of bias
(low to moderate quality of evidence), music
intervention using rhythm resulted beneficial
for improving gait velocity, stride length of the
affected side and gait cadence after stroke.
Furthermore, music intervention resulted bene-
ficial for improving the timing of upper extrem-
ity function after stroke and for communication
outcomes in people with aphasia. Finally, qual-
ity of life after stroke was detected using rhyth-
mic auditory stimulation. Treatment delivered
by a trained music therapist resulted more
effective than treatment delivered by other pro-
fessionals. Anyway, more research is needed (in
particular phase I and II trials) to better under-
stand the specific contributions of different
active ingredients that comprise music sup-
ported therapy [34].
2 Is There an Artistic Treatment for Neurological Diseases? The Paradigm of Music Therapy
2.3.2 Dementia
In dementia, behavioural changes, psychomotor
uneasiness, agitation, anxiety and insomnia are
usually managed with symptomatic drugs.
However, there is a range of non-­pharmacological,
non-invasive and inexpensive strategies to
approach these problems, and music therapy is
worth mentioning. It is common knowledge that
responsiveness to music may be preserved even
in very late stages of the disease. While language
deteriorates over the course of the illness, some
musical skills are still preserved, such as the abil-
ity to play a previously learnt piece of music or a
musical instrument [1]. Music-induced emotions
and memories are often intact even in advanced
stages of dementia and related illnesses. This is
due to a relative preservation of limbic, anterior
cingulate and medial prefrontal areas (normally
activated by familiar music) in Alzheimer disease
[35]. Many musical processes are largely bilat-
eral, with the exception of pitch and melody pro-
cessing, which are lateralized, the activity in the
right hemisphere being dominant. Familiar music
engages the brain episodic memory system.
Episodic memory refers to long-term memory for
episodes of self-experience, including the storage
and recall of sights, sounds, location, time and
other contextual information that define an event,
spread over different regions in medial temporal
(hippocampus), frontal (dorsomedial and inferior
prefrontal) and parietal (precuneus and angular
gyrus). Moreover, the emotional impact of music
is linked to a network of many dopaminergic lim-
bic/paralimbic areas (the so-called reward system
of the brain) including amygdala, hippocampus,
orbitofrontal and cingulate cortex. In dementia
spectrum disorders, the medial prefrontal cortex
degenerates more slowly, and the regions that
encode musical memory also show minimal atro-
phy, despite the Beta-amyloid deposit [35]. These
data may explain the fact that demented patients
are able to respond in a positive emotional way
and to well recognize familiar songs, even at the
late stage of the pathology. This is important to
support the therapeutic use of music across all the
dementia spectrum diseases. In this perspective,
music therapy has the capability to call the
11
patient’s attention, provoke and modulate emo-
tional responses and evoke movement patterns.
Recent studies demonstrated that a pleasant and
stimulating background music is able to tempo-
rarily enhance awareness and cognitive perfor-
mance in tasks of autobiographical memory and
to reduce anxiety [36, 37]. The ability to recall
verbal material is ameliorated if presented in a
musical (i.e. as song lyrics) versus spoken con-
text [38]. Furthermore, other studies have
reported beneficial effects of music (although
short term) on social behaviour and interaction,
agitation and anxiety [39–41]. The specific posi-
tive impact of music therapy seems to depend on
the severity of the dementia symptoms. In par-
ticular, the results observed in the early stages of
pathology might be related to enhanced cognitive
reserve, better cognitive strategy to cope with
progressive disease and use of alternative cere-
bral networks. A recent published Cochrane
Review had the objective to assess the effects of
music-based therapeutic interventions for people
with dementia of varying degrees of severity (res-
idents in institutions) on quality of life, behav-
ioural problems, cognition and mood disturbance,
both at the end of music therapy and 4 or more
weeks after the end of treatment [42]. Sixteen
randomized controlled trails of music therapy,
involving both active and receptive musical ele-
ments, were included (620 subjects, random-
ized). Five studies delivered an individual music
intervention, whereas in the others the music
therapy was administered to subgroups of partici-
pants. Considering a high risk of performance
and detection bias in most studies (low method-
ological quality), the Cochrane review found that
music therapy has a moderate quality evidence
on reducing depressive symptoms (nine studies,
376 subjects), uncertain evidence on anxiety and
social behaviour and little effect on emotional
well-being and quality of life (six studies, 181
participants), cognition and overall behaviour
problems (six studies, 257 and 209 participants
respectively). In conclusion, the Cochrane review
states that these results need to be confirmed in
future studies employing larger sample sizes,
including others important outcomes such as pos-
itive outcomes (emotional well-being and social
12
activities). Additionally, the duration of effects in
relation to the overall duration of treatment and
the number of sessions has to be analysed, and
appropriate methods have to be used for random-
ization, blinding and intent-to-treat. In future
studies, it would be useful to report also the effect
sizes or the Minimal Detectable Changes, MDC)/
Minimal Clinically Important Difference (MCID)
values of the outcome measures, in order to eval-
uate the real and practical clinical significance of
the conclusive results. In another recent review,
34 studies (16 Randomized Controlled Trials, ten
Controlled Clinical Trials and eight Randomized
Controlled Trials/crossover) were included for a
systematic review (1757 subjects allocated to
music therapy or control) with meta-regressions
and meta-analyses to evaluate if music therapy is
able to enhance behavioural and cognitive func-
tions in elderly patients affected by dementia
(Alzheimer type, from mild-moderate to severe)
[43]. The results suggested that music therapy
has a positive effect on disruptive behaviour and
anxiety and a positive trend for cognitive func-
tion, quality of life and depression. These trends
were obtained in previous meta-analyses on
dementia patients, although with fewer included
studies. These beneficial effects of music therapy
on patients affected by dementia spectrum disor-
ders met the expectations and perceptions of the
utility of music therapy as an add-on treatment
both for advanced and earlier stages of the dis-
ease. In recent studies [44–46], singing was
effective (more than listening to music) in
enhancing working memory and reducing depres-
sive mood in mild dementia patients. In particu-
lar, singing resulted more energizing and
