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

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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 eeting,
experience treacherous, judgement dif cult. “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 scienti c 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 bene ts 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
dif culties).
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 de nitive 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 de ne a diagnosis. This also
means acknowledging that time is a fundamental
tool when relating to a patient.
Scienti c 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, scienti c 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 ve 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 ef cient in treating diseases and who
are able to develop appropriate diversi ed 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 satis ed 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 scienti c 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
scienti c 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 de ne a therapy that adopts art as
part of a cure, and particularly, how can we qual-
ify it and make it acceptable to the scienti c
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 “scienti cally” signi cant as
a therapy, we need to prove its value and
effectiveness.
Fig. 1.1 ‘Waiting for
emotions’ courtesy
of Lorenzo Colombo
3
The scienti c 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 exibility 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 scienti c
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 re ect 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 bene t, 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 signi cant 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 speci c
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
rst 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 exibility
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 re ned 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 speci c 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 identi ed in the Arab–Hebrew medical
tradition [6]. Looking at the Hellenistic period
we nd how Plato and Aristotle observed that
music had a distinct power on people’s behav-
iour, especially regarding their reactions and
emotions, nding 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 tted to
soften and sooth. In ancient Greece we nd 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 fteenth century. In his letter ‘De
Musica’ to his friend Antonio Canisiano, he urges
him to mix medical and musical studies to nd
the virtue and therapeutical proprieties of sound,
building on the new musical theories of counter-
point. Speci cally, 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 re ect 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, con rms that ‘a happy and joyful soul’ is
that which pro ts 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 nite 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 ght 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 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 nd 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 con icts 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 scienti c 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 scienti c 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 rst 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-
ti c justi cation 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 scienti c 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 de nition of the actual
bene ts 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 con rmed this idea. In par-
ticular, questionnaire and interview studies on
older adults actively participating in community
choirs have demonstrated a self-perceived bene t
on quality of life, depression and satisfaction with
health due to an increase of social interaction,
cognitive stimulation and enjoyment. The long-
term ef cacy 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 signi cantly 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 con rmed 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 uency,
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 signi cantly
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 bene cial for
seniors and can serve as a practical opportunity
and an effective means to slow age-related cogni-
tive dif culties.
2.3 Music for Neurological
Diseases and Neurological
Rehabilitation
2.3.1 Stroke
Of the major neurological pathologies, the best
evidence for ef cacy of music-based interven-
tions has been reported for people affected by
stroke. Music-based intervention is de ned as
an experimental protocol which uses music in
various forms, to study the possible speci c
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
quali ed 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 de nition 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 scienti c 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 xed rhythm are presented and movements
are entrained to the previously determined
rhythm. All four studies found the intervention to
signi cantly 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 signi cant improvement in gait velocity
and double-support period on the affected side
[25]. In another not blinded study (33 participants,
overall duration of intervention 16 h in 8 weeks)
rhythmic auditory stimulation was able to improve
10
range of ankle extension and arm exibility (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 de nition, music-supported ther-
apy is not only hearing music but also singing
and playing rhythm and percussion instruments.
This approach is based on speci c principles.
These are: persistent repetition and exercising of
simple nger 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 ef cacy 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 speci cally 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 soni cation 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 de cits in proprioception. Sonication sig-
ni cantly 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- uent aphasia [32]. In melodic intonation
therapy, the intonation of speech is expressed as
high and low pitches. Production of linguistic
phrases is achieved rst 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 de nite
elds: 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 bene cial
for improving gait velocity, stride length of the
affected side and gait cadence after stroke.
Furthermore, music intervention resulted bene-
cial 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 speci c 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 de ne 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 bene cial effects of music (although
short term) on social behaviour and interaction,
agitation and anxiety [39–41]. The speci c 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 con rmed 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 signi cance 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 bene cial 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 signi cantly improve the psycho-
behavioural pro le 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 speci c
symptoms of Parkinson’s disease (stooped pos-
ture, narrow base, exed 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 dif cult 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 speci c study with this device (WalkMate)
on 20 PD subjects versus 16 healthy controls,
resulted in gait improvement, reaching the
detrended uctuation 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 eld is promising, further studies
are required, particularly integrating rhythmic
auditory stimulation. In ve 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 signi -
cantly reduction of PD disease-speci c 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 certi ed music thera-
pist (six sessions over 2  weeks). A statistically
signi cant 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 in uence and impact of speci c 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
xed-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
ef ciency) 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 ef ciency 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-
ni cant advantages in terms of sleep onset latency
and sleep ef ciency, 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 bene cial 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 speci c 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
signi cant 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 ( rst
5 min of the rst movement ‘allegro con spirito’
comparing with age-appropriated control-music).
The results showed a signi cant 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 signi cantly improved the func-
tional use of hand, as detected by a speci c 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 signi cant 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 suf cient to drive conclu-
sions, but quite interesting to suggest new proto-
cols, considering music therapy as an option to
treat speci c symptoms such as fatigue, mood dis-
turbances, spasticity or cognitive de cits.
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 bene ts of music therapy for many health
conditions (including neurological diseases).
Furthermore, a speci c 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 bene t
through interdisciplinary scienti c 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. Scienti c method is essential to
demonstrate the utility and ef cacy 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), quali cation of interventionist and/or
credentials, treatment delity (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 quali cations, setting and treat-
ment delity. The absence of information lessens
the clinical relevance, impact and scienti c 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 signi cant problems with
reporting quality for music intervention research.
To improve these methodological strategies in
order to nd a shared language that re ects 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
magni cent 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 de ne 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 re ective 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
de ne something as beautiful, ‘beautiful’ does
not determine the object, but just re ects 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 de ned 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-
ci c 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
in uential 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 eld 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, rst 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 exible 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
re ne 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 speci cally, 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-
ci c 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 classi ed as beautiful,
3 Beauty and the Brain: Neuroaesthetics
activated mainly an area known as eld 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
eld 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, triste
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 espectador
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 de ned 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 speci c 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 de niteness (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 elds 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
22
de ned parameter within presented stimuli—that
is the golden ratio—determined such brain acti-
vations, different from those aroused by stimuli
where that parameter was absent.
The key of change in perception of an ‘ugly’
or ‘beautiful’ sculpture—the sense of beauty in
art—seems then arouse from a linked activation
of cortical neural populations responding to
peculiar features available in artworks and neu-
rons located in emotional control centres.
The rst question about the relationship
between beauty and the brain is: Where is beauty?
Is it in the world or in our heads?
This question presupposes world of things and
eye of the beholder as separate entities. But like
Aniaan Chatterjee [14] suggests, after the discov-
eries of evolutionary psychology we know that
men are deeply integrated with natural world and
our minds have been modelled by nature and
environment. So, our minds have become part of
the world and our brains did evolve to nd same
objects universally beautiful. For this reason,
people from different cultures can deem the same
objects as beautiful.
Although manifestations of beauty are shared
universally, cultural in uences affect these
experiences.
In point of fact the nature of aesthetic experi-
ence presents an apparent paradox. Painting aes-
thetic judgements are highly individual, as
moving-experienced paintings differ widely
among people. The neural systems supporting
aesthetic reactions, however, are largely shared
from person to person. This re ects a major
theme in philosophical inquiry into aesthetic
experience that is the tension between universal-
ity and subjectivity.
The emerging picture of brain networks
underlying aesthetic experience presents a poten-
tial solution to this paradox.
Default mode network is a network of brain
areas associated with inward contemplation and
self-assessment that are commonly active in peri-
ods of waking rest but whose activity generally
decreases with external stimulation. Surprisingly,
some authors [15] combining fMRI and behav-
ioural analysis of individual differences in aes-
thetic response showed that with intensely
E. Grassi and M. Aguggia
powerful aesthetic experience the default mode
network is engaged.
According to authors these data show that aes-
thetic experience causes an integration of exter-
nal perception with the inner senses in a manner
that our sensory and emotional reactions link to
their personal relevance.
But, how much stable are human aesthetic
preferences, and how does stability change over
the lifespan? In a recent paper [16], authors try to
answer these questions. Using tasks with paint-
ings and photographs of faces and landscapes
they found that aesthetic stability generally fol-
lows an inverted U-shaped function, with the
greatest degree of stability appearing in early to
middle adulthood: aesthetic preferences are quite
unstable in early childhood; grow increasingly
stable in young adulthood and then gradually
become less stable in later adulthood. These
results are consistent with the idea that human
aesthetics is rooted in cognitive control (since
cognitive control performance follows a gener-
ally similar trajectory across the lifespan) in the
construction of an aesthetic taste that could be
maintained over time.
3.4 Beauty in Faces
Faces are by far the most important category of
object recognition, as they are the main way by
which we can recognize other people as well as
ourselves. For this reason, brain has a sophisti-
cated mechanism apt to face recognition, a mech-
anism actually capable of overtaking any
distortions such as caricatures or low-resolution
images.
Facial morphology is highly diversi ed in
human population and this makes possible indi-
vidual recognition. Even among a very geneti-
cally homogeneous population like Finnish are, finlandeses
we detect a great variety of features (as shown in
below picture portraying six soldiers). On the
contrary, royal penguins seem to recognize each
other by distinct vocalizations instead of de ned
somatic traits [17].
Three experimental evidences testify the exis-
tence of a face-speci c neural system: (1) a
3 Beauty and the Brain: Neuroaesthetics
double disjunction between faces recognition and
objects recognition; (2) the existence of face-
selective neurons, organized in speci c areas; (3)
the presence of speci c event-related potentials
(ERP).
Sir Francis Galton, anthropologist, explorer,
as well as Charles Darwin’s cousin (and inventor
of eugenics before its tragic racist deviations)
devised already one century ago a photographic
technique for re-creating faces through the fusion
of different real portraits. When Galton produced
his rst composite portraitures, he was surprised
to see how these faces were considered more
beautiful than the original ones. These observa-
tions have been repeated and improved thanks to
modern techniques of computer graphics.
The higher the number of superimposed faces
creating the composite portrait was, the more
attractive it was perceived; while none of real
faces used for the composition had ever been
judged more attractive than the composite face
itself.
Many researchers suggested that average-face
features re ect a stable development and are
functionally optimal, above all for their illnesses
resistance. Averageness is thus expression of
partner’s positive qualities.
Another face source of attraction lies in facial
symmetry, as partner’s signal of quality.
The last important element is sexual dimor-
phism, which increases during puberty when sexu-
ally dimorphic traits signal maturity in reproductive
potentiality and partner’s different qualities.
Femininity in women faces is obviously
attractive, as it is expression of fertility. Faces
with more feminine features than average are
also those considered more attractive, being their
peculiarities small chin, high cheekbones,
reduced visage surface and eshy lips.
Compared to femininity, more masculine
traits affect attraction in a lesser way than male
faces. Masculinity becomes again important for
women during their menstrual cycle fertile phase,
when they de nitely prefer more masculine
faces, for example with a darker complexion.
As far as this is concerned, a widespread
preference for faces of different ethnicity born
subjects is quite meaningful, as they show a
23
healthier countenance than others. And this is fea-
sible because genes can better adapt themselves to
different environments, with a higher resistance to
illnesses than same ethnicity born people.
As we behold a beautiful-esteemed face, a
dopaminergic reward pathway activates, whose
main centres lie in the mesencephalic ventral teg-
mental area, in the ventral striatum and in the
orbitofrontal cortex. It is a pathway which acti-
vates as reaction to all hedonically relevant stim-
uli and arousing pleasant sensations. Seeing a
pretty face makes us feel as we had just won some
money, whereas seeing a less attractive one makes
us feel as we had just lost some. Brain therefore
reacts to beauty rapidly and automatically.
Plato and his contemporary Greek society
considered beauty as a value closer to good than
to art; it concerned behaviours and deeds more
than artworks. On the other hand, it is an idea
which can exist beyond whatever earthly embodi-
ment it could epitomize; an idea which we can
ascend to, just through progressive spiritualiza-
tion exercises.
This can explain the reason why aesthetic
attraction is also at the root of the cognitive bias
which makes us esteem at rst sight a good-
looking person as a smart one. Therefore, a moral
idea of overall bounty associates to beauty, with
all its practical (and unconscious) consequences
it involves (over judicial decisions too).
Attractive individuals are credited with more
positive personal and interpersonal qualities (e.g.
trustworthiness, intelligence and competence)
than less attractive individuals. This suggests a
close link between aesthetic and moral valuation.
Recently [18] combining transcranial magnetic
stimulation (TMS) with a priming paradigm,
authors showed that dorsomedial prefrontal cortex
(dmPFC) plays a causal role in his linking moral
and aesthetic valuation. In this study participants
evaluated the trustworthiness of a series of faces,
each of which was preceded by an adjective
describing desirable, undesirable or neutral aes-
thetic qualities. When TMS was applied over the
dmPFC, primes had no effect on trustworthiness
judgements showing a causal role of the dmPFC
in mediating the link between aesthetic and moral
valuation.
24
So, objective beauty does exist and gives
reliable-considered pieces of information about
age, fertility, health; and our brain is well trained
to recognize it. On a recent Nature editorial Karl
Grammer, professor of anthropology at the
University of Vienna and pioneer in human
attraction research, states [19]:
Humans are obsessed with beauty. When you nd
an obsession like this, there must be something
deeper than a simple cultural norm.
Aesthetic judgement is therefore a complex mix-
ture of genetical, cultural and objective factors
which needed millions of years to evolve.
These aesthetic criteria are long-lasting and
reliable, as shown by Queen Nefertiti’s portrai-
ture: this bust, kept at Berlin Neues Museum and
crafted 3300 years ago, shows her as very beauti-
ful and seductive, thanks to her features still
going as strong as ever: eshy lips, high cheek-
bones and elongated eyes.
As Darwin discovered, human sense for
beauty roots in the reproduction biological con-
text; as a consequence, we can af rm Darwin was
the founder of a sort of ‘evolutionary history of
beauty’, as he showed how aesthetic bias co-
determined in a crucial way the whole develop-
ment of physical shapes within the totality of
sexuate living being kingdom.
3.5 Conclusion
Within this aesthetic dimension, art represents
both one of the higher human complexity expres-
sions and one of the most re ned manners for
feelings and emotions portraiture; thus providing
us with one of the most precious testimony about
brain functioning, for, as Paul Klee wrote,
Art does not reproduce the visible but makes
visible.
Aesthetic expressions may give us an insight not
only into aesthetics but also into neural process
dynamic interrelations.
Neural systems for emotion, reward and
default mode network work together to enact our
E. Grassi and M. Aguggia
aesthetic experience. Through this neural archi-
tecture we can extract pleasure from extraordi-
nary and variable aspects of our aesthetic life and
re ne the borders between the empiric world and
our sense of self.
From the analysis carried out so far, it can be
observed how the experience of beauty does not
entail just an abstract value or a re ned but
unnecessary pleasure—something like a point-
less luxury—but it rather involves a mark, at
least, of what avoids in itself each kind of reduc-
tion: the proprium of human being dignity.
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 Neurodegenerative Diseases
and Changes in Artistic Expression
Massimo Filippi, Noemi Piramide,
Sarasso Elisabetta, and Federica Agosta
4.1 Introduction
The brain is probably the most astonishing part of
human body, not enough explored yet. It our-
ishes. It learns. It changes. It adapts itself to cur-
rent events. It lets us see, hear, smell, touch, feel
emotions and more than this. It controls and inte-
grates motor functions, cognitive abilities and
emotional processes. Art represents one of the
most impressive expressions of brain capabili-
M. Filippi (*)
Division of Neuroscience, Neuroimaging Research
Unit, Institute of Experimental Neurology, IRCCS
San Raffaele Scienti c Institute, Milan, Italy
Neurology Unit, IRCCS San Raffaele Scienti c
Institute, Milan, Italy
Vita-Salute San Raffaele University, Milan, Italy
e-mail: lippi.massimo@hsr.it
N. Piramide
Division of Neuroscience, Neuroimaging Research
Unit, Institute of Experimental Neurology, IRCCS
San Raffaele Scienti c Institute, Milan, Italy
S. Elisabetta
Division of Neuroscience, Neuroimaging Research
Unit, Institute of Experimental Neurology, IRCCS
San Raffaele Scienti c Institute, Milan, Italy
Laboratory of Movement Analysis, IRCCS San
Raffaele Scienti c Institute, Milan, Italy
F. Agosta
Division of Neuroscience, Neuroimaging Research
Unit, Institute of Experimental Neurology, IRCCS
San Raffaele Scienti c Institute, Milan, Italy
Vita-Salute San Raffaele University, Milan, Italy
© Springer Nature Switzerland AG 2020
B. Colombo (ed.), Brain and Art, https://doi.org/10.1007/978-3-030-23580-2_4
4
ties. Different artistic expressions, such as paint-
ing, drawing, sculpture and music, require not
only exceptional sensorimotor capacities, but
also a combination of extraordinary cognitive
abilities and use of emotions.
For ages, strong interest has been reserved to
discover the neural mechanisms underlying brain
functions, particularly using structural and func-
tional magnetic resonance imaging (MRI). To
date, we know that there are no speci c cerebral
areas responsible for separate purposes, but dif-
ferent brain areas and circuits contribute to sev-
eral functions. For instance, the frontal lobe has
been traditionally considered responsible for
executive functions including planning, set-
shifting, inhibition and monitoring activities [1,
2], but also the cingulate cortex and parietal areas
are involved [3–5]. Together with executive func-
tions, visuospatial abilities are also relevant to
make art. The ventral stream of ‘what’ is involved
in recognising daily visual images, which are
elaborated through the temporo-occipital projec-
tions; then, the parieto-occipital projections, the
so-called dorsal stream of ‘where’, locate the
images captured by the stream of ‘what’ in the
space [6]. Visuospatial abilities also play key
roles in spatial working memory processes (pari-
eto–prefrontal pathway), visually guided actions
(parieto–premotor pathway), and motor coordi-
nation within the spatial environment (parieto–
medial temporal pathway) [6]. The identi cation
of colours starts with the visual processing in the
occipital areas and proceeds with an elaboration
27
28
through temporal cortices [7]. Temporo-parietal
areas are also responsible for auditory functions
[8]. For instance, they allow to distinguish music
from noise [8]. Patients with right anterior tem-
poral lobe atrophy are unable to recognise music
and tones [9]. Interestingly, music and emotional
interpretation of perceived sounds are processed
by complex brain emotional networks including
amygdala, insula, orbitofrontal to mesolimbic
projections, salience network and subcortical
pathways, typically involved in pleasure and
reward circuits [10].
Traditionally, the right hemisphere was
believed to underpin the most creative functions
of the brain, with an aptitude to elaborate the
critical and aesthetic meaning of language and to
govern metaphoric thinking, poetry, lyrics and
music talent [10]. It is considered the centre of
conceptualisation and imagination, while the left
hemisphere is the hub of balance and limit [11].
Many authors have recently con rmed the role of
the right hemisphere in empiric matters and of
the left hemisphere in methodical and systematic
issues, but there is not a clear watershed [12–14].
The two hemispheres continuously cooperate,
with the left hemisphere inhibiting the over ow
nature of the right one through executive and
rational characteristics and the right hemisphere
a b
Fig. 4.1 (a) W9, Conversation pieces, 1990 by William
Utermohlen. Gentle colours in a relatively spared perspec-
tive. (b) Snow, from the Conversation Pieces, 1991 by
William Utermohlen. Canvas with antithetic colours and
M. Filippi et al.
which is essential to inhibit the rigid schedules of
the left side [13, 15].
The occurrence of a neurological disease is
usually considered as a catastrophe that irrepara-
bly damages the brain. Certainly, a neurodegen-
erative disease will cause a change in the artwork,
but change does not necessarily mean worsening.
Sometimes the behavioural modi cations
induced by neurodegeneration surprisingly
enhance art production [16–21].
This chapter will discuss how neurodegenera-
tive diseases in uence art through the presenta-
tion of intriguing clinical cases.
4.2 Alzheimer’s Disease
William Utermohlen is one of the most famous
artists who had Alzheimer’s disease [22]; his
artistic production has fascinatingly mutated
after disease onset and with its progression [22].
Figure 4.1a is a reproduction of the picture ‘W9’,
Conversation pieces, painted in 1990, when the
painter was probably in the prodromal phase of
Alzheimer’s disease: the perspective is relatively
spared, even if the chair is slightly curved; the
colours are gentle and the yellow is pervasive; the
representation is still quite realistic. Figure 4.1b
distorted perception. Reprinted by permission of Chris
Boïcos Fine Arts (www.boicos nearts.com) on behalf of
the artist’s heirs
4 Neurodegenerative Diseases and Changes in Artistic Expression
shows a painting named ‘Snow’, from the
Conversation Pieces, painted in 1991, when the
diagnosis of Alzheimer’s disease was not estab-
lished yet, but the artist was conscious that some-
thing was changing and he would have never
been the same [22]. The painting expresses the
frustration of an artist who has lost his previous
light-heartedness and quietness. He wanted to x
on the canvas a moment that really counted for
him: the vulnerable joy of an intimate moment
spent with his friends and wife. The artist strongly
focused on sensorial impressions in a natural and
simple way: the sound of voices, the smell and
taste of coffee, wine and cigarettes, and the cold
and hot antithesis of the scene. He wanted to
secure on the painting his perceptions, though
con icting, before they might fade away, before
completely forgetting them. He depicted himself
outside the circle, quietly thinking of the present
warmth of his home while out of the window it is
snowing. The perspective is totally altered: the
elements overlap on a unique level; red and yel-
low stand out in the white snow. This can be
hypothesised as an initial manifestation of
Alzheimer’s disease [22]. In ‘Bed’ (Fig.  4.2a),
Conversation Pieces, 1991, the disease is going
on and the perspective is created mainly using the
contrast of colours, red, yellow and green. These
a b
Fig. 4.2 (a) Bed, Conversation Pieces, 1991 by William
Utermohlen. Perspective created using the antithesis of
colours, red, yellow and green. (b) Blue Skie, 1995 by
29
characteristics become even more evident in the
advanced stages of the disease, as in the picture
‘Blue Skie’ (Fig.  4.2b), painted in 1995 [22].
Primary colours are the concrete essence of the
painting; blue and yellow give dimension to the
environment and perspective. The space is empty
and pro les are vanishing. Not only shapes and
perspectives are altered, but also the colours: the
author has shifted from the optimism of yellow
and red to the sadness of dark green and black
[22]. This piece re ects the intimate desolation of
the remaining ill existence. The progression of
the disease is particularly evident also in Fig. 4.3,
a combination of self-portraits in which
Utermohlen depicted himself every year till
before his death [22]. The memory loss reveals
through the progressive alterations of facial fea-
tures: in the last painting, the author is
unrecognisable.
As Utermohlen, another noteworthy example
of famous artist with Alzheimer’s disease is
Willem De Kooning [23]. In his early artworks,
he focused on women gures and oils multi-
coloured canvases. After disease diagnosis, he
moved on abstract themes leaving aside the
importance of shapes, lines and gures, and he
took particular interest on colour meanings and
expressions [23].
William Utermohlen. Empty space and vanishing pro les.
Reprinted by permission of Chris Boïcos Fine Arts (www.
boicos nearts.com) on behalf of the artist’s heirs
30
Fig. 4.3 Progression of the disease denoted in serial self-portraits by William Utermohlen. Reprinted by permission of
Chris Boïcos Fine Arts (www.boicos nearts.com) on behalf of the artist’s heirs
Similar changes of painting style are evident
in the production of Carolus Horn [24].
Comparing two different pictures representing
similar environments painted before and after
disease onset (Fig.  4.4a), it is possible to note
again how Alzheimer’s disease in uences art pro-
duction. After disease onset, the artist shows an
altered ability to depict perspective, which is cre-
ated only using the contrast of colours between
foreground (brighter) and background (Fig. 4.4a)
[24]. The different objects have their own point
of view. There is a lack of depth, shading and
movement. Details are reduced and it is dif cult
to guess age and gender of the characters. Shapes
and lines stand out more clearly. With disease
progression, the patient’s painting completely
changes: an impressive insight comes out with
spatial errors and colour misperceptions. He
increasingly tends to use red and yellow. Just
before his death, artworks are inconsistent and
devoid of colour (Fig. 4.4b) [24].
M. Filippi et al.
The variations in painting style can be explained
by the main features of the disease (Table  4.1).
As known, histopathological examination of brain
tissue demonstrates that Alzheimer’s disease is
characterised by two neuropathological hallmarks:
extracellular aggregations of Aβ-amyloid plaques
and intracellular accumulation of neuro brillary
tangles resulting from the hyperphosphorylation
of the tau protein microtubules [25]. These bio-
chemical processes lead to a widespread neuronal
loss [26]. The temporal lobe, including the ento-
rhinal cortex, hippocampus, amygdala, and the
parahippocampal cortex, is the rst region
involved [27]. Then, disease spreads to other corti-
cal (parietal, frontal and occipital lobes) and sub-
cortical areas over time [27]. Therefore, the
reduced metabolism and atrophy in temporal lobes
and then in parietal areas with disease progression
may justify the dif culty, for example, in perceiv-
ing colours and perspective in patients with
Alzheimer’s disease [28, 29]. The prominent
4 Neurodegenerative Diseases and Changes in Artistic Expression
Fig. 4.4 (a) Paintings by Carolus Horn showing land-
scapes before and after the Alzheimer disease onset. (b)
Inconsistent and poor in colours latest artwork of Carolus
Horn. Reproduced with permission from Maurer K,
impairments in patients with Alzheimer’s disease
are de cits in memory and recognition of objects
and faces, reduced self-con dence and visuospa-
tial abilities with distortion/loss of perspective,
and altered perception of colours [30]. Indeed,
many studies of Alzheimer’s disease patients
showed simpli cation of drawing, reduction of
angle number with smoothed lines, impairment in
colour contrast sensitivity and alteration of spatial
relations with reduced perspective and distortion
of objects [31–33]. In these patients’ canvases,
details are redundant in the early stage of the dis-
ease and abolished later [31–33]. The emphasis on
colours and pro les in the early phase of the dis-
ease is an attempt to compensate memory decline.
31
Prvulovic D. Paintings of an artist with Alzheimer’s dis-
ease: visuoconstructural de cits during dementia. J
Neural Transm (Vienna). 2004;111(3):235-45
Later, gures become distorted, vanishing, poor in
colours and unrecognisable.
Few reports on music and sculpture changes
in Alzheimer’s disease patients are present in
literature. Language and declarative memory
functions worsen rapidly in these patients, as
seen above [9]. However, many data reported
preserved music skills in patients with
Alzheimer’s disease performing songs learned
and intensely practised before the onset of
dementia [34–36]. The authors showed impaired
anterograde and retrograde declarative memory
in recall tests or the ability to recognise previ-
ously known compositions [34–36]. Procedural
memory, instead, is preserved. While the ability

Table 4.1 Pathological features, pattern of atrophy, molecular changes and clinical characteristics of the neurodegenerative diseases described in the text
Disease Pathology
Alzheimer’s disease Accumulation of extracellular
Aβ-amyloid plaques and
intracellular neuro brillary tangles
of hyperphosphorylated protein tau
Behavioural variant Tau or TDP-43 protein deposition
of frontotemporal
dementia
Primary progressive Tau or TDP-43 protein deposition
aphasia
Dementia with Lewy bodies accumulation
Lewy bodies including aggregates of misfolded
α-synuclein protein
Parkinson’s disease Dopaminergic neuronal loss in the
substantia nigra; Lewy bodies
accumulation including aggregates
of misfolded α-synuclein protein
Abbreviations: [18F]-DOPA 18 uorodopa, [18F]-FDG 18 uorodeoxyglucose, ↑ increased, ↓ decreased
Atrophy pattern
Mild: atrophy of medial
temporal lobe
(hippocampus, entorhinal
cortex)
Advanced: atrophy of
temporal, frontal, parietal
and occipital lobes
Atrophy in the frontal lobe,
anterior cingulate, anterior
insula and thalamus
Predominant atrophy of left
frontotemporal and parietal
areas (non- uent variant
mainly in the posterior
frontal cortex and insula)
Widespread cortical and
subcortical atrophy (with
relatively preserved medial
temporal lobe)
Mild: subcortical atrophy
Advanced: widespread
cortical atrophy
Molecular changes
↓ [18F]-FDG metabolism in temporo-
parietal regions and
↑ Aβ-amyloid uptake
↓ [18F]-FDG metabolism in
frontotemporal areas and basal ganglia
↓ [18F]-FDG metabolism in
thefrontotemporal and parietal areas
(non- uent variant mainly in posterior
frontal cortex and insula)
↓ [18F]-DOPA uptake in the basal
ganglia;
↓ [18F]-FDG metabolism in occipital lobe
at disease onset and possible involvement
of the cingulate cortex
↓ [18F]-DOPA uptake in the basal ganglia
(mainly caudate and putamen);
↓ [18F]-FDG metabolism in the cerebral
cortex (mainly frontal and parietal areas)
with disease progression
32
Clinical symptoms
Memory decline;
impairment in other cognitive
domains such as visuospatial
abilities;
dementia when cognitive decline
causes dif culties in activities of
daily living
Personality and behavioural
changes (disinhibition, apathy, loss
of empathy, repetitive and obsessive
stereotyped behaviours etc.);
executive de cits
Language dif culty as the most
prominent sign at disease onset and
for the initial phases of the disease
(speci cally non- uent variant is
characterised by: agrammatism in
language production; apraxia of
speech; impaired comprehension of
syntactically complex sentences;
spared single-word comprehension;
spared object knowledge)
Cognitive impairment (alteration of
executive-attentive and visuospatial
functions, recurrent visual
hallucinations) and parkinsonian
motor features
Mild: motor impairment (rest
tremor, bradykinesia, rigidity etc.)
Advanced: non-motor symptoms
and cognitive decline
M. Filippi et al.
4 Neurodegenerative Diseases and Changes in Artistic Expression
to learn new songs may be altered, musicians
with Alzheimer’s disease are able to play easily a
well-known composition even without knowing
the respective name or author [34–36].
4.3 Behavioural Variant
of Frontotemporal Dementia
Figure 4.5 presents a panel of three paintings by
an unknown artist with frontotemporal dementia
that began as language variant and turned into
behavioural variant [19]. Before the disease diag-
nosis, the author used to paint about Eastern and
Western themes [19]. Then, typical characteris-
tics of a behavioural frontotemporal dementia
appeared on canvas: nudity and perseverated and
complex elements on background with brushing
lines. Alienated gures without empathy are
depicted. The main colours used are purple, tur-
quoise and red; they are incongruent and shiny.
The canvases are not realistic, but intensely
1 3
Fig. 4.5 Nudity and perseverated and complex elements
on background with brushing lines in canvases of a patient
with frontotemporal dementia. Reproduced with permis-
33
impressionistic. The inner air is arrogantly
pulled out [18, 19].
Erkkinen and colleagues followed up another
case of behavioural frontotemporal dementia for
5 years, describing the progression of his artistic
career [37]. The patient continued to practice art
till death, shifting from peaceful landscapes of
the early disease stage to erotic bizarre fantasy
topics with religious or mythological connota-
tions of the advanced phases. Provocative,
shaming, aggressive and haunting tones per-
vaded his artistic production [37]. With disease
progression, his artistic style developed in mix-
ing painting and sculpture. He made his master-
piece at the end of his life: a 6-square-meter
wooden painting of sexual acts performed by
demons [37]. All of these artistic expressions
can be referred to brain changes due to disease
burden (Table 4.1).
Behavioural variant of frontotemporal demen-
tia is characterised by an abnormal deposition of
tau or TDP-43 proteins, which causes neurode-
sion from Mell JC, Howard SM, Miller BL. Art and the
brain The in uence of frontotemporal dementia on an
accomplished artist. Neurology. 2003;60(10):1707-10
34
generative processes involving mainly frontal
and anterior temporal cortices and basal ganglia
with a relative preservation of parietal and occipi-
tal areas [38, 39]. Even limbic circuits are implied
[40]. This damage usually results in a lack of
empathy and sympathy, apathy, alteration in per-
sonality, de cit of executive-attentive functions
and compulsive, perseverative, ritualistic and ste-
reotypic behaviours [40]. Patients manifest sex-
ual disinhibition, as seen in artistic expressions.
Visuospatial skills, memory and sensitive percep-
tions are relatively spared [41, 42]. In fact,
patients with behavioural variant of frontotempo-
ral dementia retain spatial organisation in paint-
ing, but objects or patterns are obsessively
repeated. Human gures appear distorted, alien-
ated and deprived of emotional feelings. The pic-
tures have less symbolic and abstract
characteristics, but are more surrealistic with
harsh, striking, strident and bright colours. The
change in the use of colours may represent an
expression of frontal disinhibition and persevered
behaviour rather than a de cit of visual percep-
tion [18].
4.4 Primary Progressive Aphasia
Primary progressive aphasia is characterised by
language dif culty with aphasia as the most
prominent de cit at symptom onset and for the
initial phases of the disease (Table  4.1) [43].
Primary progressive aphasia is associated with an
abnormal accumulation of misfolded tau or TDP-
43 proteins involving frontotemporal and parietal
areas, mainly in the left hemisphere [44]. Three
speci c forms of primary progressive aphasia
have been described: non uent, semantic and
logopenic [45]. The two cases we are going to
present have been generally described as primary
progressive aphasia; however, they showed a
clinical presentation and evolution resembling
the currently known ‘non uent primary progres-
sive aphasia’. Most cases of non uent primary
progressive aphasia are characterised by an
abnormal accumulation of misfolded tau in left
posterior frontal and insular areas resulting in a
M. Filippi et al.
progressive hypometabolism and atrophy [44,
45]. Non uent speech with agrammatism, speech
apraxia and de cient comprehension of syntacti-
cally complex sentences are the main clinical
symptoms [45]. Single-word comprehension and
object knowledge are spared [45]. Interestingly,
patients with primary progressive aphasia do not
diminish, but enhance their artistic skills
[46–49].
The most famous patient with primary pro-
gressive aphasia is Maurice Ravel. The composer
developed the disease during his artistic career
[50]. He composed his most renowned piece, the
Bolero, at advanced stage of the disease. It is a
composition of perseverance, repetition, emo-
tional climax and nal collapse. Two main
melodic themes alternate, repeated eight times
over 340 bars. The volume increases till the 326th
bar of the nal collapse. The melody is strident
and heart breaking with ending acceleration [50,
51]. The complexity of the composition is
extraordinary and amazing considering the brain
damage.
Even more surprising is the visual transla-
tion of Bolero made by Anne Adams, a painter
also affected by primary progressive aphasia
[51]. She started with simple and architectural
watercolour paintings and her production con-
gruently developed with the progression of
symptoms, till the ‘Unravelling Bolero’
(Fig.  4.6a) [51]. The artist transformed each
sound in different symbols: height and width
of forms represent tone intensity and duration.
The colour palette largely re ects auditory per-
ception: dark blue stands for deep pitch; white
and yellow stand for light and high tones. At
the end of the panel, orange and purple repre-
sent the dramatic nal decline of Bolero. Even
if she did not present synesthetic characteris-
tics, she created an internal association between
colours and notes. Anne Adams had also an
asymptomatic acoustic neuroma and she was
followed up for years using MR, with very
interesting ndings [51]. In Fig.  4.6b, paired
MRI scans and paintings from the same years
are presented. With disease progression, emer-
gent atrophy became more evident in the left
4 Neurodegenerative Diseases and Changes in Artistic Expression
a b
Fig. 4.6 (a) Anne Adams ‘Unravelling Bolero’. (b)
Paired MRI scans and painting from the same years.
Reproduced with permission from Seeley WW, Matthews
BR, Crawford RK, Gorno-Tempini ML, Foti D,
interior and fronto-opercularis regions, ante-
rior insula and striatum. But also increased
volume was reported in posterior regions not
involved in the degeneration and responsible
for visual imagery and visuoconstructive abil-
ity [51]. This might justify the photographic
realism of her latest works, compared to the
symbolic character of the rst creations. Many
authors have justi ed this pattern of grey mat-
ter increase with a compensatory role of spared
areas in the attempt to overcome the impair-
ment in the other parts of the brain [18, 21, 46,
51]. In this case of primary progressive apha-
sia, the compensatory increase of the posterior
regions functions involved in visuospatial
domain resulted in an improvement of artistic
abilities [52]. In other way, this compensatory
mechanism has been already explained by
Kapur in 1996 as a ‘paradoxical function facil-
itation’ [53]. Kapur argued that normal sub-
jects present a complex harmony between
inhibitory and excitatory circuits. When a brain
area is not inhibited by the contralateral, it can
paradoxically overexpress its creativity [53].
Spared regions attempt to re-establish the max-
imal brain potential. Imbalance between hemi-
spheres could enhance functions suppressed
before [53].
35
Mackenzie IR et al. Unravelling Boléro: progressive apha-
sia, transmodal creativity and the right posterior neocor-
tex. Brain. 2007;131(1):39-49
4.5 Dementia with Lewy Bodies
A different neurodegenerative pattern is evident
in Mervyn Peake, an accomplished British artist
developing a probable Lewy body dementia [54].
Figure  4.7a shows an abstract, shapeless and
unclear canvas that re ects a decline of visuocon-
structive skills. It represents dunce caps or
pointed heads. Vivid and strong hallucinations
are detectable in twisted gures and beasts. It is
pervaded by expressions of melancholy, fear and
apprehension. A criticist argued that ‘there is a
coarseness of feeling, a lack of sympathy for the
persons he portrays’ [54]. This canvas comes
from Peake’s latest production, when the disease
was advanced. On the contrary, his previous
paintings were realistic and homogeneously
coloured [54].
Peake’s disorder involved also his poetry com-
position abilities. We can understand his inner
feelings on what he wrote:
‘Heads oat about me; come and go, absorb me;
Terrify me that they deny the nightmare
That they should be, defy me;
And all the secrecy; the horror
Of truth, of this intrinsic truth
Drifting, ah God, along the corridors
Of the world; hearing the metal
Clang; and the rolling wheels.
36
Heads oat about me haunted
By solitary sorrows’ [54].
Hallucinations and paranoid delusions are
clear in these lines.
Drago and colleagues described a similar case
of a painter who showed a clear deterioration of
forms and abstraction of gures with unrecogni-
sable arrangements (Fig. 4.7b) [55].
Dementia with Lewy body is characterised by
the presence of aggregated and insoluble brils of
a b
Fig. 4.7 Canvases of patients with Lewy body dementia;
(a) Sketches by Mervyn Peake: Figure with dunce cap, a
repetitive theme, and animal-like oating creatures sur-
round a tormented individual. Reprinted by permission
of Peters Fraser & Dunlop (www.petersfraserdunlop.
com) on behalf of the Estate of Mervyn Peake. (b)
Deteriorated and unrecognisable gures of latest stage of
the disease of a patient with Lewy body dementia.