refreshing, whereas music listening was more
calming and relaxing. Furthermore, music ther-
apy was effective in reducing the psychological
stress and burden experienced by caregivers. A
very recent study demonstrated that an integrated
approach (pharmacotherapy plus active music
therapy) can improve psychiatric symptoms
(NPI, Neuropsychiatric Inventory, assessing psy-
chic and behavioural symptoms using a caregiv-
er’s interview) and social interactions (SIB,
Severe Impairment battery Language subscale)
in patients with moderate Alzheimer’s disease if
B. Colombo
compared with control group (pharmacotherapy
only) [47]. Active music therapy included twice
weekly sessions (40 min) conducted by a music
therapist (45 patients, mean age 73.2) for
24 weeks. Each session consisted in musical
improvisation and listening to other patients
playing using a free technique. The equipment
included triangles, maracas, xylophones, glock-
enspiels and other percussions. Although in this
study the association of music therapy and phar-
macotherapy had no effects on language and ver-
bal communication, the integrated approach was
able to significantly improve the psycho-­
behavioural profile of patients affected by moder-
ate dementia. The effects of music therapy in
dementia could be driven by emotional safety
induced by familiar songs or musical pieces,
which can help to overcome (although temporar-
ily) disorientation and confusion by anchoring a
person’s attention on a positive and familiar stim-
ulus (triggering autobiographical memories and
restoring a relative sense of identity) in an other-
wise confusing situational environment.
2.3.3 Parkinson Disease (PD)
In the last 20 years, the effect of music on specific
symptoms of Parkinson’s disease (stooped pos-
ture, narrow base, flexed knees, turning en bloc,
freezing of gait) has been evaluated in several ran-
domized controlled trials. In particular, rhythmic
auditory stimulation (i.e. listening to music for
marches) has been used to improve freezing of
gait. This symptom can be provoked by perceived
obstructive environmental cues and has been asso-
ciated with a marked disruption to internal rhyth-
mic timing, which may control our conscious and
unconscious abilities to extract rhythm from the
external world [48]. Through a process called
rhythmic entrainment, humans naturally moves in
synchrony to external rhythmic cues, as evident
when people spontaneously move to the beat of
music, even without being completely aware of
their action [49]. Although internal pacing is not
well functioning in patients affected by PD, this
timing disturbance can be ameliorated and recali-
brated through motor–­sensory interaction with the
2 Is There an Artistic Treatment for Neurological Diseases? The Paradigm of Music Therapy
world. Implicit timing abilities (utilizing external
cues and engaging automatic timing systems) still
present in PD patients, can be stimulated with
external rhythmic cues such as auditory stimuli
[50]. Patients are instructed to walk while syn-
chronizing their footsteps to the beat of music or a
metronome. Music is useful as a surrogate cue for
the impaired internal timing, considering that PD
patients have problems with explicit temporal dis-
crimination tasks. In fact, explicit timing is
required to make deliberate estimates of duration
and relies on an internal sense of time. Auditory
stimuli can bypass the damaged explicit timing
performance, helping patients to improve their
gait by inducing motor–sensory feedback signals
that recalibrate internal pacing. In a recent study,
comparing to pre-treatment gait performance,
rhythmic auditory stimulation was able to improve
gait velocity and stride length during the training
sessions in 15 non-demented patients affected by
PD, with sustained improvement for 1 month
post-training [51]. In this protocol, three training
sessions per week were continued for one month.
During each session, the patients walked to the
salient beats of German folk music, without for-
mal instructions to synchronize their footsteps to
the beat. Fixed-­tempo rhythmic auditory stimula-
tion generally requires increased demand for
attention, to synchronize footsteps with auditory
cues. This procedure can be difficult for PD
patients, where multiskating while walking can
exacerbate gait disturbances [52]. To improve
these approaches, interactive devices (pressure
sensors in the shoes that via a computer system
are able to adjust the metronome cueing tempo in
real time) were studied to ameliorate gait dynam-
ics. A specific study with this device (WalkMate)
on 20 PD subjects versus 16 healthy controls,
resulted in gait improvement, reaching the
detrended fluctuation analysis fractal-scaling
exponent of healthy subjects [53]. Another pos-
sible approach to gait rehabilitation in PD is the
use of virtual reality technology. While initial
research on this field is promising, further studies
are required, particularly integrating rhythmic
auditory stimulation. In five randomized con-
trolled studies, the effect of music (music-
assisted motor training) was evaluated having as
13
a primary outcome motor performance, walking
parameters, functional mobility and functional
motor control [54–58]. The music therapist was
involved in one study only. The overall duration of
intervention ranged from 12 h in 6 weeks to 20 h
in 13 weeks. Although the sample sizes in these
studies were too small (18–61 patients), the results
suggest that music-based interventions and danc-
ing to the music (tango, waltz, foxtrot) can be use-
ful in the maintenance of motor performance in
patients affected by PD. In particular, gait training
synchronized to music resulted in improved
cadence, stride time and velocity, with a signifi-
cantly reduction of PD disease-specific motor
symptoms. Two other studies demonstrated, with
a large effect size, that a music-based therapy
improved quality of life [54–57]. A recent study
assessed the enhancement of vocal quality and
depressive symptoms in eight patients affected by
PD [59]. The individual therapeutic singing pro-
gramme was conducted by a certified music thera-
pist (six sessions over 2 weeks). A statistically
significant change in maximum phonation time
and in voice handicap index was observed at the
end of the study. The geriatric depression scale
was also improved, showing a therapeutic possi-
bility of individual singing programme for vocal
function in PD patients.
2.3.4 Insomnia
A recent Cochrane Review assessed the effects of
listening to music on insomnia in adults and eval-
uated the influence and impact of specific vari-
ables that may moderate the effects [60]. The
selection criteria of studies included in the
research were: randomized controlled trials and
quasi-randomized controlled trials comparing the
effects of listening to music with no treatment or
treatment as usual on sleep improvement in
adults with insomnia. Meta-analyses using both
fixed-effect and random-effect models were uti-
lized. Six studies were included, comprising a
total of 314 subjects. The studies examined the
effect of listening daily to pre-recorded music,
for 25–60 min, for a period of 3 days to 5 weeks.
These studies were judged to be of moderate
14
quality (one of low quality) and at high risk of
bias. Five studies (264 patients included), report-
ing on sleep quality as assessed by the Pittsburgh
Sleep quality Index, were eligible for meta-­
analysis. The results revealed a positive effect in
favour of music listening (moderate quality evi-
dence). The size of the effect on sleep quality
indicates an increase in sleep quality of the size
of about one standard deviation in favour of the
intervention compared to no treatment or treat-
ment as usual. The authors state that there is evi-
dence from literature that music may be effective
for improving subjective sleep quality in adults
with insomnia symptoms. None of the studies
reported any negative adverse events caused by
listening to the music, and the intervention is
easy to administer. Anyway, more high quality
research is needed to establish and investigate the
effect of listening to music on other aspects of
sleep (sleep onset latency, total sleep time, sleep
efficiency) as well as the daytime consequences
of insomnia. A more recent systematic review
(network meta-analysis) assessed music inter-
vention as a non-pharmacological method of
treatment for primary insomnia in adults [61].
The primary outcome was sleep quality, the sec-
ondary outcomes were sleep efficiency and sleep
onset latency. Twenty trials were eligible for the
analysis (1339 patients, 12 intervention arms).
For overall sleep quality, music-associated relax-
ation was statistically more effective than
patients’ usual care. Listening to music had sig-
nificant advantages in terms of sleep onset latency
and sleep efficiency, the same for music-­
associated relaxation. In conclusion, listening to
music and music-associated relaxation are prob-
ably the best options to consider in the applica-
tion of music intervention.
2.3.5 Depression
A very recent Cochrane review investigated the
effects of music therapy for depression in people
of any age (from adolescents to elder people)
compared with treatment as usual and/or other
therapies (psychological or pharmacological)
[62]. The effects of different forms of music
B. Colombo
therapy were also compared (active, where peo-
ple sing or play music, and receptive, where
people listen to music). All randomized con-
trolled trials and controlled clinical trials were
selected for the analysis. Nine studies involving
a total of 421 subjects were included in the
review. As far as primary outcomes are con-
cerned, a moderate-­quality evidence of short-
term large beneficial effects favouring music
therapy and therapy as usual versus therapy as
usual alone was found, for both patient-reported
depressive symptoms and clinician-rated depres-
sive symptoms. Regarding secondary outcomes,
music therapy and therapy as usual was superior
to therapy as usual alone for anxiety and func-
tioning (maintaining involvement in job, rela-
tionships and activities), not for quality of life. It
is not clear if one form of music therapy is better
than another and whether music therapy is better
than psychological therapy. Additionally, music
therapy was not associated with specific adverse
events. For future research, new trials should
investigate in larger samples depression in
children.
2.3.6 Epilepsy
In one study, it was demonstrated that the expo-
sure to patterned auditory stimuli provides a non-­
invasive excitatory stimulation of the cortex,
reducing the brain epileptiform activity. To vali-
date this suggestion, in one randomized con-
trolled trial (73 participants, single blinding,
without involvement of a music therapist) patients
were exposed to Mozart’s music (sonata for two
pianos in D major K 448) at periodic intervals
every night for 1 year [63]. Primary outcome was
seizure occurrence. During the study period, a
significant 17% reduction in seizure frequency
was detected in the music group. Moreover, a
carry-over effect of 16% reduction in seizure fre-
quency persisted for 1 year. Up to now, no other
randomized controlled trials have been pub-
lished. A systematic review and meta-analysis of
12 studies (including both adult and children
affected by epilepsy) about the effects of Mozart’s
music on interictal activity in epileptic patients
2 Is There an Artistic Treatment for Neurological Diseases? The Paradigm of Music Therapy
showed a good response to music (average reduc-
tion of 31% in interictal epileptic activity during
the listening period and 24% after the listening
period) in 85% of 153 subjects included in the
studies [64]. A recent work studied the character-
istics of electroencephalograms (epileptic dis-
charges) in 45 children (2–18 years) before,
during and after listening the K448 sonata (first
5 min of the first movement ‘allegro con spirito’
comparing with age-appropriated control-music).
The results showed a significant reduction in the
frequency of epileptic discharges during listening
the Mozart music if compared to the baseline,
which is not present with control music [65].
2.3.7 Multiple Sclerosis
Only three randomized controlled trials have eval-
uated the effect of music therapy in ameliorating
the symptoms of multiple sclerosis. In one study
(without music therapist, 19 participants, not
blinding, with an overall duration of intervention
of 7.5 h in 2 weeks and the hand functionality as a
primary outcome), the effect of keyboard playing
(mute versus audible) was studied [66]. Audible
keyboard playing significantly improved the func-
tional use of hand, as detected by a specific and
validated questionnaire. In another study (ten
patients, music therapist involved, not blinding,
Fig. 2.2 ‘The rhythm’
courtesy of Lorenzo
Colombo
15
2 weeks of duration, gait parameters as primary
outcome using a computerized gait analysis)
rhythmic auditory stimulation was able to reduce
double-support time [67]. In a recent study, the
effect of two 12-week exercise training interven-
tions (movement-to-music and adapted yoga, three
60-min exercise sessions per week for 12 weeks),
on psychosocial and physical outcomes were
investigated on 81 multiple sclerosis (MS) patients.
The results demonstrated a significant group dif-
ferences in primary outcome measures (6-min
walk test and Timed Up and Go) in patients treated
with music therapy if compared to controls [68].
These results are not sufficient to drive conclu-
sions, but quite interesting to suggest new proto-
cols, considering music therapy as an option to
treat specific symptoms such as fatigue, mood dis-
turbances, spasticity or cognitive deficits.
2.4 Conclusion
Music may evoke several affective and emotional
states such as joy, sadness, tenderness, power and
peacefulness. At the same time, the impact of
music on the brain is able to activate motor sys-
tem and attention control areas, not only depend-
ing on rhythmic patterns in the music but also on
evoked emotional experience (Fig. 2.2). For these
reasons, both public interest in and publication of
16
music intervention studies are increasing, with
about 1500 articles indexed in PubMed (and
about 200 reviews) over the last 20 years examin-