M. Filippi et al.
α-synuclein proteins included in Lewy bodies
(Table 4.1) [56]. At disease onset, a reduced dopa-
mine transporter uptake in the basal ganglia is
present, together with a reduced generalised
metabolism in the occipital lobe and cingulate
cortex [57]. A widespread cortical and subcortical
grey matter damage occurs with disease progres-
sion, with a relative preservation of the medial
temporal lobe [57]. Clinical manifestations
include de cits in attentive, executive, visuospa-
tial and visuocostructive functions [58]. Indeed,
Reproduced by permission of the artist’s heirs. (c)
Comparison of canvases before and after the onset of
Parkinson’s disease: from abstract and symbolic features
to realistic images. Reproduced from Shimura H, Tanaka
R, Urabe T, Tanaka S, Hattori N.  Art and Parkinson’s
disease: a dramatic change in an artist’s style as an initial
symptom. J Neurol. 2012;259(5):879-81 (Open access
article)
4 Neurodegenerative Diseases and Changes in Artistic Expression
patients are unable to copy a gure; they lose
details, lines and salient elements. They miss the
knowledge of objects. This is evident in the Mini
Mental State Examination, particularly in the
pentagon-copying [59, 60]: in patients with Lewy
body dementia the lines are missed and objects
are unrecognisable, while in Alzheimer’s disease
patients the pentagons are distorted [59, 60].
Moreover, vivid and structured visual hallucina-
tions interfere, as seen in Mervyn Peake’s works.
Visual perceptual alterations are the main changes
in art of patients with Lewy body dementia [54].
4.6 Parkinson’s Disease
About over, relatively little is known about art
expression in Parkinson’s disease [61]. Salvador
Dalì is famous for his peculiar and iconic inputs
to the surrealistic school. He was probably
affected by Parkinson’s disease or drug-induced
Parkinsonism but little is known about his dis-
ease [23]. Nevertheless, on his canvases it is pos-
sible to appreciate the extrapolation of interior
agitation and upset [23]. The artist puts human
gures of different sizes in dry and harsh land-
scapes with accurate details and melancholic
colours.
The main pathological trait of Parkinson’s dis-
ease is the loss of dopaminergic neurons in the
substantia nigra (Table 4.1) [62, 63]. As in Lewy
body dementia, Parkinson’s disease is characterised
by inclusion of misfolded α-synuclein in Lewy
bodies [62, 63]. The neurodegenerative process
involves neurons from medulla oblongata and
olfactory bulb in the prodromal phase, then extends
to the brainstem and substantia nigra in the pars
compacta in the early stages, and to the cortex in
the advanced stages [62, 63]. Bradykinesia, rigid-
ity and resting tremor are the main motor symp-
toms [64]. The progression of the pathology
implies motor impairments, autonomic dysfunc-
tions and behavioural-cognitive decline in the last
stages of the disease. Alteration in mood usually
occurs when the disease is advanced, but some-
times earlier in time [64].
Chatterjee and colleagues reported of a patient
with Parkinson’s disease who became artistically
37
productive well into the course of his disease
[65]. He was bradykinetic and his dexterity was
more impaired in hands than in proximal joints,
so he emphasised larger amplitude proximal
movements developing a personal version of the
cross-hatching style, described by Lakke [66],
with ne and regular lines. He started painting
landscapes with brushes and turned to abstract
compositions using coloured pencils, which
allowed him to produce ner lines; he also shifted
to denser, darker and more vibrant colour tonali-
ties [65]. He felt compelled to paint and thought
his disease and medications were contributing to
his artistic generativity. This might be considered
a particular manifestation of obsessive-
compulsive traits that commonly occur in patients
with Parkinson’s disease [66, 67]. An opposite
pattern was evident in a patient with Parkinson’s
disease described by Shimura [61]. He started
drawing abstract and symbolic canvases and
shifted to realistic images during the progression
of the disease. He found dif culties in decon-
structing a realistic gure and reconstructing it
into a mental and intangible form. Daily objects
and items became the subjects of his later pro-
duction (Fig. 4.7c) [61].
4.7 Conclusion
Artists are exceptionally capable to manifest
internal representations of the world and to
emphasise external signs. Through artistic
expression, they interpret and present their inner
vision of life. With the occurrence of a disease,
the manifestation of emotions, perceptions and
thoughts is inevitably different and it lets us know
how patients see and experience the world. Some
pictures result richly endowed with colours and
forms; others are abstracted, simple and sym-
bolic. Different approaches and manifestations of
the individuals stand for different pathologies
and particular inner characteristics. Neurological
de cits can modify the form of art with surpris-
ing and fascinating results. Thus, creativity and
originality embody an unexpected and pleased
feature of neurodegeneration [19]. Not all is lost
[68]!
38 M. Filippi et al.

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 Painting in Neurology
Bartlomiej Piechowski-Jozwiak
and Julien Bogousslavsky
Visual art is probably the oldest and most universal
and timeless form of human communication and
artistic productivity. The oldest cave paintings, dat-
ing back 36,000  years, were discovered by
Marcelino Sanz de Sautuola, in Altamira Cave near
Santillana del Mar in Cantabria, Spain. These cave
paintings were made during the Upper Palaeolithic
period using ochre and charcoal and they contain
very realistic handprints, and animals such as
bison, and horses. These cave paintings give unique
opportunity to look straight into cavemen daily
reality thousands of years later [1]. Painting is a
form of artistic creativity involving translation of
complex information this being emotional,
abstract, subconscious, expressive, impressive,
purely informative or surreal into two−/three-
dimensional plane through application of dyes,
colorants or other marking substances with usage
of bare ngers, wooden sticks, paintbrushes, paper,
cloths or other materials speci c to the époque,
artistic style or technical ability and availability. In
this context Altamira Cave drawings were contem-
porary and based on available materials such as
B. Piechowski-Jozwiak
Neurological Institute, Cleveland Clinic,
Abu Dhabi, UAE
J. Bogousslavsky (*)
Center for Brain and Nervous Disorders
(Neurocentre), Genolier Swiss Medical Network,
Genolier, Switzerland
Genolier Swiss Medical Network, Neurocentre,
Montreux, Switzerland
e-mail: jbogousslavsky@cliniquevalmont.ch
© Springer Nature Switzerland AG 2020
B. Colombo (ed.), Brain and Art, https://doi.org/10.1007/978-3-030-23580-2_5
5
ochre and charcoal. Artistic production process is
very complex involving continuum of conceptual
development and active executive art production.
The mechanical process of painting/drawing
involves unique paint/dye application techniques
supported by visual–spatial skills and again it is
related to the historical/stylistic/cultural and other
variables. Art perception and appreciation is likely
a mirror process to artistic production where affer-
ent artistic triggers ignite emotional, intellectual
and other reactions in the viewer. It is important to
mention a direct informative aspect of visual art as
illustrated in the case of cave paintings. The neural
network behind all these processes, both at the side
of the artist and viewer, is very complex and it
should be viewed beyond simple anatomical land-
marks such as brain lobes and laterality. Of course
cortical organisation and connectome both serve as
hardware underpinning for artistic production. Due
to the above mentioned complexity of artistic brain
activity it is really interesting to discuss and anal-
yse these processes in artists with central nervous
system disorders. The concept of analysis a dis-
eased brain is supported by the fact that under-
standing the nature of disease can be mapped
against changes in artistic productivity. In this
chapter we will walk the reader brie y through a
concept of mirroring connection between the artist
and art receiver as well as through various fascinat-
ing scenarios including development of artistic
skills de novo and artistically naïve individuals, or
change of artistic skills in relation to central ner-
vous system disorders in established artists.
41
42
5.1 Mirror Neurons and Art
The concept of mirroring functions involved in
artistic production and reception has been widely
discussed in the literature [2–6]. The original
concept of mirror neurons was developed by
Gallese and co-workers in primate model. They
discovered that same neuronal pathways and net-
works were activated when witnessing certain
motor action and when performing the very same
activity. In other words their discovery pointed
towards the translation of visual input into motor
neuronal activities, which was based on frontopa-
rietal reciprocal connections. Hence sensory
aspects of the perceived motor activities were
crucial to the activation of mirror neurons as they
trigger the motor representation of the same
action within the observer brain. This mechanism
constitutes the frame for the primates recognising
actions of their peers [7, 8]. The same team was
also able to demonstrate that other sensory
modalities such as hearing can serve as an avenue
triggering mirroring activity suggesting of pres-
ence audiovisual mirror neurons. Overall this
cortical mirroring system seems to pair observa-
tion with performance, which enables individuals
to understand and to participate in the behaviour
of others [7]. As far as human mirroring systems
are concerned they are different from primates in
the sense that they are sensitive to a wider range
of triggers. They are also more sensitive in
responding to more subtle stimuli such as antici-
pation of a possible purposeful movement (e.g. a
person approaching a fruit to eventually reach for
it). The neurons activated in anticipation of a
motor action are called canonical neurons and
their activities are closely related to mirror neu-
rons [9]. Canonical neurons were shown to be
activated in humans in response to images of
sexual organs, tools and food, and they were fur-
ther stimulating executive motor regions of the
cortex [10, 11]. The next important component of
mirroring is sensory. Keysers and colleagues in
their important work showed that the secondary
sensory cortex was activated in response observa-
tion of someone or something else getting
touched by tested objects [12]. This gives a phys-
iological substrate to tactile or sensory empathy.
B. Piechowski-Jozwiak and J. Bogousslavsky
Moving into more complex spatial orientation
and motion mirroring and anticipation it is impor-
tant to cite the work of Knoblich et al., who sug-
gested that humans may develop an impression
of movement based on a static image. They found
that the more the actions one observes resemble
the way one would carry them out, the more
accurate the simulation was [13].
In addition to mirroring motor activities simi-
lar phenomena were found for emotions based on
activation of the insular region in response to
images of disgusted facial expression of others.
Of note is the fact that relation between the
degree of facial disgust and the intensity of insu-
lar activation was proportional [14]. The role of
insula in emotional mirroring was further sup-
ported by research of Wicker et  al., who were
able to demonstrate that both the exposure to dis-
gusting scents and presentation of short clips of
other people smelling the content of a glass and
demonstrating grimacing disgust led to insular
activation [15]. Adding to motor, sensory and
emotional mirroring Singer and co-workers
found evidence of mirroring of pain based on the
observed emotions of others. What is very inter-
esting is that this empathic brain response was in
a way proportional to the intensity of displayed
emotion and also to the perception of the fairness
of the suffering person. This observation may
explain our ability to share and perceive feelings
with others [16].
Based on these ndings we can say that the
human brain is active in the rst and in the third
person in motor activities, anticipation of com-
plex motor actions, emotions and feelings. In our
brains we re ect actions and perceptions of oth-
ers using our executive motor and perceptual sen-
sory cortical structures. On this note it is
important to mention Gallese and co-workers
ndings. They suggested that on the neuronal
level rst-person experience would not be differ-
ent than the third person (Fig. 5.1). Both of these
experiences would be mirrored via the neuronal
networks, and two different bodies/minds would
develop the same functional state which was
named as ‘embodied simulation’ [17].
Leon Battista Alberti, the Renaissance
humanist in his short passage from De Pictura
5 Painting in Neurology
Fig. 5.1 Mirroring of sensory and emotional afferents—
connection between the artist and art receiver (by Julia
Andrzejewska, with permission)
(On Painting) engulfs all aspects the mirroring
potential of human brain highlighting its great
role in emotional, societal or simply human
coexistence:
...we weep with the weeping, laugh with the laugh-
ing, and grieve with the grieving... [18]
Freedberg and Gallese suggested how the mirror-
ing multimodal functions of the brain would con-
tribute to the connection between the artist and
art receiver. They proposed a model in which
activation of embodied mechanisms involving
simulation of actions, emotions and bodily sensa-
tions would constitute the aesthetic response to
images or other forms of visual art. They further
developed a theory of empathic response to art
based on the association between the simulation-
triggered empathetic feelings in the art receiver
and the content but also mechanical technique of
artistic creation (chisel marks, texture, brush
work and so on) [19].
5.2 Artistic Creativity in Context
of Brain Disease
The act of artistic creation is very complex and it
has not been dissected to the physiological level as
of yet. Benchmarking development of knowledge
in other physiological processes one may consider
looking at the disease and change of physiological
function to better understand the natural process.
The main problem is that de nition of change in
43
artistic output is very broad and may not represent
the actual decay or alteration caused by dysfunc-
tion/disease. This is of course far from very
mechanical and simplistic changes such as
hemineglect with respective shifting of painting
focus to one side of the canvas. When looking at
other cortical functions de cits such as dysphasia/
aphasia one may expect similar changes in artistic
output with various forms of ‘dysartria’ or ‘anar-
tria’. The main dif culty in studying changes in
artistic output in the context of brain disease is
lack of clear methodology both from the medical,
neurological and also artistic perspective.
There were attempts to introduce systematic
approach to studying artistic changes in people
with brain disease. One of them was suggested by
Espinel in studying Dutch abstract expressionist
Willem de Kooning’s works [20]. Espinel pro-
posed a stepwise approach to analysing artistic
creation with the rst step of method of observa-
tion including ‘Gathering of Information’ on the
technical aspects of painting (lines, colours and
surfaces). The second step ‘Recognizing the
Observed’ involved synthesising collected visual
information into speci c patterns. Later Espinel
was putting his observations into context of de
Kooning’s changing artistic output and other fac-
tors such as de Kooning’s health status and fam-
ily input in his activities to come up with a
conclusion about the in uence of dementia on de
Kooning’s artistic productivity and output [20].
This approach is de nitely methodical but it is a
single observer assessment of a single artist
hence any standardisation or objecti cation of
this interaction was not met.
Forsythe, Williams and Reilly suggested more
objective, observer independent way to analyse
visual artistic production. They used fractal anal-
ysis of paintings to de ne unique technical pat-
terns attributable to individual artists. It is very
interesting that this technology has been used in
determination of authenticity of paintings. The
authors used method of fractal analysis which
involves assessment of fractal dimension, which
is a ratio re ecting a statistical index of complex-
ity comparing how detail in a pattern changes
with the scale at which is measured. They anal-
ysed artistic production of seven artists—four
44
with neurodegenerative condition (Parkinson’s
disease: surrealist Salvodor Dali and Norval
Morrisseau; and dementia: James Brooks and
Willem de Kooning—both abstract expression-
ists) and three ‘healthy controls’ (Marc Chagall—
cubist and surrealist; Pablo Picasso—cubist;
Claude Monet—impressionist). Forsythe and
colleagues studied more than 2000 large size dig-
ital images of paintings. They conducted longitu-
dinal analysis including paintings representative
of all artistic production for each artist from their
early to late works and they analysed the relation
between fractal dimension and aging. The results
of this study con rmed highly signi cant correla-
tion between the age and decline in fractal in art-
ists with dementia [21]. Although this
mathematical approach is independent and based
on analysis of enormous quantity of high de ni-
tion scans it seems to be far from explanatory of
complex neurocognitive aspects of artistic pro-
ductivity in diseased brain.
In the next part of this chapter we conduct a
case by case individual analysis of visual artistic
production in artists with various central nervous
system disorders to illustrate the complexity of
mechanisms of disease and development of new
artistic skills in otherwise art naïve subjects as
well as change in artistic style in established art-
ists with new or progressive neurological disor-
der. We will discuss examples of savant syndrome
in autistic spectrum disorder, de novo artistic out-
put after subarachnoidal haemorrhage, effects of
stroke, epilepsy and migraine.
5.3 De Novo Artistic Creativity
The occurrence of visual artistic creativity may
be a part of either developmental or acquired
brain disorders. This is a very interesting phe-
nomenon as it points towards disease mecha-
nisms triggering artistic output in otherwise art
naïve individual. A very illustrative example is
that of Stephen Wiltshire, born in London in
1974, who was diagnosed with autism. He
started drawing at the age of three, and he
explains his drive for visual artistic production
B. Piechowski-Jozwiak and J. Bogousslavsky
with the following words highlighting the very
communicative and interactive aspect of his
works:
I started drawing at the age of three, as communi-
cation was not an option for me at the time until the
age of ve, so this was my form of language [22].
At school his teachers encouraged him to draw in
order to communicate and one of them took him
out on drawing excursions and inspired Wiltshire
to submit his drawings to competitions.
Wilthsire draws accurate and very details pan-
oramas of major cities. It is enough for him to take
a short helicopter trip over, for example Rome to be
able to reproduce what he saw—street by street,
building by building. In 2001  in a British
Broadcasting Corporation (BBC) documentary he
was followed when completing a complex and per-
fectly scaled aerial London panorama which
included 12 historic landmarks and 200 other build-
ings within 3  h only. According to his sister,
Wiltshire works swiftly wearing his headphones.
He skims the large canvas using his pencil and he
later nishes the sketches in pen adding all neces-
sary details of buildings. Of note is the fact that
some of the canvases are as long as 10 m which was
the case with panorama of Tokyo he drew within
7 days of helicopter tour over the city. Wiltshire is a
very proli c artist selling his drawings to collectors
around the globe. His great achievements were
widely recognised and in 2006 he was awarded
Member of the Order of the British Empire for his
artistic accomplishments. In addition to this he was
awarded PhD degree in drawing and printmaking
awarded by City & Guilds of London Art School.
According to his sister Wiltshire considers himself
as an artist as he had overcome his autism hurdles
with visual art production [22]. Wiltshire befriended
a famous US neurologist, writer and doctor. Oliver
Sacks who considered his artistic creativity as a
form of translating limitations to strength. In his
article for the New Yorker Sacks stressed the direct
communicative aspect of Wiltshire’s art with the
following words:
His vision is valuable, it seems to me, precisely
because it conveys a wonderfully direct, unconcep-
tualised view of the world [23].
5 Painting in Neurology
The second scenario we would like to demon-
strate is that of sudden occurrence of visual artis-
tic output in otherwise artistic naïve person. The
example comes from Mr. Tommy McHugh a for-
mer builder and youth offender who could not
stop painting since he emerged from a coma
caused by aneurysmal subarachnoid bleeding. He
was treated with coil embolisation and aneurys-
mal clipping. What may be found in public press
is that he presented with reduplication syndrome
and creative compulsions for poetry and picto-
rial/visual activity. The suddenness of onset of
his artistic expressive needs is best summarised
with his own statement:
I didn’t know much about who I was and what I
was. My brain wasn't telling me I was hungry, I
was talking in relentless rhymes. Everything was a
rhyme [24].
Mr. McHugh started drawing multiple pencil
sketches and later he moved to painting large-
scale pastels on the walls of his house. He also
a b
Fig. 5.2 Examples of Tommy McHugh’s paintings. (a) 09S-02-Untitled. (b) My Beautiful Mind. (c) Owe Franny A
Dance
45
started making multiple sculptures. He described
what was driving his activities with the following
words:
I just plough into it, nish it, move away and then
go and maybe make a clay head. I nish that and
go and play with a bit of stone, come back and do
another picture, sit down and write a poem, get up
and make a butter y out of birds’ feathers [24].
Of note is the fact that his change was a shock for
his family and friends as he started speaking in
rhyme, loved kittens, who wanted to know what
life meant. The example of Mr. Tommy McHugh
is very interesting as it demonstrates incredible
expressive artistic potential released by likely dif-
fuse brain damage from subarachnoid haemor-
rhage. It is really fascinating that over owing
need for artistic expression was translated into
visual art both painting and sculpture as well as
poetry (Fig.  5.2a–c). The contrast of pre stroke
lifestyle and background to post stroke creativity
demonstrates almost unlimited capacity of the
brain to transform.
46
5.4 Change of Artistic Style
in Established Artists
with Brain Disease
In contrast to individuals without previous artis-
tic skills and experience the occurrence of neuro-
logical de cits caused by central nervous system
disorders in established artists has different bear-
ing as we are dealing with traceable and measur-
able changes in artistic output in relation to
anatomically and pathophysiologically de ned
disease.
5.5 Stroke
Stroke is of special interest here as it is a sudden
onset disease which involves cortical and or sub-
cortical structures causing cortical, cognitive as
well as long tract de cits. The direct aspects of
stroke related disability may be affecting artistic
output but also more subtle neuropsychological,
neurocognitive and behavioural elements may be
of equal importance.
Annoni et  al. reported on two professional
painters who suffered from ischemic stroke. The
authors conducted in-depth analysis of their
changes in artistic creation. What is interesting is
that both of the artists were not aware of the
changes in their style at the initial phase. The rst
artist studied by Annoni et al. was a 57-year-old
right handed lithographer. In his premorbid artis-
tic production he was utilising simplistic and
primitive geometric forms. This artist developed
sudden onset right superior visual eld defect
with macular sparing and a concomitant illusion
of seeing his body lying on the oor. His mag-
netic resonance imaging (MRI) brain con rmed
respective primary and secondary visual cortical
infarct. Over the few days after ictus his neuro-
logical symptoms improved and he was left with
paracentral scotoma only and recurrent photop-
sias in the previously defective right upper visual
quadrant. His neuropsychological assessment
revealed only minor changes with delays in
visual detection tasks, perseveration in gural
uency and mild dysexecutive syndrome.
Features of post-traumatic stress disorder were
B. Piechowski-Jozwiak and J. Bogousslavsky
found on psychiatric assessment. He restarted
painting 1  month after stroke and he started
receiving feedback about subtle change of his
artistic style. He started painting more stylised
motifs, he simpli ed on the level of details and
started using more monochromatic colours. He
also started introducing his photoptic themes in
his paintings in the right upper part of his art-
works. His artistic output changed into more
abstract, and symbolic. In addition to this he had
a physical barrier in a form of his luminous pho-
topsia stopping him from visualising his paint-
ings in the preconceptual phase. This example
shows a very fascinating phenomenon of subtle
change of artistic style as well as direct impact of
neurological symptoms on artistic production in
a patient with cortical stroke [25].
The second artist, who was ambidextrous,
reported by Annoni and colleagues started his
artistic career in his sixth decade of life. His main
area of interest was painting Swiss landscape and
his premorbid style was viewed as gurative
impressionism by art critics. At the age of 72 years
he presented with sudden onset MRI con rmed
left sided thalamoperforating territory stroke with
contralateral hemisensory loss, hemiparesis and
hemiataxia. On neuropsychological assessment
performed 1 year after his index stroke there were
features of mild/moderate dysexecutive syndrome
with verbal perseverations, impaired gural u-
ency and semantic/mental imagery tasks. There
also was a slight change in his personality with
emotional control problems. He restarted painting
a few weeks after stroke initially using his left
hand and later was alternating sides, which was a
new development for him. He wanted to train his
left hand in case of further deterioration of right
hand strength and precision. Similarly to the pre-
vious artist he started receiving comments from
his clients referring to change in his artistic output
into more realistic, coloured, detailed and geo-
metrically structured style. He declared that he
wanted to reveal more the hidden beauty of
nature, being more realistic rather than impres-
sionist in his production. He also noted that his
left hand painted elements were more loaded with
emotions, and were bolder in colours in contrast
to right hand crafted objects which were more
5 Painting in Neurology
clear. In addition to this he noticed increased cre-
ativity with his left hand painting [25]. This
example greatly illustrates profound changes in
artistic output in relation to cortical and basal gan-
glia strokes. These developments were in part
linked to dysexecutive syndrome but also due to
post stroke emotional changes. Hence, no direct
linkage between stroke location and de ned or
reproducible alteration of artistic style can be
made here.
Bazner and Hennerici reported on a larger
selected case series of 13 painters only with right
hemispheric strokes which affected their artistic
production [26].
One of the artists, Anton Rädersheidt reported
was a protagonist of magic realism, which is
close to photographic art and it is characterised
by signi cant reduction of emotional content. In
1967 he presented with left sided homonymous
hemianopia, hemineglect, spatial disorientation
and severe prosopagnosia. After stroke
Rädersheidt artistic style changed in response to
hemispatial neglect with special focus on paint-
ing self-portraits. This deliberate change can be
considered as autotherapy aimed at regaining
ability to see correctly again and to regain con-
trol over lost perceptual and painting abilities
[26]. Another artist with right hemispheric stroke
reported is Reynold Brown, who in the premor-
bid artistic creation was initially focusing on g-
ures, comics, head drawings and later on painting
portraits, harbour scenes and landscapes. Of note
is the fact that he was painting with the left hand.
Brown developed sudden onset left sided hemi-
paresis, hemianopia and hemineglect and in the
recovery phase he partially regained motor func-
tion. He started painting with his right hand but
the main de cit interfering with his artistic pro-
duction was left hemianopia and hemineglect.
He would leave the hemianoptic area of the can-
vas till the very end stage of his artistic produc-
tion, which produced a clear gradient with right
side of the canvas heavily loaded with content
and left being literarily neglected. Brown’s
change in artistic output can be interpreted in
relation to change of painting hand and to sig-
ni cant and lasting impact of hemineglect and
hemianopia [26].
47
Bazner and Hennerici in their case series iden-
ti ed the main themes in the overall impact of
right hemispheric stroke on artistic output with
high prevalence of emotional impact of stroke
with depression, suicidal ideation and suicidal
attempts leading to termination of artistic careers.
In right hemispheric stroke painters the post-
stroke artwork was mainly in uenced by negative
neurological signs (e.g. visual eld loss, visual
and spatial neglect). Some artists were able to
compensate for these de cits. In addition to that
neurological signs such as prosopagnosia were
re ected in loss of self-resemblance in autopor-
traits and facial distortion. Spatial perception dis-
turbances induced changes in three dimensional
arrangements of paintings [26].
A very interesting change in visual artistic
production was reported by Colombo-Thuillard
& Assal a right-handed painter and sculptor Carl
Frederik Reutersward suffered from left internal
capsule and left lenticular nucleus haemorrhage
[27]. He presented with sudden onset right sided
hemiplegia, hemisensory loss and subcortical
aphasia. Of note is the fact that he was able to
speak four languages—Swedish, German, French
and English and 3 weeks post stroke he was apha-
sic in all four of them. The interesting fact was
that his primary language Swedish was less
affected than the secondary ones. Six months
after stroke on neuropsychological assessment he
had minimal associative visual agnosia and mod-
erate executive disorder. He partially resumed his
painting after stroke and in the initial period post
stroke with the affected dominant hand hoping
that he would recover strength in it. He later
switched to use his left hand and after a year of
strenuous exercised to come to the point when he
felt ready to restart drawing, painting and sculp-
ture. Reutersward considered his de novo left
handed artistic skills as a precious addition to his
work, and he summarised this with the following
words:
…it’s marvellous…it’s not a handicap…the left
hand is the dreamer…the soul is localized in the
left hand [27].
This precious addition to Reutersward’s artis-
tic capacity with left hand creativity impacted on
48
a b
Fig. 5.3 (a) Krystyna Habura’s premorbid painting
(‘El k’) (with permission). (b) Habura’s post-stroke
painting ‘Grey Hawk, Chief of the Witkowice Tribe’; an
his artistic output as his paintings became more
emotional and artistically intense. According to
art critics his paintings gained fresh vitality,
expressivity and psychic intensity. The other
change was that he gained more playful side. In
his premorbid pivotal Non-Violence sketches of
the pistol he used a strong message with heavy
and decisive strokes. However after stroke he
drew the lethal weapon more like a toy [27].
Reutersward’s post stroke artistic changes are
extremely interesting with gain of artistic output
by developing new skills and reaching to new
inspirations and artistic expression by using non-
dominant hand.
The theme of right hemispheric stroke impact-
ing on artistic creativity was further explored by
Pachalska and colleagues in Polish painter
Krystyna Habura [28]. Habura was ambidextrous
and she considered this as an important element
of her artistic style. She was painting the main
gures with the left hand and was detailing them
with her right hand. She was ambidextrous in
B. Piechowski-Jozwiak and J. Bogousslavsky
oil portrait made by Habura during art therapy signed
‘Sick Habura’ (with permission)
writing too, but her right hand was dominant. She
was converted from left to right hand writing in
childhood as left-handedness was not tolerated in
the past in schools in Poland and children were
forced to switch. Habura experimented with new
forms and ideas and she focused mainly on real-
istic to surrealistic portraits (Fig. 5.3a).
Habura’s creative periods were very intense
and exhausting as she was barely sleeping and
she smoked and drank heavily. This de nitely
added to her cardiovascular risk and likely con-
tributed to a right middle cerebral artery territory
infarction involving frontal, parietal and tempo-
ral lobes she developed at the age of 61  years.
Habura developed left sided hemiparesis, aphasia
with slow speech tempo and anomia, and dif -
culties of spatial orientation. Her neurological
symptoms impacted on her artistic output and she
was unable to imagine anything and having a sen-
sation of emptiness in her brain. She considered
this as a loss her creative gift. She could sit in
front of the canvas declaring that her head is
5 Painting in Neurology
empty and was not able to paint. Habura coined a
term of ‘creative aphasia’ referring to her inabil-
ity to create art. As part of her post-stroke man-
agement she received art therapy based on
Neurolinguistic Reprogramming of Images. She
started her artistic production with symbolic
drawings to eventually regain full artistic capaci-
ties. In the initial period her style lacked detailed
features and was ambiguous. Habura, however,
used her ambidexterity to overcome her neuro-
logical de cit and she used her right hand to paint
details and the left one to complete the outlines.
Overall her painting style changed into more
sketch-like and logically disconnected (Fig. 5.3b).
Habura’s post-stroke artistic style softened in
comparison to the premorbid one with weaker,
less decisive and crisp brushes. Habura also
focused more into themes related to disease and
suffering. Overall she summarises her post-stroke
recovery process as added value to her as a per-
son and artist [28].
5.6 Epilepsy
In contrast to stroke epilepsy is a chronic parox-
ysmal condition with episodes of altered aware-
ness but also paroxysmal positive neurological
phenomena which can impact of artistic creativ-
ity and visual art production. Sacks and Chatterjee
independently reported on Franco Magnani, an
Italian painter born in 1938 [29, 30]. At the age of
31 years he developed pyrexial illness, delirium,
seizures and psychosis suggestive of encephali-
tis. In the chronic phase of his condition he devel-
oped signi cant changes in personality and
behaviour. He started having vivid dreams of his
home town Pontito which were stereotyped, par-
oxysmal in nature and coming during wake cycle
in ashes. This presentation can be interpreted as
ictal and caused by complex partial seizures.
These spells were transformed into his artistic
production and he compulsively painting scenes
from Pontito and people in it. His artistic com-
pulsive and stereotyped output was likely ictally
stimulated, but lack of proper medical assess-
ment, imaging and electrophysiological studies
subtracts some objectivity from this observation.
49
Although the ictal artistic trigger seems plausible
and likely here [29, 30].
Another interesting case of De Chirico, a
Greek-born Italian painter, who is known for his
‘metaphysical school art movement’ was reported
by Fuller, Bogousslavsky and others. The etiol-
ogy of De Chirico’s symptoms has been debated
in the literature and they were not strongly con-
sidered to be epileptic or related to migraine. His
spells were most likely attributed to recurrent
malaria crises [31, 32]. De Chirico’s painting
style included dreamlike themes with sharp con-
trasts of light and shadow, with threatening, and
mysterious quality. His paintings were consid-
ered as giving access to the unseen landscapes of
the mind. De Chirico suffered from various recur-
rent symptoms composed of visual auras, abdom-
inal crises, with pain and vomiting. De Chirico
had negative visual symptoms such as a shadow
of a cock obstructing his visual eld which he
incorporated in his paintings. He also had posi-
tive visual phenomena he described with the fol-
lowing words:
…delightful ribbons, ames without warmth,
thrust forward like thirsty tongues, disturbing bub-
bles… [31]
De Chirico described his symptoms as ‘a spir-
itual fever’. In addition to this he incorporated all
his visual symptoms including geometric pat-
terns (distortions, metamorphopsias), scotomas
into his surreal artistic production [30–32].
The important contribution into understanding
of the impact of epilepsy on artistic productivity
and style should be attributed to Schachter, who
with a great dedication collected series of paint-
ings from contemporary artists with epilepsy
[33]. He was able to demonstrate that visual artis-
tic productivity was signi cantly in uenced by
epileptic seizures in individual artists. The impact
of the disease on art was related to the effects of
psychiatric comorbidities, and other psychoso-
cial aspects of epilepsy. In addition to this the
actual content of seizures was directly translated
into visual artistic output with using themes of
brainstorm associated with seizures, picturing
body image distortions or positive sensory,
including visual phenomena. The artists were
50
incorporating elements related to interruption of
time related to ictal memory gap, post-ictal
fatigue, derealisation, embarrassment and depres-
sion caused by disease. Some artists were also
symbolically highlighting the societal impact of
their chronic neurological condition such as sep-
aration from the family and social isolation [33].
In a way the impact of paroxysmal epileptic
spells on visual artistic production can also be
seen as part of a manifesto and statement express-
ing the profound bearing of this disease on indi-
vidual life.
5.7 Migraine
Migraine is another example of a non-focal and
paroxysmal central nervous system disorder with
both positive and negative neurological symp-
toms in uencing and triggering artistic produc-
tion. Migraine has been the curse, trigger and
artistic inspiration for numerous visual artists.
The difference of positive, for example cortical
symptoms of migraine in comparison to those in
partial seizures, is that the former as they are
more inclined towards surreal, less formed and
structured [30].
A very illustrative example is that of the art
work of Ignatius Brennan an Irish painter who
suffered from migraine. He is best known for his
surrealistic drawings and sculptures. He was get-
ting complex visual auras with visual hallucina-
tions formed of cloudy shapes, geometric gures,
zig-zag lines, tunnel and kaleidoscope vision.
Moreover, he was experiencing de cits of three-
dimensional vision, spatial awareness/orientation
and he had body image perception disturbances
with delusional reduplication of extremities. All
these positive visual phenomena were elements
of his complicated visual auras. They were also
accompanied by emotional expulsions in a form
of fear. Brennan was translating all of these
visual and emotional elements into his art pro-
duction which proved to be successful for his
artistic career. In some of his paintings such as
‘Always Look on the Bright Side of Life’ he delib-
erately used scotomas and zig-zags to symbolise
the unknown and disturbing. The appearance of
B. Piechowski-Jozwiak and J. Bogousslavsky
negative visual scotomas was bearing emotional
(i.e. fearful) load. Brennan was adding a sym-
bolical meaning to zig-zag lines of the experi-
ence of a whole being broken up. His auras
constituted his visual and artistic vocabulary that
he was using subconsciously [30, 34].
Another example of impact of migraine on
artistic production comes from Sarah Raphael, a
UK born painter, who suffered from prolonged
migraines including one episode lasting
18 months in a row. Raphael started as a gura-
tive and portrait painter and later in her career
shifted towards more abstract art. Her migraines
impacted her artistic production in three ways.
Firstly, she started painting strips which were not
requiring too much effort from her thus letting
her work in between migraine attacks in a stac-
cato pattern. Secondly, she incorporated visual
aspects of migraine aura in her paintings. Thirdly,
she became extremely sensitive to smell and the
constituents of the oil paint were triggering her
migraines. That is why she needed to switch into
odourless acrylic paints that she considered at.
One may say that she developed ‘a migraine-
friendly’ painting style as she adopted the scope
of her visual output to her capacity, she added
positive phenomena from her auras into paintings
and also she modi ed the materials she used to be
able to paint during her headaches. In her ‘Strip’
series produced during her 18-month long
migraine she painted regular unrecognisable
objects with superimposed photopsia-like zig-
zag lines and scotomas [35]. This in a way is a
pictographic documentation of chronic disease
and related suffering which was transformed into
visual art and exposed or shared with viewers.
Migraine Art Competition was organised
between years 1980 and 1987, and it was sup-
ported by British Migraine Association, and WB
Pharmaceuticals, a sister company of Boehringer
Ingelheim. One of the aspects of this activity was
to educate and inform the lay public about the
symptoms, consequences and impact of migraine
on daily life. The art served as a mean of com-
munication between the sick and the rest of soci-
ety [36].
The results of the analysis of the Migraine Art
Competition remain in concordance with these
5 Painting in Neurology
individual artists’ experiences. From all of the
artworks submitted more than two-thirds showed
spectral appearances, half showed forti cations.
Less frequent were artistic alterations related to
visual loss and mosaic vision. This nding gives
solid grounds for considering migraineous posi-
tive visual phenomena as armamentarium for
visual artistic output and also as a strong mean of
communicating disease state to the broader pub-
lic [30, 37].
In this chapter we discussed multiple central
nervous system disorders in the context de novo
acquisition of artistic potential in art naïve indi-
vidual as well as in already established artists
whose artistic production changed due to brain
disease. Analysis of these correlations is of
great value both in direct medical, neurological
meaning and also from broader humanistic and
societal one. The neurological aspect adds into
understanding of neural basis of artistic creation
and the change triggered by developing disease
process. Second of all one may speculate that
neurological conditions affecting the central
nervous system may add additional dimension
and depth into visual art expanding the interface
between art producers and receivers. Progress in
the eld of neuroesthetics will allow for better
understanding of complex neurophysiological
foundations of brain artistic creativity and it
may create scienti c basis for art reception.
Further development of more structured and
reproducible ways to study art and artistic out-
put seems of great use to expand this fascinating
territory.
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1985;5(3):151–7.
 Art and Neurologists
Nicholas J. Wade
6.1 Introduction
Links between art, brain and neurology have
multiplied of late both in articles, chapters and
books [1–4]. Moreover, there has long existed a
rich seem of portraits of neurologists [5, 6]. In
this brief chapter, I will adopt a novel approach—
linking art, brain and portraiture. These ‘percep-
tual portraits’ of neurologists are presented with
the aim of combining art, history and the brain.
They generally consist of at least two elements—
the portrait and some appropriate motif. The
nature of the latter depends upon the endeavours
for which the portrayed person was known. In
some cases the motif is drawn speci cally to dis-
play a phenomenon associated with the individ-
ual, and in others it is derived from a gure or text
in one of their books. The portraits and motifs
have themselves been manipulated in a variety of
ways, using graphical, photographical and com-
puter graphical procedures. Figure  6.1 is an
example portraying Thomas Willis (1621–1675)
and Andreas Vesalius (1514–1564). Willis [7]
introduced the term ‘neurology’ in his Cerebri
Anatome, and the renaissance of anatomy is con-
sidered to have been heralded by Vesalius [8] in
his De Humani Corporis Fabrica. The prints
derived from Vesalius’s dissections are taken to
be a synthesis of science and art.
N. J. Wade (*)
Psychology, University of Dundee, Dundee, UK
e-mail: n.j.wade@dundee.ac.uk
© Springer Nature Switzerland AG 2020
B. Colombo (ed.), Brain and Art, https://doi.org/10.1007/978-3-030-23580-2_6
6
Thomas Willis and his circle of anatomists at
Oxford pursued the examination of the brain
rather than relying solely on the tracts of others.