ing the benefits of music therapy for many health
conditions (including neurological diseases).
Furthermore, a specific task-force (the NIH-­
Kennedy Center Sound Health: music and the
mind initiative) is working with the goal of better
understand the power of music for health benefit
through interdisciplinary scientific approach
[69]. The growth of music therapy as a possible
standard care, necessitates close examination of
intervention reporting to improve the global qual-
ity of results. Scientific method is essential to
demonstrate the utility and efficacy of music
therapy approach. The Reporting Guidelines for
Music-based Interventions specify the essential
components of music interventions that publish-
ing authors are encouraged to discuss and report
[70]. In particular, details on: person selecting the
music, source of music, music delivery method
(live or recorded), intervention materials (music
or non-music materials), intervention strategies
(music listening, improvisation, rhythmic audi-
tory stimulation), intervention delivery schedule
(number of sessions, session duration and fre-
quency), qualification of interventionist and/or
credentials, treatment fidelity (strategies used to
ensure that treatment was delivered as intended,
setting and unit of delivery) are necessary for
improve clinical relevance of the study. A recent
systematic review evaluated 187 articles (128
experimental, 59 quasi-experimental with 121
publishing journals and authors from 31 coun-
tries) to report quality of music intervention
research in chronic and acute medical settings
(dementia for neurological diseases) [71]. The
results showed that quality for music intervention
studies was poor, with absence of information in
the majority of studies about intervention theory,
interventionist qualifications, setting and treat-
ment fidelity. The absence of information lessens
the clinical relevance, impact and scientific qual-
ity of the resulting work. Furthermore, few
authors provided detailed information about the
music and music experience used. Providing
detailed descriptions of these items is indeed very
important if we have to evaluate and understand
B. Colombo
the potential mechanisms of action of music ther-
apy. This review found significant problems with
reporting quality for music intervention research.
To improve these methodological strategies in
order to find a shared language that reflects a
fruitful interprofessional cooperation, a strong
effort is required. If we want to validate music
therapy approaches we need more well-designed
studies to assess their effects on brain function,
hoping to integrate different disciplines to
develop a global strategy in order to optimize the
music therapy approach on different neurological
diseases.
Acknowledgements The author gratefully thanks the
magnificent Ferretti family for the continuous support and
for the irreplaceable help.
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 Beauty and the Brain:
Neuroaesthetics
Enrico Grassi and Marco Aguggia
3.1 The Idea of Beauty
The pleasure of beauty is always something more
than a simple achievement of our senses. It
shapes up to be a sensitive perception, with its
own cognitive variations, emotional involve-
ments and practical behavioural consequences.
In many languages the concept of beauty not
only represents the main characteristic of aes-
thetic evaluation, but also includes a perceivable
positive quality. The perception of beauty, regard-
less of whatever could be able to define it objec-
tively, has its peculiar emotional dimension
which can be felt subjectively as an aesthetical
pleasure. This is the reason why beauty has such
a strength capable of pushing to action: beauty
awakes desire and, as a consequence, a behaviour
tending to rapprochement.
The perceivable positive quality that beauty
contains does not arouse exclusively from the
properties of the object under analysis, but in a
good extent it comes from the very subject
involved in the aesthetic judgement. And that is
the reason why Immanuel Kant, in his Critique of
Judgement, introduces a distinction between
determinate and reflective judgement. When we
E. Grassi
Neurological Department, Santo Stefano Prato
Hospital, Prato, Italy
M. Aguggia (*)
Neurological Department, Cardinal Massaia Hospital,
Asti, Italy
e-mail: maguggia@asl.at.it
© Springer Nature Switzerland AG 2020
B. Colombo (ed.), Brain and Art, https://doi.org/10.1007/978-3-030-23580-2_3
3
define something as beautiful, ‘beautiful’ does
not determine the object, but just reflects the feel-
ing of pleasure (what in neurosciences we would
call a reward-circuit expression) experienced by
the subject advancing his judgement.
In the continuation of this chapter, we will
observe how these theoretical statements receive
an exact feedback from the studies on neurobio-
logical basis of what can be defined as ‘aestheti-
cal mind’, representing as well one of the main
and most fascinating subject matter of the neu-
roaestethic research.
Whatever experience we may undergo, being
it cognitive, social, amorous, religious, political,
artistical, it passes through the activation of spe-
cific brain areas.
Thanks to neuroimaging techniques, nowa-
days we can visualize which brain areas do acti-
vate or deactivate when a subject confronts with
one or more of above experiences.
Aesthetic experience too is subject to laws
regulating brain activities and their involved ner-
vous structures, hence art can be considered as an
extension of brain function.
Traditionally, art has been linked to beauty,
but since Marcel Duchamp exhibited his pis-
soir—which he euphemistically entitled The
Fountain—we acknowledge the possibility of
considering artwork even something we do not
actually perceive as beautiful.
Twentieth century avant-garde could shift the
ground beneath whatever beauty theory’s feet, as
avant-garde itself committed heart and soul to the
19
20
denial of beauty and the research for shock and
slaps in the face to common taste.
In 2003 Arthur Coleman Danto, a contempo-
rary philosopher considered one of the most
influential critics on these matters, introduced the
concept of The abuse of beauty, so putting an end
to the theory—prevailing through eighteenth and
the start of twentieth centuries—where art pecu-
liarity would lay in its very ownership of beauty.
But in the last 15 years, along with the pro-
gresses achieved in our knowledge on neurobiol-
ogy of artworks production and enjoyment, the
problem of beauty has strongly come back to
regain its primary role in philosophical debate.
The neuroscientist Thomas Jacobsen and his
colleagues [1] collected associative naming for
the word ‘aesthetics’ from 311 non-artist German
college students in a timed verbal association
task. The adjective ‘beautiful’ was given by more
than 90% of the participants. The adjective ‘ugly’
was the second most frequent naming, used by
almost half of the students. This clearly distin-
guishes a semantic field of aesthetics where there
is a clear primacy of beauty.
3.2 The Promise of Beauty
If it is true, as Stendhal notoriously remarked,
that beauty is the promise of happiness, the expe-