His Cerebri Anatome placed dissections of the
brain on rmer foundations: he numbered the
cranial nerves and described the arterial circle at
the base of the brain which still bears his name.
In Willis’s images, the anatomy of brain circum-
volutions and sulci are more clearly de ned than
in the representations by Vesalius. Willis is
shown enclosed within the diagram of the brain
(drawn by Christopher Wren) taken from his
Cerebri Anatome, together with its title page.
The portrait of Vesalius is presented within the
woodcut of the brain as seen from below (from
Fabrica). Vesalius presented an account of anat-
omy that was almost free from the legacy of
Galen. It was based on human rather than animal
dissection, and the illustrations were produced
by an artist (probably Jan Stephen van Calcar, a
Dutch painter living in Italy and a member of the
school of Titian) who was present during the
dissections. While Vesalius could examine the
structure of the brain with his own rather than
Galen’s eyes, he did not pay too much attention
to it. Although Vesalius was Flemish by birth, he
carried out his dissections in Italy, principally in
Padua.
53
54 N. J. Wade

Fig. 6.1 The brains of Willis and Vesalius by Nicholas Wade

Fig. 6.2 The brains of Eustachi, Fabrici and Varoli by Nicholas Wade

6.2 Brain Structure
The impact of the Fabrica was felt throughout
Italy and beyond. Some of the anatomists so
in uenced are shown in Fig.  6.2. Bartolomeo
Eustachio (ca. 1500–1574) was renowned for his
dissecting skill, but he was reluctant to publish all
his plates representing the body and its parts dur-
ing his life: he feared that testing the restrictions
of the church on human dissection would result
in his excommunication. His anatomical tables
were published long after his death, and that with
which his portrait is combined appeared in
1714  in his book Tabulæ Anatomicæ [9].
Hieronymus Fabricius ab Aquapendente (ca.
1533–1619) conducted many dissections on both
6 Art and Neurologists
Fig. 6.3 The brains of Descartes by Nicholas Wade
humans and other animals in Padua. He did not
publish the results of his research until the sev-
enth decade of his life. Although Fabricius’s ana-
tomical images were used to illustrate the various
editions of his works, the originals of these
images, in the form of coloured paintings
remained unknown to the public until they were
discovered in 1910  in the depositories of the
Marciana Library in Venice [10–12]. These
images, painted by artists of the Bassano school,
are of exceptional scienti c and artistic quality
and can be considered among the most beautiful
anatomical images ever produced. Fabricius is
portrayed in one of the surviving coloured plates
of the brain from 1600; it has been argued that
this is the rst illustration of the Sylvian ssure,
and it was produced four decades before the
name of Sylvius was associated with it. Costanzo
Varolio (1543–1575) was an anatomist in
Bologna who eventually worked in Rome where
he served as the personal physician to the Pope.
His examination of the brain began at its base,
and his illustration of the structure (in which his
portrait can be discerned) clearly shows the
course of the optic nerves to the optic chiasm.
The illustration of the brain was printed in his
book De Nervis Opticis. The woodcut was made
from a drawing in Varolio’s own hand [13]. By
commencing at the base of the brain, rather than
from the top as was the accepted custom, he
bared the cranial nerves and described the pons,
also known as the bridge of Varolius. Parts of the
brain are designated by numbers on the right side
and letters on the left.
55
The anatomy of Vesalius had a great in uence
on René Descartes (1596–1650), and two ‘per-
ceptual portraits’ of him are shown in Fig.  6.3.
Representations of Descartes’s treatment of the
brain were produced after his death, and his por-
trait is embedded in two of them. The one shown
on the left is taken from Traité de l’Homme [14]
and that on the right is from De Homine [15]. It
would seem that the illustration has played a
greater role in historical interpretations than the
text from which it was derived, and the credit
should be placed with the artist as well as
Descartes. It is particularly signi cant in this
case because neither of the series of diagrams
was produced by the author of the text. The
Traité rst appeared over a decade after his
death, and two separate versions of it were
printed. The rst, in 1662, was translated into
Latin (De Homine) and illustrated by Florentius
Schuyl, who is said to have worked from a defec-
tive manuscript copy of the French. The French
version appeared 2 years later: the text was given
to two illustrators (Gerard van Gutschoven and
Louis de la Forge), who each made a complete
set of drawings independently of the other; van
Gutschoven’s were the ones most generally
printed, though some of La Forge’s were
included, too. The whole set of La Forge’s illus-
trations can be found in the Latin edition of 1677
[16]. Descartes’ mechanistic approach to the
senses clari ed many issues in perception, but he
had to grasp the thorny problem of accounting
for the interaction of the rational mind with the
mechanistic body. Communion between mind
56
Fig. 6.4 The ssures of Sylvius and Rolando by Nicholas Wade
and body was achieved via structures in the
brain, particularly the unpaired pineal body (the
pear-shaped structure labelled H in the
illustrations).
It seems remarkable that a brain structure as
prominent as what we call the Sylvian ssure
was not named until the seventeenth century. It
was described by Franciscus de la Boë (1614–
1672), whose name was Latinised to Sylvius, and
his portrait can be seen spanning his eponymous
ssure (Fig.  6.4). The engraving of the brain is
taken from Caspar Bartholin’s Institutiones
Anatomicae which was published in 1641 [17].
Sylvius also described the narrow passage
between the third and fourth ventricles, subse-
quently called the aqueduct of Sylvius. He car-
ried out most of his anatomical studies in Leiden,
although he was German by birth. He occupied
the chair of medicine at Leiden, and his succes-
sor was Boerhaave. Sylvius integrated anatomy
with the developing knowledge of chemistry to
found the iatrochemical approach to medicine:
bodily processes both in health and disease were
attributed to chemical actions. According to
some scholars, Sylvius was also the inventor of
genever (gin) which was used for medical pur-
poses. If the description of the Sylvian ssure
seemed surprisingly late, then that of a ssure as
prominent as Rolando’s is even more remark-
able. It is based on a work by Luigi Rolando
(1773–1831) published in 1824 [18], and his
name was linked to it in 1839. It is also called the
central sulcus and it separates the parietal and
frontal lobes, as can be seen in the illustration
N. J. Wade
dividing Rolando’s portrait (Fig.  6.4). He also
stimulated the brain with electric currents and
concluded that voluntary functions of the body
were under cerebral control whereas the cerebel-
lum controlled involuntary functions.
6.3 Brain Function
In an earlier treatise on the structure of the human
and animal brain, Rolando [19] discussed cortical
localisation and the functions of the cerebellum.
The treatise was contemporary with the works of
Gall and Spurzheim [20] and their support of
localisation was opposed by the ablation studies
of Marie Jean Pierre Flourens (1794–1867); all
three are represented in Fig.  6.5. Franz Joseph
Gall (1758–1828) represents the emergence of
medicine and physiology as sources of psycho-
logical speculation. From the early nineteenth
century, anatomists dissected neural pathways in
the brain with increasing precision and these
were related to the developing understanding of
nerve transmission. These anatomical and physi-
ological discoveries were applied to individual
differences in the gross structure of the brain and
to disorders of its function due to trauma or dis-
ease. Gall’s studies on the spinal cord, using a
comparative approach, were of particular impor-
tance, because they showed that this part of the
central nervous system is not only an appendix of
the brain (as was commonly held at the time), but
is endowed with its own functional capabilities
(especially in lower vertebrates). In 1791 he
6 Art and Neurologists
Fig. 6.5 The heads of Gall, Spurzheim and Flourens by Nicholas Wade
advocated cortical localisation of mental
functions; he drew a clear distinction between the
grey matter of the cerebral cortex and the under-
lying white matter. These advances were
described long before his publications on phre-
nology, with his collaborator, Johann Gaspar
Spurzheim (1776–1832). However, it is for phre-
nology—assessing mental characteristics from
the external shape of the skull—that Gall is best
known. Although Gall’s phrenological opinions
would be discredited, they played an important
historical role in the emergence of the theory of
cerebral localisation. The sculpted head of Gall
shown here has phrenological markings on both
sides, but those on the left of the original are
coloured as well as numbered. Spurzheim’s name
is forever linked with that of Gall. He was Gall’s
student, then collaborator and they journeyed
around Europe together lecturing on cranioscopy,
or phrenology as it was later called. They went
their separate ways after 1813, and Spurzheim
continued spreading the word of phrenology
throughout Europe and beyond. Phrenology
assigned faculties of functions to protuberances
on the skull. Gall proposed that there were 27
such faculties, but these were extended to 35 by
Spurzheim. The stylised phrenological markings
on drawings of the head became the stock in trade
and Spurzheim’s portrait is combined with his
representation of a phrenological head (from
[21]). Flourens was an admirer of Gall’s dissect-
ing skills but a harsh critic of his phrenology,
57
both in terms of its psychological speculations
and its support of cortical localisation based on
anecdotal and clinical observation. His summary
of Gall’s position was succinct: ‘The entire doc-
trine of Gall is contained in two fundamental
propositions, of which the rst is, that under-
standing resides exclusively in the brain, and the
second, that each particular faculty of the under-
standing is provided in the brain with an organ
proper to itself. Now, of these two propositions,
there is certainly nothing new in the rst one, and
perhaps nothing true in the second one’ [22]. It is
likely that his quali cation of the second objec-
tion suggests that he was more con dent arguing
about originality than validity. The experimental
animals examined by Flourens, mostly pigeon
and rabbit, were unlikely to have provided evi-
dence in favour of a theory of human cortical
localisation. However, it was in the context of the
functions of cerebellar control of posture that
Flourens was most able to demonstrate the inad-
equacy of Gall’s localisation of faculties. For
Gall, this was where amativeness and the instinct
of the love of offspring resided. Flourens retorted
that ‘the cerebellum is the seat of the principle
that presides over the locomotion of the animal,
and that it is not the seat of any instinct’ [22].
Indeed, Flourens’s studies of the maintenance of
posture by the functions of the semicircular
canals and the cerebellum can be considered as
amongst his greatest contributions to nineteenth-
century neuroscience. The technique Flourens
58
applied to question functional localisation in the
brain was that of extirpation or ablation: the sur-
gical removal of parts of the brain to examine
how the remainder functioned by studying post-
operative behaviour. In his initial experiments
Flourens [23] examined extirpation of increasing
parts of the cerebellum, which he found (as
Rolando had before him) to be intricately
involved in the control of posture. He viewed the
brain as having some degree of localised func-
tion, but that it acted as a unit. Flourens’s portrait
is combined with the scalpels he wielded with
such precision in conducting experiments on
extirpation.
Gall’s ideas received particular attention from
a wider spectrum of the French medical milieu
than Flourens and acted in promoting the rst
localisation of language areas in the brain by
Pierre Paul Broca (1824–1880) and then its appli-
cation to clinical conditions by Jean-Martin
Charcot (1825–1893); both are represented in
Fig.  6.6 together with Carl Wernicke (1848–
1905). The debate between the localisers and the
equipotentialists reverberated throughout the
nineteenth century. Broca provided evidence from
clinical examination and autopsy to support cere-
bral localisation of function. He treated a patient
suffering from loss of speech, referred to as aphe-
mia by Broca and later as aphasia. The patient was
known as Tan since this was the only utterance he
made but he was able to understand speech. After
his death his brain was found to have a cavity in
the left frontal lobe. This is now referred to as
Broca’s area or Broca’s convolution and he is
shown in a diagram of the area, taken from Broca
Fig. 6.6 Broca’s area, Charcot’s hysteria and Wernicke’s area by Nicholas Wade
N. J. Wade
[24]. Charcot was, with Broca, a staunch sup-
porter of cerebral localisation, and he dealt with
aphasia at length in his lectures. He related clini-
cal symptoms to brain autopsies and developed
the clinical-anatomical method. Charcot’s portrait
is shown together with a drawing of a hysterical
patient in a classical posture—l’arc de cercle—
derived from Charcot’s book with the artist Paul
Richer Les démoniaques dans l’art [25]. Broca’s
report of language de cits associated with spe-
ci c brain lesions stimulated others to pursue the
link between language and lesion. One of these
was Wernicke who found results that did not cor-
respond to those of Broca’s Tan, who was unable
to articulate speech even though he could compre-
hend it. Wernicke examines a patient who had suf-
fered a stroke and was capable of speech but was
not able to understand either spoken or written
language. On examining his brain after death,
Wernicke found a lesion in the left hemisphere but
in the rear parietal/temporal region. He published
his results in 1874 and named the condition sen-
sory aphasia, but it is now also known as
Wernicke’s aphasia. The portrait of Wernicke is
shown in his diagram of the brain from his
Lehrbuch der Gehirnkrankheiten, published in
1881 [26], specifying the regions involved in lan-
guage comprehension by cross-hatching. He
referred to the gure as a schema for cortical lan-
guage mechanisms with x indicating the sensory
and y the motor language centres.
Evidence favouring cortical localisation
derived from electrically stimulating the brains
of animals. The long-held view that the brain
was unaffected by direct stimulation had been
6 Art and Neurologists
Fig. 6.7 Fritsch, Hitzig and Ferrier, brain stimulators by Nicholas Wade
overturned by Gustav Theodor Fritsch (1838–
1927) and Eduard Hitzig (1838–1907) in 1870
[27] and extended by David Ferrier (1843–1928)
3 years later [28]; they are shown in Fig. 6.7. The
portrait of Fritsch can be seen within the dia-
gram of a dog’s brain taken from his article with
Hitzig, whose portrait is combined with the title
page of the article. Fritsch and Hitzig stimulated
the exposed brains of unanaesthetised dogs and
found speci c precentral areas that resulted in
muscular contractions. They made a simple dis-
tinction between brain areas: ‘One part of the
convexity of the cortex of the dog is motoric…
another part is not motoric’ [27]. The starting
point for their studies on dogs was some experi-
ments that Hitzig had conducted on galvanic
stimulation of the ear: dizziness and directed eye
movements ensued. Their conclusion was that,
contrary to Flourens, local areas of the brain
have speci c functions. In the preface to his
book on functions of the brain Ferrier (29, p xiv–
xv) wrote: ‘The discovery of new methods of
investigation opens up new elds of inquiry, and
leads to the discovery of new truths. The discov-
ery of the electrical excitability of the brain by
Fritsch and Hitzig has given a fresh impetus to
researches on the functions of the brain, and
throws new light on many obscure points in cere-
bral physiology and pathology’. There were few
59
institutions were experimental physiology could
be practiced in Britain, and many of Ferrier’s
experiments in the early 1870s were conducted
in the laboratories of the West Riding Lunatic
Asylum, and the results were published in its
Reports. He electrically stimulated the brains of
many species and mapped areas of the cortex.
The signi cance of his research was rapidly
realised, and the rst edition of Functions of the
Brain was based upon them. Later, he was able
to map the monkey motor cortex with greater
precision. Unilateral lesions to the motor cortex
yielded hemiplegia, and in 1881 a monkey in this
condition was demonstrated before those attend-
ing an international congress in London; on see-
ing the animal Charcot exclaimed ‘It is a patient’.
The involvement of certain cortical regions in
motor control had been proposed by John
Hughlings Jackson (1835–1911) on the basis of
his studies of epilepsy and these, too, were the
stimulus for Ferrier’s investigations. In 1873, he
commenced a series of experiments on anesthe-
tised frogs, pigeons, guinea pigs, rabbits, cats,
dogs and monkeys in which he applied faradic
stimulation to localised areas of the cortex; he
also carried out ablations of the same areas.
These demonstrated large species differences,
and pointed to the dangers of extrapolating
broadly, as Flourens had done. Consequently,
60
most attention was paid to stimulation of mon-
key cortex, and Ferrier described his results in
The Functions of the Brain [29], which was dedi-
cated to Jackson. Precise movements of muscle
groups followed localised stimulation in the pre-
central area, sensory defects resulted from more
posterior ablation and lesions in the frontal cor-
tex disturbed intelligent behaviour. Ferrier is
represented in a drawing of the human brain that
is marked with the motor map of monkey cortex:
the numbers specify localised movements with
the letters representing movement areas for the
hand and wrist. The drawing of the brain is taken
from the second edition of his book, the title
page of which is also shown. Ferrier was one of
the founding editors of the journal Brain in 1878,
and he was instrumental in instigating the rst
surgical removal of a tumour from a human
brain.
Cortical localisation became even more precise
in the twentieth century largely as a consequence
of warfare, surgery or experiment (Fig. 6.8). In the
context of warfare, Alexander Romanovich Luria
(1902–1977) worked with soldiers who had
received head wounds during World War II and
afterwards [30]. He examined brain injury with-
out slavish adherence to either the equipotential-
ists or the localisers, and in the process developed
many new tests for detecting subtle de cits in per-
ception, thought and language. In his later work,
Fig. 6.8 The brains of Luria, Sperry and O’Keefe by Nicholas Wade
N. J. Wade
Luria examined the perceptual and cognitive
problems associated with injury to the right cere-
bral hemisphere. By demonstrating spatial and
perceptual de cits, he provided a balance to the
emphasis placed on left hemisphere function dat-
ing from Hughlings Jackson’s description of it as
the leading hemisphere. He is represented in an
outline skull showing the paths of bullets through
the brain and the overlapping parietal lesions in
the left hemisphere for ten patients; all suffered
semantic aphasia as a consequence. This is sym-
bolised in the illustration by the coincidence of
these regions with Luria’s mouth. Early indica-
tions regarding hemispheric interactions across
the corpus callosum had been provided by a
Russian physiologist, Konstantin Michaelovich
Bykov (1886–1959). In 1924, using Pavlov’s con-
ditioning techniques in dogs, Bykov found that
transfer of learning does not occur between the
hemispheres in the absence of the corpus callo-
sum [31]. Further evidence was provided by
Roger Walcott Sperry (1913–1994) in patients
with epilepsy when the nerve pathways that link
the two cerebral hemispheres were severed surgi-
cally. By presenting visual patterns to one side of
a xation point, thus projecting to one hemisphere
alone, it was possible to determine the differences
in the functions the hemispheres perform [32].
This research provided a tremendous spur to later-
ality research, although the results were frequently
6 Art and Neurologists
over-interpreted in popular books: the
specialisations in function were even related to
ancient dichotomies such as yin-yang. Sperry’s
full-face portrait is matched with a diagram of a
transverse section of the brain indicating a lesion
of the corpus callosum. His portrait is contained
within a design derived Ferrier’s diagram of the
human brain marked with the motor map of the
monkey cortex. John O’Keefe is a more recent
Nobel laureate receiving the prize in 2014 for his
research on place cells in the hippocampus.
Together with Lynn Nadel, he provided evidence
for coding of a cognitive map in the hippocampus
[33]. The characteristics of the neural circuits
involved have been re ned since then and O’Keefe
is shown in his map of the hippocampus (repeated
three times) with its areas specialised for different
aspects of spatial representation [34].