rience of art in whatever form, is often, first of all,
an experience of pleasure both to senses and
intellect. It is therefore reasonable to expect that
part of the neural response to art determines the
reward-circuit activation. This circuit consists of
the ventral striatum (VS), a region that includes
the nucleus accumbens and extends into the ven-
tromedial putamen and caudate, along with the
interconnected medial prefrontal and orbitofron-
tal cortex (OFC), the amygdala and dopaminer-
gic midbrain nuclei. Pleasures are positive
reinforcers; a reward is everything an organism
will work to achieve: sex and food are primary
rewards with clear survival value; money and art
are secondary rewards. Thanks to brain plasticity,
in the course of evolution, we learn how to derive
pleasure from secondary rewards.
E. Grassi and M. Aguggia
By studying the reward-circuit in neurogas-
tronomy, neuroeconomics and neuroaesthetics,
neuroscientists have begun to illuminate a variety
of interconnected processes including decision
making, emotions and memory.
This highly flexible reward system, deeply
rooted in our evolutionary past, can assign value
to very different thing, from money to food and
beautiful faces, as well as da Vinci’s ‘Gioconda’
or Mozart’s ‘Requiem’.
Not surprisingly, then, it has been the primary
focus for earlier neuroimaging studies of
responses to visual art. These studies investigated
in turn the neural correlates of aesthetic prefer-
ence [2–5], gender differences in aesthetic pref-
erence [6] and contextual effects on aesthetic
experience [7–9].
Neural systems for emotion, reward and
default mode network work together to enact our
aesthetic experience. Through this neural archi-
tecture we can extract pleasure from extraordi-
nary and variable aspects of our aesthetic life and
refine the borders between empiric world and our
sense of self [10].
But how can we sense beauty across the dif-
ferent forms of art?
More specifically, how can artworks, involv-
ing different senses and using various means of
expression, actually produce the same set of feel-
ings? Why music, painting, poetry, dance and
other forms of art can move similar emotions and
give us a similar pleasure?
In 2011 Professor Semir Zeki, one of the
founding fathers of neuroaesthetics, in his study
[11] carried out at the Wellcome Laboratory of
Neurobiology in London University College
showed how our brain dedicates to beauty a spe-
cific area, which activates when we experience
the pleasure of an artwork or a piece of music.
His study requested 21 subjects of different
culture and ethnicity to evaluate a series of paint-
ings and pieces of music, classifying them as
beautiful, ugly or neutral. During evaluations,
their brain activity was under control of func-
tional magnetic resonance imaging (fMRI). Zeki
thus discovered how subjects perceiving a piece
of music or picture classified as beautiful,
3 Beauty and the Brain: Neuroaesthetics
a­ ctivated mainly an area known as field A1 of
medial orbitofrontal cortex.
Mathematicians often describe mathematical
formulae in emotive terms and the experience of
mathematical beauty has often been compared by
them to the experience of beauty derived from the
greatest art.
Plato considered the experience of mathemati-
cal beauty as the highest form of beauty, since it
comes from the intellect alone and is concerned
with eternal and immutable truths. After all
Bertrand Russell (1907) [12], the British mathe-
matician and philosopher, in his ‘The Study of
Mathematics’ [11] wrote:
Mathematics, rightly viewed, possess not only the
truth, but supreme beauty—a beauty cold and aus-
tere… The true spirit of delight, the exaltation, the
sense of being more than Man, which is the touch-
stone of the highest excellence, is to be found in
mathematics as surely as poetry.
In 2014, Zeki [13] used functional magnetic
resonance imaging (fMRI) to display the brain
activity of 15 mathematicians when they viewed
mathematical formulae that they had previously
rated as beautiful, neutral or ugly. The results
showed that the experience of mathematical
beauty correlates with activity in a part of the
emotional brain—namely the medial orbito-
frontal cortex (mOFC)—the same as the experi-
ence of beauty deriving from art or music. The
fact that the experience of mathematical beauty,
like the experience of musical and visual
beauty, correlates with activity in A1 of mOFC
suggests that there is, neurobiologically, an
abstract quality in beauty that is independent of
culture and learning. According to Chatterjee,
taking pleasure in maths gives an evolutionary
advantage. Actually, the ability to reduce infor-
mation to a succinct quantitative relationship is
a skill that would have enabled our ancestors to
accumulate important information from their
environment.
These studies have shown how activity in the
field A1 of mOFC correlates parametrically with
the declared intensity of the experience of beauty
derived from a variety of stimuli, such as faces,
paintings, music, moral judgements and mathe-
matical equations.
21
But what happens in our brain confronting
with sorrow-derived beauty?
In a recent paper (Ishizu and Zeki 2017)
authors have shown that the medial orbitofrontal
cortex (mOFC) was active during the experience
of each type of beauty (i.e. both from joy and sor-
row) but, in the experience of sorrowful beauty,
the activity within the mOFC was modulated by
the supplementary motor area/middle cingulate
cortex, usually engaged during empathetic expe-
riences provoked by other peoples’ sadness.
Maybe, as in Michael Trimble’s words:
beauty may be in the eye of the beholder but there
is even more beauty in the tears.
3.3 Does Objective Beauty Exist?
One of the aesthetics most debated questions is
whether beauty could be defined by objective cri-
teria or if it depends on subjective factors only.
Notwithstanding subjective criteria play an
important role in everyone’s aesthetic experi-
ences, we know today that some biologically
based specific principles do exist and they can
facilitate the perception of beauty.
Actually, a venerable western thought tradi-
tion confers beauty the features of balance, pro-
portion and measure. Aristotle’s Poetics related
beauty to the ideas of size and regular arrange-
ment of parts, whereas his Metaphysics stated:
‘The chief forms of beauty are order (tàxis) and
symmetry (symmetrìa) and definiteness (tò
horismèon), which the mathematical sciences
demonstrate in a special degree’.
This idea of order will spread everywhere dur-
ing next centuries, achieving a crucial weight
over theoretical and artistic fields during the
Middle Ages and Renaissance. But after
Baroque’s relative denial of such order idea,
astronomical and physical discoveries lead to a
new truth-bounty-beauty link, within the cosmic
model. Neuroaesthetics discoveries entrench the
basis of this vision in the principles of central
nervous system organization.
In a Parma Group study [3], led by Giacomo
Rizzolatti and Vittorio Gallese, the presence of a
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7 Bake. Place pan on rack in center of 8 Look at cookies when minimum

oven. If cooky tops do not brown
properly, move to a higher rack for last
few minutes. Pans should be
narrower, shorter than oven (to leave
a 1″ space for circulation of heat).
baking time is up. As soon as they are
done (according to recipe), remove
from oven. With a wide spatula, slip off
baking sheet or out of pan onto wire
rack to cool (as recipe directs).

Store cooled cookies properly to keep

top eating quality. Where to Find:

Drop Cookies 16-21

Keep crisp, thin cookies in can with
loose cover. Refrigerator
22-24
Cookies

Miscellaneous
25
Cookies

Bar Cookies 26-29

Rolled
30-39
Cookies

Molded 25,
Cookies 40-42

Keep soft cookies in air-tight Press

43
container (a covered earthen jar or a Cookies
can with tight cover). Slices of apple
or orange in jar help mellow and
moisten cookies. Change fruit
frequently.
DROP COOKIES “Quickies” busy
mothers love to make.

HOW TO MAKE DROP COOKIES (preliminary steps on pp. 14-15)

2 Drop dough by rounded or heaping

1 It will save time in spacing dough, if
teaspoonfuls, depending on size of
you grease in symmetrical rows where
cookies desired. With another
you want to drop the dough. It will also
teaspoon, push dough onto baking
save washing browned grease off a tin
sheet ... being careful to peak up the
pan.
dough.

BROWN SUGAR DROPS ( Reecipe) Soft, chewy. Wonderful

brown sugar flavor.
Mix together thoroughly ...

1 cup soft shortening

2 cups brown sugar
2 eggs

Stir in ...

½ cup sour milk or buttermilk

Sift together and stir in ...

 3½ cups sifted GOLD MEDAL Flour
1 tsp. soda
1 tsp. salt

Chill at least 1 hour. Drop rounded teaspoonfuls about 2″ apart on

lightly greased baking sheet. Bake until set ... just until, when
touched lightly with finger, almost no imprint remains.
temperature: 400° (mod. hot oven).
time: Bake 8 to 10 min.
amount: About 6 doz. 2½″ cookies.