Sperry was awarded the Nobel Prize in 1981
together with David Hunter Hubel (1926–2013)
and Torsten Nils Wiesel in recognition of their
neurophysiological studies of the visual system,
applying microelectrodes to determine the recep-
tive eld characteristics of single cells in the
visual cortex. Gross recording from the surface
of the scalp had been pioneered by Hans Berger
(1873–1941). All are shown in Fig.  6.9. Berger
recorded electrical potentials on the surface of
the human scalp and plotted the electroencepha-
logram (EEG). His life-long search was for an
objective index of subjective experience. He ini-
tially measured variations in brain circulation
V4
Fig. 6.9 Berger, Hubel and Wiesel—recorders of the brain by Nicholas Wade
61
and temperature in an attempt to capture the
essence of psychic energy, but he abandoned that
approach. Small cortical potentials had been
recorded from the exposed brains of rabbits, cats
and monkeys as early as 1875 by the Liverpool
surgeon, Richard Caton (1842–1926), but no suc-
cess had been achieved with recordings from
humans. After many vain attempts on his patients,
Berger achieved success with recordings from his
teenage son and from himself, and he was able to
report in 1929 that he believed he had discovered
the human electroencephalogram. Berger is
shown together with the rst tracing of the alpha
rhythm published, in his second report [35]. The
record has been graphically multiplied and is
accompanied by those for the heart rate and time
base.
When recordings of nerve impulses could be
made from individual cells in the visual pathway,
their adequate stimuli could be determined. It
came as something of a surprise that retinal gan-
glion cells of frog responded to quite complex
features of stimulation (like moving dark regions
of a speci c visual angle, resembling a bug), and
stimulus properties that excited or inhibited neu-
rons were generally called ‘trigger features’.
Retinal ganglion cells of cat, on the other hand,
were excited by rather simpler stimulus arrange-
ments. It was found that they were concentrically
and antagonistically organised; if the centre was
excited by light, the surround was inhibited, and
vice versa. Such an arrangement served the
V4
62
detection of differences in luminance well, but
steady states would have little effect, since exci-
tation nulli ed inhibition. This pattern of neural
activity was retained in the lateral geniculate
body, but it underwent a radical change at the
level of the visual cortex. From the 1960s, Hubel
and Wiesel found that single cells in primary
visual cortex (V1), rst of cat then of monkey,
responded to speci cally oriented edges [36].
They are shown enclosed within the pattern of
ocular dominance columns that they disclosed in
monkey cortex using autoradiography. They dis-
covered that single cells in the visual cortex
respond to speci c features of the light patterns
striking the eye, such as oriented edges moving in
a particular direction. These feature detectors
have an orderly representation in the visual cor-
tex, and they project to clearly de ned eye domi-
nance regions. The striations displayed in the
illustration are of the alternating patterns of eye
dominance regions over the visual cortex, and the
visual scientists are represented in ipsi- and con-
tra-lateral columns, Hubel in the centre and
Wiesel on the right. The response of a single cor-
tical cell to light bars in different orientations is
also displayed with the portrait of Hubel, and the
pathways from the six layers of the lateral genic-
ulate body to the layers in the cortex are shown
with Wiesel’s portrait.
The EEG was an early and important tool for
diagnosing brain damage, but it also provided a
research tool for examining electrical responses to
events (event related potentials, or ERPs).
Productive research using ERPs to map cognitive
activity in the brain was conducted but there have
always been problems of interpretation due to lim-
ited information about the spatial origins of ERP
components. Subsequent developments of dense-
mapped ERP and the related technique of using a
magnetometer to record the magnetoencephalo-
gram (MEG) and detect magnetic event-related
elds (ERFs) attracted much more attention. In
part, this was because the precise temporal infor-
mation gained by these techniques could comple-
ment the spatial precision achieved with newer
techniques of brain imaging. Another technique
based on magnetic elds generated in the cortex is
called transcranial magnetic stimulation (TMS).
N. J. Wade
Following the lead of Silvanus Thompson (1851–
1916), alternating magnetic elds can be applied
to restricted regions of the head in order to stimu-
late or to disrupt neural activity in some way [37].
In TMS, a magnetic coil is positioned over a par-
ticular area of a subject’s head and a current is
brie y passed through the coil. The magnetic eld
so produced induces an electrical current in a spe-
ci c part of the subject’s brain. The timing of such
TMS is very precise and so it can be applied at
known intervals after some visual stimulation has
taken place. It is as if the technique produced vir-
tual patients because the disruption is temporary.
The armoury of techniques for probing the
workings of the brain has been extended such
that the operation of the whole working brain can
now be imaged. Initially, positron emission
tomography (PET) scans were used to examine
the regional cerebral blood ow when volunteers
looked at different kinds of visual patterns. For
example, a coloured pattern produced activation
in regions corresponding to V1, V2 and V4; when
the same pattern was shown in shades of grey, the
activation in V4 was much reduced, suggesting
that V4 was an area for the analysis of colour in
humans. Similarly, a moving compared with a
static pattern produced speci c activation of
‘human V5’, and illusory motion seen in static
patterns has also been attributed to this area [38].
Semir Zeki is one of the pioneers of neuroaes-
thetics, and he has argued that we are at the
threshold ‘of learning something about the neu-
robiological basis of one of the most noble and
profound of human endeavours’ [38]. Both
Thompson and Zeki examined aspects of visual
illusions associated with geometrical patterns
and both are shown in Fig. 6.10. A double portrait
of Thompson combines a photograph taken with
his head between induction coils and with his
portrait in a pattern of ‘strobic circles’ that he
used to examine visual motion [39]. A portrait of
Semir Zeki can be seen in a pattern that produces
apparent rotation around the annuli. He con-
ducted neuroimaging studies of observers view-
ing a similar pattern [40].
There are sophisticated ways of examining
human brain activity but all techniques have
drawbacks, and experiments must be designed
6 Art and Neurologists 63

Fig. 6.10 The visual patterns of Thompson and Zeki by Nicholas Wade

Fig. 6.11 Explorers of the mind—Breuer, Freud and Jung by Nicholas Wade

with great care if they are to be clearly interpre-
table. In comparison to PET scans, magnetic
resonance imaging (MRI) yields more precise
spatial resolution. Developments in functional
MRI (fMRI) allow activity to be temporally as
well as spatially mapped, and it will be work
using fMRI combined with developments in
other technologies with more temporal precision
such as TMS and MEG which is likely to hold the
key to understanding the neural processing of
visual information by people.
Some neurologists had a great in uence on art
when they ventured into the territory of the mind.
This was evident from the work of Josef Breuer
(1842–1925), Sigmund Freud (1856–1939) and
Carl Gustav Jung (1875–1961) who are shown in
Fig.  6.11. Breuer stimulated Freud’s interest in
hysteria by discussing one of his cases with him.
Despite his work in physiology, Breuer is proba-
bly known most widely for his collaboration with
Freud. Breuer treated Anna O (Bertha
Pappenheim, 1860–1936) from 1880 until 1882,
and described four phases through which her
mental illness passed. All involved two distinct
states of consciousness. Breuer found that her
symptoms could be relieved (although not perma-
nently removed) by talking in great detail about
the origins and appearances of each of them. This
64
constituted Breuer’s talking cure. Anna’s case,
together with others treated by Freud, was pub-
lished in their Studies on Hysteria [41]; the theo-
retical chapter was written by Breuer, who can be
credited with linking neuroses to unconscious
processes and with developing a technique to ren-
der the unconscious processes conscious. Breuer
is depicted in combination with two views of
Anna O re ecting her dual personality. The con-
trast between her two states is de ned by contour
and colour: the lines on left and right are orthogo-
nal and the same red colour is present in both but
it appears quite different due to colour contrast.
Freud set in train a major change in theories of
neuroses. He established psychoanalysis as a
treatment, and developed a theory of mind that
emphasised unconscious motivation. His meth-
ods in psychopathology did not draw upon his
neurological training nor did his theoretical con-
cepts re ect his exposure to the mechanistic neu-
rophysiology of his day. Psychoanalysis involved
patients saying whatever came into their mind,
without any selection or censorship. The method
was taken to expose, indirectly, repressed memo-
ries and desires. Three forces and their interac-
tions fashioned behaviour, and he once displayed
these in graphical form: the id represents uncon-
scious, biological desires which are partially
repressed by the superego; a resolution is achieved
by the preconscious ego, which also interacts via
the senses with the real world. These concepts
were initially formulated in 1923, and his models
of motivation and personality affected both art
and literature in the rst half of the twentieth cen-
tury. Freud’s model is often represented graphi-
cally in terms of concentric or overlapping circles,
and it is within such a graphical scheme that his
portrait is presented. The overbearing and enclos-
ing effects of socialisation de ne the superego;
the ego is orderly and well-formed, unlike the id,
which is primitive and generally unseen. These
(oversimpli ed) characteristics of his system are
also echoed in the scripts used: the dominant and
aggressive forms of ‘superego’, the neat, present-
able ‘ego’ and the unschooled ‘id’ (which was
written with the left hand). In contrast, Jung
established an analytic psychology that empha-
sised the self—the achievement of harmony
N. J. Wade
among the various strands of personality. He was
closely associated with Freud between 1907 and
1912, but thereafter Jung developed his analytic
psychology, concentrating upon individual differ-
ences in personality and cross-cultural compari-
sons. His system became increasingly complex
and amorphous, in contrast to Freud’s more con-
strained model of personality. The collaboration
ceased in 1914, when their disparate views on the
importance of psychosexuality led to a bitter split.
Following the schism Jung entered a depression
and sought to express his feelings in paintings.
Initially they were representational but became
increasingly abstract—often in the form of circu-
lar, quartered designs. He was later struck by the
similarity of his paintings to the symbols and
myths used in all human cultures. In particular,
the mandala was treated as a symbol of total unity.
Even his graphical model of mind consisted of
concentric circles, with sensations in the outer-
most annulus, progressing centripetally through
thinking, feeling, intuition and memory to the
central core of the personal unconscious. Jung
studied comparative religion and the occult
throughout his life, and he placed particular sig-
ni cance on visual symbols, like the mandala,
used in different cultures [42]. These included
yin-yang—representing the union of opposites—
and Jung is shown within a variant of this symbol
made up of concentric circles.
The imaging techniques referred to above now
form one of the cornerstones of neurology.
Communication of advances in neurology has
seen computer imagery displace engraving and
photography. The honed eyes and hands of the
medical artists were initially replaced by photo-
graphs, then pen recordings and now by the skills
of computer programmers; the resulting images
of the latter are displayed on screens rather than
paper.
6.4 Conclusion
There is a lot of art in neurology but it is rarely
considered as such. That is, articles and books on
neurology are replete with images of brains, both
normal and disordered, and their neural parts.
6 Art and Neurologists
Moreover, advances in understanding the brain
have often proceeded along with developments in
the technology of image production. The detailed
engravings that re ected the dissections of
Vesalius have been replaced by non-invasive
techniques (like functional magnetic resonance
imaging) yielding computer-generated images
that would have seemed like abstract art to him.
Throughout these transformations, patients and
their symptoms have changed less. The distance
between what the patient presents to the neurolo-
gist and what is represented on paper or computer
screen has always been a matter of contention but
the distance would be much greater without
images. What most of us know about brains is
from such artistic representations. The artistry has
been ampli ed of late with all manner of com-
puter assisted imaging devices producing repre-
sentations which might suggest a closer link to
brain processes than is the case. I have adopted a
different approach—one of distancing the repre-
sentations of neurologists from their own appear-
ances. Few of the faces shown are immediately
evident and the viewer is left to puzzle on the
relationship between the dimly discernible vis-
ages and the contributions they made to our pres-
ent understanding of the brain. For those wishing
to see further examples of such ‘perceptual por-
traits’ many more can be found in Wade [43–48]
and at the website https://neuroportraits.eu/.
References
1. Finger S, Zaidel DW, Boller F, Bogousslavsky J, edi-
tors. The ne arts, neurology and neuroscience: his-
tory and modern perspectives. Oxford: Elsevier; 2013.
2. Kandel ER.  Reductionism in art and brain science.
New York: Columbia University Press; 2016.
3. Rose FC, editor. The neurobiology of painting. San
Diego, CA: Academic Press; 2006.
4. Skov M, Vartanian O, editors. Neuroaesthetics.
Amityville, NY: Baywood Publishing; 2009.
5. Finger S.  Origins of neuroscience. A history of
explorations into brain function. New  York: Oxford
University Press; 1994.
6. Haymaker W, Schiller F, editors. The founders of neu-
rology. 2nd ed. Spring eld, IL: Thomas; 1970.
7. Willis T.  Cerebri Anatome: cui accessit Nervorum
Descriptio et Usus. London: Martyn and Allestry;
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8. Vesalius A.  De Humani Corporis Fabrica. Basel:
Oporini; 1543.
9. Eustachi B.  Tabulæ Anatomicæ. Rome: Gonzage;
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10. Fabricius ab Aquapendente H (1600) Tabulae pictae.
(See 11, 12).
11. Zanchin G. De Anatomia Capitis Cerebri Nervorum.
Le tabulae pictae di Fabrici sul sistema nervoso. In:
Bonati MR, Pardo-Tomas J, editors. “Il teatro dei
corpi”. Le Pitture colorate d’anatomia di Girolamo
Fabrici d’Acquapendente. Milan: Mediamed; 2004.
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12. Zanchin G, De Caro R.  The nervous system in
colours: the tabulae pictae of GF d’Acquapendente
(ca. 1533–1619). J Headache Pain. 2006;7:360–6.
13. Choulant L.  History and bibliography of anatomic
illustration. M.  Frank, trans. Chicago: University of
Chicago Press; 1920.
14. des Cartes R.  De Homine Figuris et Latinitate.
F.  Schuyl, Trans. Leiden: Leffen and Moyardum;
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15. Descartes R. Traité de l’Homme. In: Adam C, Tannery
P, editors. Oeuvres de Descartes, vol. 11. Paris: Cerf;
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16. Descartes R.  Tractatus de Homine et de Formatione
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18. Rolando L.  Ricerche Anatomiche sulla Struttura del
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19. Rolando L. Saggio sopra la vera Struttura del Cervello
dell’Uomo e degli Animali e sopra le Funzioni del
Sistema Nervoso. Sassari: Stamperia Privilegiata;
1809.
20. Gall FJ, Spurzheim JC. Anatomie et Physiologie du
Systême Nerveux en general, et du Cerveau en par-
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Treuttel, Wurtz and Richter; 1829.
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Propriétés et les Fonctions du Système Nerveux dans
les Animaux Vertébrés. Paris: Crevot; 1824.
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Primates. Paris: Reinwald; 1888.
25. Charcot J-M, Richer P. Les Démoniaques dans l’Art.
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30. Luria AR. Traumatic aphasia. Its syndromes, psychol-
ogy and treatment. The Hague: Mouton; 1970.
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31. Wade NJ.  Divided hemispheres. Cortex. 2011;47:
633–4.
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lecture.pdf.
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 Music and Mirror Neuron System
Arturo Nuara
“What is music at the end?
It is a movement.
Who is moving? Is it the sound?
No, it is the consciousness of who is listening to and of who is moving the sound.”
Sergiu Celibidache [1]
7.1 Introduction
Music is a universal form of artistic expression.
Humans may engage in music for many reasons:
true enjoyment, religious rituals, therapy, social
identi cation, and art. Today, progresses in
anthropology, ethnomusicology, and neurosci-
ence have offered signi cant advancement in the
understanding of this unique human capability,
providing a detailed picture of the biological and
cultural processes that shape music experience,
both in its productive and perceptive aspects.
While, at least in modern Western society,
music production is generally a specialized activ-
ity performed by trained people, its listening may
occur at different levels of musical awareness.
What happens most commonly is that music-
untrained listeners are engaged in listening to
music through emotional response [2] or activa-
tion of body movement. The latter occurs in the
form of dance, rhythm entrainment [3], as well as
in the mere feeling to be “internally” driven by
musical groove.
In some other cases, we encounter music-
trained listeners that are intrinsically able to
A. Nuara (*)
Istituto di Neuroscienze, Consiglio Nazionale delle
Ricerche, Parma, Italy
Dipartimento di Scienze Biomediche, Metaboliche e
Neuroscienze, Università di Modena e Reggio Emilia,
Modena, Italy
© Springer Nature Switzerland AG 2020
B. Colombo (ed.), Brain and Art, https://doi.org/10.1007/978-3-030-23580-2_7
7
recognize the action from which the musical
phrase arises just by listening to it (i.e., the lis-
tened music belongs to their motor repertoire). In
fact, they would distinguish in this music gesture
the melodic contour, the rhythmic shape, the
sound dynamics, tempo and tone color, and be
ideally able to perform it in a similar way. In this
framework, a system suited to directly transform
a musical-sensorial information into its corre-
sponding motor representation—favoring its
prompt action understanding—is crucial.
In the last decades, the discovery in monkey’s
premotor cortex of the mirror neurons [4, 5]—a
particular class of neurons that discharge both
during the performance of a given motor act and
during the observation of another person per-
forming a motor act with a similar goal—and the
subsequent description of their activity in
humans’ brain [6, 7], offered to Neuroscience the
possibility to study brain mechanisms underlying
human inter-activities, including music, accord-
ing to a new perspective.
The essence of the mirror neuron mechanism
is the transformation of speci c sensory informa-
tion into a motor format. Such process, enabling
the perceiver to identify the goal of the observed
(or listened) action relying on his own motor rep-
resentations [8], allows the direct understanding
of the perceived action. Due to their development
of a consolidated association between motor and
auditory systems, musicians constitute an inter-
esting population for investigating audio-motor
67
68
integration and the related ability to transform
auditory complex stimuli into a motor
representation. In fact, several neuroimaging and
neurophysiological studies [9–12] suggested that
just listening of known melodies or chords can
activate in musicians some motor areas actively
recruited during the execution of the same melo-
dies. Mirror mechanism is regarded as a key sub-
strate of such audio-motor resonance arising
during listening to music, potentially driving
music learning processes. While playing in
ensembles, musicians further exploit their capac-
ity to mirror a sound (the musical note) into the
action required to produce it (the musical ges-
ture). This entails the performing of a “sensorim-
otor conversation,” in which they exchange
information needed to correctly predict other’s
musical intentions.
In the rst part of this chapter, an overview on
the mirror neuron system in monkey, songbirds
and humans is provided. Since in music the major
impact of action on the perceiver is auditory—
with musical gestures providing a visual counter-
point—particular emphasis will be given to the
description of audio-motor modality of mirror
mechanism. In the second part, the discussion
focused on the role of mirror mechanism in
audio-motor transformations occurring in expert
musicians, both at individual and ensemble lev-
els. Finally, the last paragraph brie y takes into
account some clinical considerations and per-
sonal proposals, in order to exploit the audio-
motor properties of human mirror neuron system
for music-oriented neurorehabilitation.
7.2 Mirror Neuron System
in Monkeys
Mirror neurons are a distinct class of motor neu-
rons that discharge both when a monkey per-
forms a speci c motor act and when it observes
the same or a similar motor act done by another
individual. Originally discovered in a speci c
sector (area F5c) of the ventral premotor cortex
(vPMC) of the macaque monkey [4, 5], they have
been subsequently described also in the rostral
inferior part of its parietal lobe (area PFG and
PF) [13]. A fundamental property of mirror neu-
A. Nuara
rons is that they are activated by the observation
of motor acts having the same goal they encode
motorically.
In mirror neurons, there could be two main
levels of congruence between the observed action
and the executed one. Strictly congruent mirror
neurons discharge when observed and executed
effective motor acts are identical in terms of goal
and in terms of the way to achieve it. By contrast,
broadly congruent mirror neurons are triggered
by similarity—but not identity—between the
observed and executed motor act [14].
Before discussing the functional role of mirror
neurons, it is important to de ne some terms
regarding motor organization: movement, motor
act, and action. Movement indicates a mere dis-
placement of body parts, not including the idea of
goal. Motor act de nes a series of joint move-
ments aimed at achieving a goal (e.g., grasping
an object). Finally, motor action can be de ned
as a sequence of motor acts (e.g., reaching, grasp-
ing, bringing to the mouth) allowing individuals
to ful ll their intention (e.g., eating).