★ HOLIDAY FRUIT COOKIES

Elegant. Richly studded with fruits and
nuts. Butterscotch-flavored. Perfect for
your loveliest hospitality.

Follow recipe above—and

mix into the dough 1½ cups
broken pecans, 2 cups candied To prevent drop cookies spreading ...
cherries, cut in halves, and 2 chill dough, peak it up, be sure oven
cups cut-up dates. Place a temperature is correct.
pecan half on each cooky. Make
these rich cookies smaller ... only 2″.

SALTED PEANUT COOKIES

These tempting peanut crunches are always a favorite both with children and
grown-ups.

Follow recipe above—except in place of the 3½ cups flour, stir in

2 cups sifted flour, 2 cups rolled oats, 1 cup wheaties, 1 cup
coarsely chopped salted peanuts (without husks). Bake until brown,
12 to 14 min.

BUSY-DAY NUT DROPS

Easy budget-savers. One of our home testers calls these her “wash day” cookies.
Follow recipe above—and mix into the dough 1 cup cut-up nuts.

BUSY-DAY COCONUT DROPS

Follow recipe above—and mix into the dough 1 cup moist
shredded coconut.

“Cozies” from the cooky jar.

COFFEE-AND-SPICE DROPS ( Recipe) Intriguing flavors from

the Far East.
Mix together thoroughly ...

1 cup soft shortening

2 cups brown sugar
2 eggs

Stir in ...

½ cup cold coffee

Sift together and stir in ...

3½ cups sifted GOLD MEDAL Flour

1 tsp. soda
1 tsp. salt
1 tsp. nutmeg
1 tsp. cinnamon

Chill at least 1 hour. Drop rounded teaspoonfuls about 2″ apart on

lightly greased baking sheet. Bake until set ... just until, when
touched lightly with finger, almost no imprint remains.
temperature: 400° (mod. hot oven).
time: Bake 8 to 10 min.
amount: About 6 doz. 2½″ cookies.
★ HERMITS
Spicy, fruity, satisfying ... contributed by Mrs. William G. Dorr, who worked with us
in our test kitchen one summer. She says they were always first choice with her
little girls.
Follow recipe above—and mix into the dough 2½ cups halved
seeded raisins and 1¼ cups broken nuts. Be careful not to overbake.

MINCEMEAT COOKIES
Extra quick, no extra fruits needed ... they are
in the mincemeat.
Follow recipe above—and mix into
the dough 2 cups well drained
mincemeat.

SPICED PRUNE DROPS Wash them and spread out in a

Follow recipe above—and add ¼
tsp. cloves with other spices. Mix into
dough 2 cups cut-up cooked prunes
(pitted and well drained), and 1 cup
broken nuts.
flat pan. Cover the pan and heat
slowly in a moderate oven.
To get full flavor from seedless
raisins, cut them in two with
scissors after plumping.

APPLESAUCE COOKIES
Yummy applesauce cake in cooky form.
Follow recipe above—except add 1 tsp. cloves with other spices.
Mix into the dough 2 cups well drained thick applesauce, 1 cup cut-
up raisins, and ½ cup coarsely chopped nuts. Bake 9 to 12 min.

WHEATIES DROP COOKIES

Treats for young champions.
Mix together thoroughly ...

1 cup soft shortening

1 cup sugar
2 eggs
Stir in ...

1 cup sour milk

Sift together and stir in ...

2 cups sifted GOLD MEDAL Flour

½ tsp. soda
½ tsp. salt
1 tsp. cinnamon
½ tsp. nutmeg
½ tsp. cloves

Stir in ...

¾ cup coarsely chopped nuts

1 cup cut-up raisins

Fold in ...

3 cups WHEATIES

Chill dough. Drop by teaspoonfuls about 2″ apart on lightly greased

baking sheet. Bake until, when touched lightly with finger, no imprint
remains.
temperature: 400° (mod. hot oven).
time: Bake 10 to 12 min.
amount: About 5 doz. 2½″ cookies.

Some of grandmother’s prize cooky favorites.

OLD-FASHIONED SOUR CREAM DROPS ( Recipe)

Soft, tender, cream-rich.
Mix together thoroughly ...
 ½ cup soft shortening
1½ cups sugar
2 eggs

Stir in ...

1 cup thick sour cream

1 tsp. vanilla

Sift together and stir in ...

2¾ cups sifted GOLD MEDAL Flour

½ tsp. soda
½ tsp. baking powder
½ tsp. salt

Chill at least 1 hour. Drop rounded teaspoonfuls about 2″ apart on

lightly greased baking sheet. Bake until delicately browned, just until,
when touched lightly with finger, almost no imprint remains.
temperature: 425° (hot oven).
time: Bake 8 to 10 min.
amount: About 5 doz. 2½″ cookies.

★ BUTTERSCOTCH COOKIES WITH BURNT BUTTER ICING

Really delectable, especially with the unusual buttery icing. Mrs. R. C. Karstad of
Nicollet, Minnesota, won a prize on them.

Follow recipe above—except use brown sugar in place of

granulated sugar. Mix into the dough ⅔ cup cut-up nuts. Spread
cooled cookies with

BURNT BUTTER ICING

Melt 4 tbsp. butter until golden brown. Blend in 1 cup sifted
confectioners’ sugar and ½ tsp. vanilla. Stir in 1 to 2 tbsp. hot water
 until icing spreads smoothly.
amount: Icing for about 30
cookies.

COCONUT CREAM DROPS

Follow recipe above—except
mix into the dough 1 cup moist
shredded coconut.

CHOCOLATE CREAM DROPS

Use freshly soured cream for good
flavor. Buy it from the dairy. Or
sour it yourself by adding 1 tbsp.
vinegar or lemon juice to 1 cup
sweet cream.
Follow recipe above—except
stir into shortening mixture 2 sq.
unsweetened chocolate (2 oz.),
melted. Mix into the dough 1

cup cut-up nuts. Frost cooled

cookies if desired with

CHOCOLATE ICING
Melt together over hot water 1
tbsp. butter and 1 sq.
unsweetened chocolate (1 oz.).
Stir in 3 tbsp. top milk and 1½
cups sifted confectioners’ sugar. to give iced cookies a professional
Thin with cream to make glossy air: Place the same amount of
and easy to spread. icing (1 tsp.) on center of each.
Then, with a spatula, spread the
amount: Icing for about 30 icing with circular motion in pretty
cookies. swirls.

FRUIT-AND-NUT DROPS
Follow recipe above—except sift with dry ingredients 1 tsp.
cinnamon, ½ tsp. cloves, ¼ tsp. nutmeg. Mix into the dough 1 cup
cut-up dates (or raisins) and 1 cup cut-up nuts.
note: The spices may be omitted.
 Molasses ‘n’ spice, my how nice!

★ GINGER CREAMS Fluffy ginger cakes ... topped with creamy

white icing.
They bring memories of a real farm home near Owatonna, Minnesota, where
children trooped to the cooky jar after chores were done. Mildred Bennett (now
Mrs. Axel Anderson), who was honored one year as national 4-H girl, brought us
this recipe when she was a member of our staff.
Mix together thoroughly ...

¼ cup soft shortening

½ cup sugar
1 small egg
½ cup molasses

Stir in ...

1 tsp. soda dissolved in ½ cup hot water

Sift together and stir in ...

2 cups sifted GOLD MEDAL Flour

½ tsp. salt
1 tsp. ginger
½ tsp. nutmeg
½ tsp. cloves
½ tsp. cinnamon

Chill dough. Drop rounded teaspoonfuls about 2″ apart on lightly

greased baking sheet. Bake until set ... just until, when touched
lightly with finger, almost no imprint remains. While slightly warm,
frost with Quick Cream Icing (below.)
temperature: 400° (mod. hot oven).
time: Bake 7 to 8 min.
amount: About 4 doz. 2″ cookies.
QUICK CREAM ICING
Delicious, creamy-tasting topping ... ideal for Ginger Creams and other festive
cookies.
Blend together ¾ cup sifted confectioners’ sugar, ¼ tsp. vanilla, and
cream to make easy to spread (about 1 tbsp.).

OATMEAL DROP COOKIES

Chewy ... with a hint of molasses.
We created this recipe in our test kitchen for the little daughter of a famous
actress, and for all little children.
Mix together thoroughly ...

½ cup soft shortening

1¼ cups sugar
2 eggs
6 tbsp. molasses

Sift together and stir in ...

1¾ cups sifted GOLD MEDAL Flour

1 tsp. soda
1 tsp. salt
1 tsp. cinnamon

Stir in ...

2 cups rolled oats

½ cup cut-up nuts
1 cup cut-up raisins

Drop rounded teaspoonfuls about 2″ apart on lightly greased baking

sheet. Bake until lightly browned.
temperature: 400° (mod. hot oven).
time: Bake 8 to 10 min.
amount: About 5 doz. 2½″ cookies.

★ MONKEY-FACED COOKIES
You’ll be amused by the droll faces.
In an antique shop, pasted on the
under side of a drawer in an old table,
a radio friend of Fultonville, New York,
discovered this recipe written in faded
ink in old-fashioned script: “for Elsa.”
Mix together thoroughly ...

½ cup soft shortening

1 cup brown sugar
½ cup molasses

Stir in ...

½ cup sour milk or buttermilk

1 tsp. vinegar

Sift together and stir in ...

2½ cups sifted GOLD MEDAL Flour

1 tsp. soda
½ tsp. salt
½ tsp. ginger
½ tsp. cinnamon

Drop rounded teaspoonfuls about 2½″ apart on lightly greased

baking sheet. Place 3 raisins on each for eyes and mouth. Bake until
set. The faces take on droll expressions in baking.
temperature: 400° (mod. hot oven).
time: Bake 10 to 12 min.
amount: About 4 doz. 2½″ cookies.
 Easy to “jumble up” in a hurry!

SUGAR JUMBLES ( Recipe) Little sugar cakes of old-time

goodness.
Mix together thoroughly ...

½ cup soft shortening (part butter)

½ cup sugar
1 egg
1 tsp. vanilla

Sift together and stir in ...

1⅛ cups sifted GOLD MEDAL Flour

¼ tsp. soda
½ tsp. salt

Drop rounded teaspoonfuls about 2″ apart on lightly greased baking

sheet. Bake until delicately browned ... cookies should still be soft.
Cool slightly ... then remove from baking sheet.
temperature: 375° (quick mod. oven).
time: Bake 8 to 10 min.
amount: About 3 doz. 2″ cookies.

COCONUT JUMBLES
Follow recipe above—and mix into the dough 1 cup moist
shredded coconut.

★ CHOCOLATE CHIP COOKIES

Follow recipe above—except in place of ½ cup sugar use ¾ cup
(half brown, half white). Then mix into the dough ½ cup cut-up nuts
and one 7-oz. package chocolate pieces (about 1¼ cups).