The most widely accepted hypothesis on the
function of the parieto-frontal mirror circuit is
that it mediates the understanding of the observed
motor acts. This issue has been addressed by two
series of experiments. In the rst one [15], mirror
neurons responding exclusively during the obser-
vation of the late phase of grasping were tested in
two conditions. In the rst one the monkey saw
an object-directed action (“full vision” condi-
tion), in the other one the same action was pre-
sented with its nal critical part (the hand-object
interaction) deliberately hidden (“hidden condi-
tion”). The results showed that most of the neu-
rons responding to the observation of grasping in
the “full vision” condition, also discharge in the
“hidden condition,” suggesting that it is the
meaning of observed action—and not the mere
vision of it—that triggers mirror neurons. The
second study [16] tested whether mirror neurons
were able to represent action from their sound.
Mirror neurons were studied while the monkey
was observing a motor act characterized by a
typical sound and while this sound was presented
without the associated vision of the related motor
act. The results showed that many mirror neurons
that were responding to the observation of motor
7 Music and Mirror Neuron System
act accompanied by its sound also discharged
when the sound was presented alone. These neu-
rons were named “audio-visual” mirror neurons.
In addition to providing evidence that mirror
activity re ects the meaning of the observed motor
act, the above described experiment proved that the
activity of a subset of mirror neurons could be elic-
ited not only by visual stimuli but also by action-
related sounds. This latter property—widely
exploited by songbird in communicative context—
may also play a key role in musical language learn-
ing in human (see the next paragraphs).
7.3 Mirror Neuron System
in Songbirds
Humans and songbirds share several common
traits in their vocal communication, despite the
considerable evolutionary distance between
them. For instance, both birdsong and speech are
composed by complex vocal behaviors learned
by imitation, and in both cases they facilitate
individual recognition and group cohesion [17–
20]. From a neuroanatomical point of view, they
both present with specialized sensorimotor net-
works, playing an essential role in learning, pro-
duction and perception of vocal stimuli. Thanks
to recent neurophysiological studies, the activity
of putative auditory-vocal mirror neurons in such
sensorimotor regions, involved in active and
receptive aspects of vocal communication, have
been recorded. Before discussing these experi-
ments, birdsong system will be brie y described,
for ease of understanding.
Birds song system consists of a distributed net-
work of forebrain and brainstem nuclei that distin-
guishes songbirds from other birds producing
innate and unlearned vocalizations [17, 21]. This
system is composed of two pathways: a song motor
pathway (SMP) strongly involved in singing, and
an anterior forebrain pathway (AFP), showing simi-
larities to mammalian basal ganglia networks. Even
if they do not completely prevent the act of singing,
AFP lesions interfere with songbird’s ability to
copy a tutor song, as well as with their audition-
dependent vocal plasticity and vocal modulation
capacity. Both SMP and AFP receive projections
from HVC, a fundamental vocal-learning nucleus
69
whose function can be roughly linked to that of
human Broca’s area. HVC contains one kind of pro-
jection neuron that innervates song motor neurons
(analogues of vocal motor representation in human
primary motor cortex), whereas another projection
neuron (HVCx) provides input to the striatopallidal
structure (area X) in the AFP [22].
Interestingly, HVC lesions impair the ability
to recognize songs of other conspeci c birds
[23], suggesting that HVC has both premotor
and auditory functions. This hypothesis has been
validated by previous recordings performed
from HVC in songbirds, showing that the audi-
tory playback presentation of the bird’s own
song is able to activate HVC neurons [24].
Furthermore, single-unit studies using anti-
dromic stimulation methods demonstrated that
HVCx neurons only have an auditory activity,
showing that a subset of them are active both
during active singing and auditory presentation
of the bird’s own song. Of note, regardless of
whether the bird is singing or listening to its
song, HVCx neurons discharge at exactly the
same time in the song phrase [25]. In conclusion,
auditory-vocal mirror neurons in HVC could
play a role in singing behavior of birds having
multiple song types due to their sensorimotor
properties. They could help both to select the
appropriate song according the communicative
context and to promote song recognition in the
framework of the individual’s own repertoire.
These mirror neurons, however, don’t seem to
code the goal of the motor act, as in human pho-
nological resonance (see the paragraph below).
Instead, they map sequences of heard sounds on
the main motor invariants used to produce them.
Such speci c ability could be exploited during
male-to-male rivalries in bird’s species with
multiple song types undergoing matched coun-
tersinging, a complex behavior in which a resi-
dent male chooses from its own repertoire a song
similar to that of its rival. As suggested by
Mooney [22], the auditory-vocal mirror system
could promote this vocal-matching process: “lis-
tening to the rival’s song would activate mirror
neurons in the resident that encode a similar
song in its own repertoire; this auditory activity
could then lead to the selective recruitment of
premotor neurons encoding for that song”.
70
4
PMd
PrePMd
(F7) (F2)
C
SP
SF FEF
IPa
IF
PMv (F5c)
45
44 PMv (F5p)
IPd
F5a
Fig. 7.1 Lateral view of the human cortex. Frontal and
parietal nodes of human mirror neuron system are respec-
tively highlighted in yellow and green. Numbers corre-
spond to Cytoarchitectonic subdivision according to
Brodmann. In the enlarged view of the frontal lobe (on
the left), the possible homologies between human and
7.4 Mirror Neuron System
in Humans
Thanks to neuroimaging and neurophysiological
studies, the existence of a mirror system has been
reported even in humans: when we observe an
action, our motor system generates its inner rep-
resentation, as if the action had been really
executed.
The mirror neuron network in humans is com-
posed by two main nodes: the frontal one includes
the ventral premotor cortex (PMv) and the caudal
part of the inferior frontal gyrus (IFG); the pari-
etal one is the inferior parietal lobule (IPL) [26].
On the basis of anatomical and functional obser-
vations, the frontal and parietal nodes of human
mirror system can be globally regarded as homol-
ogous areas of F5 and PFG in the monkey (the
localization of human parieto-frontal mirror sys-
tem is shown in Fig.  7.1). Of note, a huge and
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PMv (F4)
40
44
45
monkey premotor regions are indicated. C central sulcus,
IF inferior frontal sulcus, FEF frontal eye eld, PMd dor-
sal premotor cortex, PMv ventral premotor cortex,
PrePMd predorsal premotor cortex, SP upper part of the
superior precentral sulcus
growing body of experimental evidences showed
that, beyond premotor and inferior-parietal
regions, a large number of cortical areas involved
in the production of speci c motor behaviors,
selectively responds even when that behavior is
merely perceived, indicating that the mirror
mechanism is a basic principle of brain function-
ing [6, 27].
The rst human neurophysiological evidence
of motor activation elicited by the observation of
actions has been described in a electroencephalo-
graphic (EEG) experiment performed by Gastaut
and Bert in 1954 [28]. Studying the oscillations
recorded over sensorimotor regions during cine-
matographic presentations, the authors registered
a suppression of the “rolandic rhythm en arceau”1
1
The oscillations recorded over sensorimotor regions that
desynchronize during active movement—nowadays
named mu rhythm—were rst described by Gastaut [29]
under the name of rolandic rhythm en arceau.
7 Music and Mirror Neuron System
during the observation of movies including
human actions. This nding was interpreted as a
“motor induction speci c to the cinematographic
presentation” related to a “process […] occur-
ring whenever the spectator identi es himself
with one of the active gures projected on the
screen”. A large number of studies con rmed this
observation quantifying the EEG suppression of
motor rhythms during action observation [30,
31], providing a detailed description of its
dynamics [32].
Unlikely to monkeys, motor activation in
humans can be evoked by the observation of both
transitive and intransitive actions. Indeed, one of
the rst transcranial stimulation (TMS) study
investigating mirror mechanism in humans
showed that the observation of meaningless
movements enhances cortical excitability, with a
somatotopical correspondence to the effector
performing the observed movements [33]. The
nding that mirror neuron system may also
encode intransitive movements is very relevant
and outlined the fact that mirror mechanism is
involved in the process of imitation. In an func-
tional magnetic resonance imaging (MRI)
study—in which volunteers movement in
response to an observed action (imitative behav-
ior) was compared to movement triggered by a
cross (non-imitative behavior)—Iacoboni et  al.
[34] showed that areas endowed in mirror mecha-
nism (in particular the posterior part of IFG) were
wider activated during imitation. Further neuro-
imaging studies suggested that mirror neuron
system could carry out the rst steps of learning
by imitation. In particular, they are responsible
for the discrimination of the individual elements
of the action to be imitated and their transforma-
tion into the corresponding potential motor act by
the observer [35].
In humans, in addition to the mirror system
able to transform observed intransitive move-
ments into potential movements, a mirror match-
ing mechanism that convert heard phonemes in
the corresponding motor representation of the
same sound has been ascertained [36, 37]. In the
rst TMS experiment providing this evidence,
Fadiga and colleagues [36] measured motor-
evoked potentials (MEPs) of tongue muscles
71
while listening acoustically presented verbal and
non-verbal material. The results showed that
MEPs amplitude was higher during listening of
phonemes related to a stronger tongue’s muscles
involvement (e.g., word containing double “r”).
Of even greater interest, activation during word
listening was higher than during listening of
pseudo-words. This strongly support the assump-
tion that phonology and—at least in part—the
semantics are processed by the motor system.
These ndings are in line with Lieberman’s
motor theory of speech perception [38], accord-
ing to which our ability to perceive speech sounds
depends on shared representations of speech
motor invariants between the sender and the
receiver. While it is a matter of debate at what
extent mirror neuron system intervenes in the
comprehension of word meaning, there are strong
evidences supporting that this system could play
a fundamental role in language learning [39, 40].
A central feature of mirror neuron system is
that its activity is strongly in uenced by the
motor knowledge of the perceiver, being favored
by the belonging of the perceived motor act to the
observer’s motor repertoire. This has been shown
by a series of neuroimaging studies that investi-
gated mirror activation in subjects trained in spe-
ci c motor skills, comparing it to the activation
induced by the same stimuli in untrained persons.
Buccino et  al. [41], in an fMRI study, investi-
gated brain activation in response to observation
of motor acts performed by different species:
human, monkey and dog. Two types of gestures
were shown: the act of biting a piece of food and
oral silent communicative gestures (e.g., speech
reading, lip smacking and barking). Biting,
regardless of the action’s agent, produced bilat-
eral activations in the IPL-IFG circuit, virtually
identical for three species especially in the left
hemisphere. Communicative gestures performed
by a human activated the mirror system (in par-
ticular IFG); those performed by non-conspeci cs
only weakly activated it (monkey gesture) or did
not activate it at all (silent barking). In a further
study, the mirror responses have been investi-
gated in three different groups of participants:
classical dancers, teachers of Capoeira and
dance-naïve people. Stimuli consisted in videos
72
of either Capoeira or classical dance. The two
expert group showed a strong mirror activation
accordingly to their speci c expertise: mirror
responses to Capoeira steps were stronger in
Capoeira experts, while mirror responses to clas-
sical dance steps were stronger in ballet per-
former. In the following experiment, the authors
disentangled the “visual” knowledge of dance
steps with their motor expertise. Studying classi-
cal dancers, the effect of the observation of steps
done by different genders on brain activity of
male and female dancers was studied: mirror sys-
tem was activated more strongly by steps exe-
cuted by individuals of the same gender of the
observer. Thus, we can conclude that the activa-
tion of mirror system depends on motor expertise
and not on visual experience.
As it will be discussed in the next paragraph,
musical expertise provides further evidence on
the relationship between mirror mechanism and
motor knowledge.
7.5 Mirror Neuron System
and Musical Expertise
Since the beginning of modern neurosciences,
music practice has been regarded as a paradig-
matic human activity able to induce neural mor-
phological and functional changes, that is, to
induce brain plasticity [42]. Indeed, the skills of
expert musicians arise from an extensive practice
that starts in childhood and goes on throughout
their lifetime, engaging perceptual, motor, and
cognitive domains. The shaping of multimodal
integration of brain networks leading to the
development of musical abilities is sustained by
the growing capacity to transform auditory stim-
uli into correct motor representation. As a result
of the reiterated coupling between the musical
note and the gesture required to produce it, musi-
cians reinforce their audio-motor integration
abilities, progressively expanding their sensory-
motor repertoire. The importance of such inti-
mate association between musical perception and
production is supported by the widespread adop-
tion of music pedagogical methods based on the
evocation of motor representation from auditory
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stimuli. For example, listening to just practiced
music is regarded to be an activity capable of
consolidating musical learning and improving
instrumental performance [43]. Furthermore,
musicians often report that listening to a trained
piece of music is able to trigger its associated
movements (e.g., nger movements in pianists).
One of the rst studies aimed to explore audio-
motor coupling in musicians used magnetoen-
cephalography (MEG) to compare brain activity
of pianists with that of other musicians, while
listening to piano pieces belonging to pianists’
repertoire [10]. An increase in activation in the
primary motor cortex contralateral to the hand
associated to the execution of the listened notes
was evident in pianists. Besides, a spatial disso-
ciation of the activity was found between notes
preferably played by the thumb and the little n-
ger, according to the motor homunculus. The
authors interpreted the failure to detect any activ-
ity arising from other motor areas (SMA, PMC)
as the results of the pianists’ high-level skill, so
that the motor programming processes were
highly automated, requiring little recruitment in
these brain regions.
Brain regions involved in the coupling
between action and perception in professional
musicians were further investigated using fMRI
[10, 44], comparing activation occurring during
silent-piano performance to that observed in
motionless-listening to corresponding piano
sound. Only in professional musicians, it is pos-
sible to observe a partial overlap between brain
regions involved during both listening and execu-
tion of the same music piece. This network
includes dorsolateral and inferior frontal cortex
(in particular, Broca’s area), the superior tempo-
ral gyrus (Wernicke’s area), the supramarginal
gyrus, and supplementary motor and premotor
areas. Interestingly, the distribution of such acti-
vation resulted to be similar to that described in
other studies on action-observation in musicians,
suggesting that a common system is able to mir-
ror both visual and auditory stimuli into a com-
mon action.
A key question is whether musical actions are
encoded by sound into their simple constitutive
movements (i.e., motor acts) or more abstract
7 Music and Mirror Neuron System
action goals. An fMRI study [45] targeted this
question monitoring brain activity in subjects
while they were listening to a newly acquired
piece. Brain activation was found bilaterally in
the fronto-parietal motor related network (includ-
ing the premotor region, Broca’s area the intrapa-
rietal sulcus, and the inferior parietal region),
consistent with neural circuits that have been
associated with action observations. In particular,
left posterior IFG (including Broca’s area) maps
the global representation of actions (trained mel-
odies), whereas the presentation of the practiced
notes in a different order (new melodies with
trained notes) is mapped in vPMC. Of note, the
listening to an equally familiar but motorically
unknown music did not activate this network.
These ndings con rm the hypothesis of a match-
ing hearing–doing system depending on the indi-
vidual’s motor repertoire, having Broca’s area as
its hub.
Neuroimaging fMRI techniques are a valuable
tool to depict the topography of the shared net-
works of music listening and production, but
they’re not able to answer a crucial question: is
the listening of known music able to facilitate the
motor output? This issue is easily addressable
measuring the modulation of the motor cortico-
spinal excitability induced by listening to prac-
ticed music. For this purpose, the
neurophysiological technique of Transcranial
Magnetic Stimulation (TMS) has been used in a
study aimed to test excitability changes in piano
players during auditory presentation of rehearsed
versus non-rehearsed musical pieces [46].
Pianists were tested before being trained to the
listened music, after 30′ of training and after a
longer training period (5 days), using both tradi-
tional recruitment curves of motor-evoked poten-
tials (MEPs) amplitudes obtained from
single-pulse TMS and Intracortical Facilitation
(ICF) measures achieved from paired-pulse
TMS.  While the former globally measures the
cortico-spinal motor output [47], the latter
re ects the synaptic excitability resulting from
the balance between inhibitory and excitatory
neural circuits at the level of the motor cortex
that, in turn, control cortico-motor neurons excit-
ability [48]. The increased amplitude of motor-
73
evoked potentials (MEPs) collected during
listening after the longer training period, indi-
cated the acquisition of an active cortico-spinal
motor facilitation associated to the perception of
the practiced melody. Interestingly, Intracortical
facilitation (ICF) during listening was already
increased after 30 min of training, indicating that
listening to the just trained music is able to acti-
vate plasticity processes, promoting an early shift
in the balance of the synaptic ef cacy of the
motor cortical circuits towards “less inhibition
and more facilitation.”
Action representation during music listening
has been also investigated measuring the modula-
tion of sensori-motor brain rhythms induced by
action-related auditory stimuli. A recent EEG
study [49] demonstrated that the listening of
known melodic sequences sustains the induction
of a suppression of mu-rhythm in trained musi-
cians, indicating an increase of motor activity
associated to the listening of sounds belonging to
musician’s own repertoire. Even in naïve sub-
jects, the controlled musical training can repro-
duce a pattern similar to that observed with
experts. The passive listening to trained musical
excerpts leads to an increase in EEG motor activ-
ity that emerges after only 20  min of training,
being rmly established within a few weeks [12].
Besides listening-to-play approaches, even the
observation of musical gestures is deeply involved
in music learning and practice. In fact, especially
in the rst years of training, musicians improve
their hand-motor skills observing, rehearsing and
then imitating the hand movements of their mas-
ter. As hand dexterity is progressively acquired,
musicians became able to ef ciently associate the
observation of hand postures to their speci c
auditory and motor representation [12, 50, 51].
An interesting fMRI study exploring such multi-
modal sensori-motor transformations in musician
has been performed by Haslinger and colleagues
in 2005 [12]. While observing piano-playing
hand movements with and without synchronous
piano sound, pianists—compared to music-naïve
controls—showed stronger activations within
fronto-parieto-temporal network. Observation of
silent piano playing additionally recruited audi-
tory areas in pianists. Perception of piano sounds
74
coupled with hand movements evoked increased
activation to a greater extent within this senso-
rimotor network, including the inferior frontal
gyrus (BA 44 and 45) and the ventral part of the
lateral premotor cortex (vPMC) as well as the
inferior parietal/intraparietal cortex and the tem-
poral cortex within the superior temporal sulcus
(STS) and the adjacent temporal cortex (BA
21/22/42) bilaterally. Taken together, these data
indicate that a professional musical training
induces a specialization of multimodal auditory–
sensorimotor systems.
The motor facilitation—having its core in the
inferior fronto-parieto-temporal network—
occurring in musicians during the perception of
music belonging to their own repertoire suggests
the operation of a “mirror-matching” system.
This matching system, translating perception to
action by means of action recognition and under-
standing, ensures adequate preparation of musi-
cal motor responses and gesture imitation [5, 52,
53]. Furthermore, the consolidation of musical
abilities due to listening, observation and subse-
quent imitation of musical stimuli, supports the
mirror-like neuronal computation in musical
practice. The development of this specialized
system, during long-term musical training, is
linked to a key element of “musical intelligence”:
the ability to understand the meaning of listened
music and transform such complex system of
auditory stimuli into the actions required to pro-
duce them. This may constitute the neurobiologi-
cal basis of auditory-based, observative and
imitative teaching approaches that are fruitfully
applied in all musical cultures.
7.6 Mirror Neuron System
and Music Interplay
Ensemble playing involves a set of peculiar
skills that goes beyond the abilities required for
individual musical performance. In particular, a
requisite for ensemble performers is to under-
stand what other musicians are doing, their
intention and feelings, in a precise and timely
manner. In fact, in a joint musical action it is fun-
damental, in order to establish and maintain a
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shared coordinative goal, to correctly encode
other’s subtle sensorimotor messages. For such
an interplay, an ef cient exchange of needed
information is mandatory to exactly predict oth-
er’s motor intentions, without any complex cog-
nitive elaboration. In other words, what occurs is
a “sensorimotor conversation” [54].
Over the last few decades, a series of studies
revealed that these capacities are mediated, at
least in part, by mirror mechanism [55]. The
frontoparietal network endowed with mirror
properties—able to transform sensory informa-
tion describing actions of others into an internal
motor representation similar to that needed to
perform it—might play a key role in interper-
sonal coordination occurring in social interactive
models as musical ensembles. Of note, not only
synchronous but also complementary action
observation may recruit human mirror neuron
areas, suggesting that this mechanism might be
tuned for general action coordination, as well as
for simple action mirroring [56].
The duet is the smallest form of musical
ensemble in which musical interplay can be
investigated. A recent neurophysiological study
[57] employed a musical joint action task (piano
dyadic interaction) to investigate how the brain
dissociates the self from the other-related moto
representation. Pianists executed the right-hand
part of already known piano pieces, while the
complementary left-hand part either was not exe-
cuted or was believed to be played by a co-
performer. The amplitude of motor-evoked
potentials (MEPs) obtained stimulating the right
primary motor cortex indicated that corticospinal
excitability was modulated by whether the repre-
sentation of the left hand was associated with the
self or the co-performer’s execution. In particular,
MEP’s amplitude resulted to be higher in the “co-
performer” condition and correlated with pianist
self-reported empathy, suggesting that the social-
ity of the musical context is able to modulate
action representation, ultimately affecting motor
facilitation. The same authors demonstrated that
the perturbation of the motor system (induced by
transcranial magnetic stimulation) negatively
affects interpersonal coordination only when the
complementary part has been trained [58], due to
7 Music and Mirror Neuron System
impairment in the ability to predict the dynamics
of co-performer actions [59].
In the eld of small music ensembles, the
string quartets represent the one in which cogni-
tive neuroscience mostly focused its investiga-
tions. Being the most important chamber
ensemble in western music, the quartet con gu-
ration represents a valuable case study, since all
its components offer a balanced contribution to
the overall performance, adopting similar instru-
mental techniques. The motor interpersonal coor-
dination of string quartet members has been
investigated measuring the dynamics of bowing
movements in couples of quartet members, dur-
ing the execution of musical phrases required to
be synchronically played at a steady tempo [60].
Showing a high degree of motor synchrony dur-
ing music interplay, this study evidenced that the
coordinate motor coupling between the string
players is a key component of the joint musical
activity. In addition to promoting motor synchro-
nization, playing music in a group in uences the
musician’s own bodily expressive features during
musical performance. Comparing expressive
head’s movements of the rst violinist when
playing solo and in a quartet, Glowinski and col-
leagues [61] showed that head movements are
more regular and predictable in ensemble playing
than in individual performance. In order to quan-
tify the sensorimotor information ow among
musicians during the performance, the mathe-
matical tool of Granger Causality has been
recently used in quartet ensembles [62]. This sta-
tistical method is able to determine whether two
time-series are causally related to one another,
estimating the ability of past values from one
time-series to predict future values of another
time-series. Badino and colleagues [62] investi-
gated sensorimotor communication in profes-
sional string quartets measuring head movement
kinematics, applying Granger Causality in order
to test the causality patterns between participants.
The introduction in the musical score of temporal
and dynamical perturbations known by the rst
violin only negatively affects the in uence of the
rst violin on other components, suggesting that
the effective musical leadership requires prior
sharing of knowledge and information.
75
Differently from quartets—in which all musi-
cians equally contributed to the performance—
bigger orchestral ensembles are characterized by
a leadership exerted by a conductor that “uses his
motor behavior in order to drive the musicians
towards a common aesthetic goal” [54]. The
increase of in uence exerted by the conductor on
musician’s motor behavior, together with the
reduction of musician-to-musician coordination
(an index of conductor’s leadership) determines
the aesthetic quality of execution, as assessed by
expert musicians [63]. The speci c association
between performer’s motor coordination capa-
bilities and listener’s musical appreciation points
the light on the importance to integrate bodily
and auditory information to achieve a rewarding
musical experience.
An intrinsic limitation of the studies on music
interplay performed on classical ensembles is
represented by the presence of score constraints.
Indeed, classic musicians play their music repro-
ducing a pre xed sequence of notes. On one side,
this approach favors the reproducibility of the
musical performance reinforcing experimental
control, on the other, it limits the multiple possi-
bilities of the sensori-motor interplay on a pre-
established musical conversation, restricting
musician’s spontaneous behaviors in the eld of
dynamics elements and slight rhythmic
deviations.
Jazz ensembles could represent and interest-
ing model able to overcome these issues.
Although “improvised” rather than composed,
jazz music interplay is based on a shared knowl-
edge and rules undergoing dynamic changes and
adaptations, according to reciprocal expecta-
tions. During a jazz session, the performer
extemporaneously decides the notes to be played,
basing his choice on both his own feelings and
the musical phrases listened right away. In fact,
more than ne sound dynamics, basic concerns
of jazz performers are the prompt understanding
of just listened musical actions and the following
proper tuning of own musical responses. To date,
to my knowledge only one fMRI investigated
neural substrates of interactive improvisation in
jazz music players [64]. In the stylistic conven-
tion of trading four—an exchange of improvised
76
material in four measure segments—participants
performed a musical dyadic improvisation in
which they introduced novel melodic material,
responded to each other’s ideas, and elaborated
or modi ed those musical ideas in the course of
performance. The activation of perisylvian lan-
guage areas—including inferior frontal gyrus
and posterior superior temporal gyrus—during
the jazz conversation indicated a neural overlap
between music and language processing, sup-
porting the view that these systems share a com-
mon network of prefrontal and temporal cortical
areas. However, the absence of a comparison
with brain activation during listening-phases of
interactive improvisation did not allow the
authors to verify the presence of a mirror-
matching mechanism.
Future researches aimed to investigate the role
of mirror mechanism in musical ensembles
should consider the extraordinary opportunity
offered by music genres based on improvisation,
such as jazz or classical Indian music. This
framework could take advantage not only from
the more spontaneous motor behavior of musi-
cians, but also from a basic features of improvis-
ing ensemble performers: the ability to act in a
“mutual tuning-in relationship” [65]. Relying on
the ability to coding other’s musical behavior,
this skill allows musicians to anticipating the
motor consequences of other’s action, optimizing
instantaneous online action inhibition, selection,
and modulation. In this context, a network
endowed with mirror properties would surely
play a key role in the achievement of the joint
motor, emotional, and aesthetic goals of music.
7.7 Clinical Considerations
and Perspectives
Intriguingly, neuroimaging studies on sensori-
motor integration and language pointed out that
brain regions consistent with that of mirror mech-
anism overlap areas activated in language pro-
cessing [53, 66]. In particular, Broca’s area is
involved in the development of musical abilities
with respect to hierarchical organization of sound
sequences [67–69], sound-action matching [10,
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12, 46] and interpersonal musical coordination
[54, 57, 64]. The evidence of common neural
substrates for music, language and motor func-
tions is also supported by clinical studies address-
ing developmental language disorders. Indeed, in
addition to speci c language de cits, dyslexic
children often display dif culties in music
domains [70] and motor control [71].
But, the most enlightening insights about the
close relationships among auditory-motor match-
ing musical abilities and language derives from
clinical observations on patients suffering from
non- uent aphasia due to lesions of the posterior
part of the inferior frontal gyrus (in particular
Broca’s area). In the rst half of the last century,
French neurologist Alajouanine [72] provided a
remarkable description of the disturbances expe-
rienced by his patient Maurice Ravel. In the com-
poser, the pathological processes related to his
neurodegenerative disease—today believed to be
primary progressive aphasia [73]—led to a
mutual impairment of both language uency and
musical abilities consisting of recognition of
sounds or music gestures and music interpreta-
tion. In the last stages of his disease, musical
activities were completely arrested due to the
occurrence of a severe ideomotor apraxia and
behavioral abnormalities [72].
The interaction between music and language
via a mirror mechanism is also suggested by
rehabilitation studies on patients affected by non-
uent aphasia due to ischemic stroke and under-
going Melodic Intonation Therapy (MIT). This
rehabilitative approach is based on the observa-
tion that aphasic patients are often able to sing
words they cannot produce during speech. MIT’s
capacity to unlock verbal communication can be
explained both with the recruitment of non-
affected hemisphere during singing words [74]
and with the key rhythmic and formulaic features
of MIT [75]. In MIT protocols, short phrases are
embedded in simple melodic pattern. First, as in
operatic recitative, these sentences are exposed
by therapist and subsequently imitated by the
patient. As the aphasic patient improves, the
melodic contour is progressively faded in normal
speech prosody, and confrontation question are
introduced [76]. In a recent study [77], MIT has
7 Music and Mirror Neuron System
been proven to be effective in improving patient
daily life communication and object naming sig-
ni cantly more than controls receiving traditional
language rehabilitation. Interestingly, speech
improvement achieved with MIT [78] is associ-
ated with changes in neural activity of brain
sensori-motor transformation regions [79], in
particular Broca’s area [80]. It can be speculated
that the effectiveness of MIT approach is related
to its strong imitative scaffold favoring a con-
tinue transformation from sensory information to
motor plans and resulting into a strong recruit-
ment of brain regions involved in perception and
language production.
In the same way, the perception of action-
related stimuli is able to access the cortical motor
system also when the limb motor functioning is
impaired, promoting cortical reorganization and
improving motor abilities in action execution.
Thus, the clinical application of this mecha-
nism—namely Action Observation Treatment
(AOT)—has been found to be effective in improv-
ing motor functions in several neurological disor-
ders. While mirror-mechanism has been widely
exploited in its visuo-motor modality, none of the
neurorehabilitative studies investigated sound-
related action putatively able to promote upper
limb motor recovery. This could be partially jus-
ti ed by two facts: (1) human action-oriented
perception has evolved in favor of visual modal-
ity; (2) auditory action-related stimuli are less
capable to engage our attention compared with
visual ones.
These issues could be overcome implementing
Action Listening Treatment (ALT) protocols
where sound stimuli are arranged into music.
Such approaches could be integrated in recently
developed music-based interventions as the
movement soni cation therapy [78]. In this neu-
rorehabilitative approach, gross movements of
upper limbs are transformed into sound, provid-
ing continuous feedback. Movement soni cation
therapy has been proven to reduce joints pain and
to improve movement kinematics more than
movement therapy without sound. One proposal
could be the enrichment of movement soni ca-
tion sessions, similarly to AOT protocols, placing
a listening and a rehearsal phase before the active
77
movement phase. In addition to reinforce the
auditory-motor coupling processes, this strategy
might increase its therapeutic effect, taking
advantage from the intrinsic features of musical
experience. Indeed, more than a complex system
of action-related sound, music is a human activity
of boundless emotional and motivational value.
Acknowledgements I gratefully acknowledge Prof.
Rizzolatti for his helpful and valuable suggestions on the
manuscript and Dr. Dacia Dalla Libera for her encourage-
ment and help in English revision.
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 Opera and Neuroscience:
A Historical Approach and Its
Relevance Today
Lorenzo Lorusso and Alessandro Porro
8.1 Music and Neuroscience:
Comparisons and Literature
The interest of neuroscientists in music might
seem to be of recent origin, but especially since
the nineteenth century, we can reconstruct a path
of knowledge that intercepts different disciplin-
ary de nitions [1]. In some respects, it is a ques-
tion of tracing the evolution of neuroscience, as
well as the very de nition of neuroscientists
themselves. Who were they? How could they
de ne or identify those scienti cally involved in
analysing music, as well as its therapeutic uses?
A rst route leads us to physiologists, with
their equipment in their laboratories, in search of
the understanding of graphically recordable
parameters. Towards the end of this century, it
should be remembered how the physiological and
psychological viewpoints were integrated within
experimental dimensions. The events of Wilhelm
Wundt (1832–1920) and his laboratory in Leipzig,
as well as those of his pupils, such as Friedrich
Kiesow (1858–1940), active in Turin and in col-
laboration with the physiologist Angelo Mosso
(1846–1910), are all emblematic of this. The lat-
L. Lorusso (*)
Neurology Unit, Neuroscience Department,
ASST-Lecco, Merate, Italy
A. Porro
Dipartimento di Scienze Cliniche e di Comunità,
Università degli Studi di Milano, Milano, Italy
© Springer Nature Switzerland AG 2020
B. Colombo (ed.), Brain and Art, https://doi.org/10.1007/978-3-030-23580-2_8
8
ter being of enormous interest, due to his studies
on blood circulation and brain temperature [2].
Consequently, for a good part of the twentieth
century, the main disciplinary area in which we
nd the scienti c re ections that most interest us
appears to be in the eld of neurology. To point
out some general references, such as examples of
a willingness to take stock of neuroscienti c
research in its relations with the world of music, it
is worth mentioning speci c works. In the late
1970s, Macdonald Chritchley (1900–1997) and
Ronald Alfred Henson (1915–1994) edited the
book entitled ‘Music and the Brain’ [3]; this was
an original collection of 24 essays in chapter form
in which neurology, psychology, anatomy, neuro-
physiology, neuropathology, psychiatry, otorhino-
laryngology were integrated in correlation with
music. The idea for such a volume was conceived
at the Neurology Congress held in Vienna in 1972
[4]. It was only towards the end of the twentieth
century did basic studies become increasingly
neuroscienti c, thanks to technological evolution
in the eld of neuroimaging. We must however,
remember that the aforementioned Mosso, had
experimentally de ned and recorded data on the
relationship between blood ow and brain activity
at the end of the nineteenth century [5]. A series of
scienti c meetings dedicated to the theme
Neurosciences and Music were organized begin-
ning in 2000: the rst, in New York in May 2000,
was dedicated to The Biological Foundations of
Music, forming volume 930 of the Annals of the
New York Academy of Sciences [6]. The second,
81
82
in Venice, in October 2002, with the support of
the Mariani Foundation, covered The
Neurosciences and Music and the proceedings
were published in volume 999 of the Annals of the
New York Academy of Sciences [7].
The above was an attempt to open up the anal-
ysis of the theme to other disciplines, including
biology, and a single brief poster contribution
dealt with the relationship of dementigenic
pathologies, although not in a therapeutic context
[8]. A subsequent meeting, from the same title
(The Neurosciences and Music), took place in
Leipzig in 2005: it was a continuation of the 2002
meeting and the records occupied the 1060 vol-
ume of the Annals of the New York Academy of
Sciences [9]. Functional neuroimaging was
becoming increasingly important around this
time and a round table was dedicated to music
therapy. This was an attempt at conducting a
search for more solid scienti c evidence: it was a
path fraught with dif culty and only the rst few
steps had been taken [10, 11]. What emerged was
an awareness that the evolution of music therapy
would be increasingly directed towards the eld
of neuroscience through a psychosocial model
[12]. In those years, con rming the constant
interest of neurologists, Frank Clifford Rose
(1926–2012) edited the publication of a book
entitled ‘Neurology of the Arts: Painting, music,
literature’ [13] aimed at proposing a classic sys-
tem, in which neurology acted as a kind of cement
in unifying these areas [14]. Over the years, Rose
limited himself more and more to the eld of
music and in 2010 published a similarly oriented
and speci c volume (Neurology of Music, [15]).
Meanwhile, The Neurosciences and Music meet-
ings continued and were enriched by another edi-
tion, held in Montreal in June 2008 and a new
volume (number 1169) of the Annals of the
New  York Academy of Sciences [16].
Neuroscienti c research in the musical eld
could be said to have been instilled with a quali-
tative and quantitative robustness. However, ther-
apeutic application to a wide range of cognitive
disorders remained episodic, albeit very signi -
cant, since it was preconceived as being effective
in cognitive training and rehabilitation [17–19].
The Montreal meeting marked the transition to a
L. Lorusso and A. Porro
greater coexistence of clinical experiences com-
pared to previous meetings, which had favoured
the basic disciplines. This progression, from
basic to applied research (in clinical form),
became ever more evident, and the meeting held
in Edinburgh in June 2011 focused on the peda-
gogical dimension, being dedicated to Learning
and Memory [20]. Despite the prospects inherent
in the development of music therapy, and its
application in different clinical situations (stroke,
autism), the theme of dementia states seemed to
be almost a ‘straw man’. In the fth meeting,
held in Dijon in May/June 2014 [21] the theme of
training and rehabilitation were placed centre
stage. Naturally, the problem of cognitive impair-
ments could not be ignored, and the music ther-
apy problem of discriminating these from other
non-pharmacological interventions emerged
[22]. Cases involving dementia began to be put
forward as evidence [23, 24]. We will return later
to the work of Cuddy, Sikka and Vanstone on the
analysis of the therapeutic choices proposed by
them. Again in 2015, two volumes dedicated to
Music, Neurology, and Neuroscience were pub-
lished by Eckart Altenmüller, Stanley Finger and
François Boller; the rst speci cally addressed
Historical Connections and Perspectives [25]; the
second dealt with Evolution, the Musical Brain,
Medical Conditions and Therapies [26].
Regarding the data that interests us most, as well
as some general or special chapters oriented in
chronological order [27–29] a chapter was dedi-
cated expressly to Music and Dementia [30]. The
need to analyse the existing scienti c literature
on the subject was recon rmed, because the sci-
enti c evidence did not yet appear to be suf -
ciently sound. Also in 2015, a meeting was held
in Milan on Music Therapy and Relationships
[31], which highlighted, on the one hand, the
problems of speci c application [32] and on the
other, the possibilities of greater integration
within the psychology eld [33, 34].
The last meeting of the series The Neurosciences
and Music was dedicated to Music, Sound and
Health, and held in Boston in June 2017 [35], the
theme of dementias seems to disappear again, like
a Karstic river: we therefore feel it useful to stay
speci cally focused on this subject.
8 Opera and Neuroscience: A Historical Approach and Its Relevance Today
8.2 Opera and Neuropsychiatric
Diseases
From the historical viewpoint, the relationship
between music and medicine is evident [36, 37].
However, interest among historians of medicine in
the description of medical aspects in lyrical works
is a recent development [38–43]. While song repre-
sents the particular aspect of many musical works
[44], there are few systematic studies on the thera-
peutic effects it has on different pathologies [45,
46]. Similarly, there are no systematic studies on
the therapeutic implications between opera and
neuroscience [47]. The representation of neuropsy-
chiatric pathologies in opera is a consequence of
the cultural and social changes regarding mental
illnesses, and in particular insanity, throughout
various historical periods [38, 40]. The representa-
tion of madness re ects its cultural context and var-
ies according to the scienti c knowledge of the
time in question. These representations have been
presented since the birth of the melodrama, which
dates back to the seventeenth century and is an inte-
gral part of the historical development of opera.
The rst operatic representations take up the
themes of classical mythology connected to mad-
ness such as: Il ritorno di Ulisse in patria (1640) by
Claudio Monteverdi (1567–1643) and with La
nta pazza Licori (The feigned madwoman Licori)
(1627), un nished and lost, and later reprised by
Francesco Sacrati (1605–1650) with the title La
nta pazza (1641), both libretto works by Giulio
Strozzi (1583–1652). In the seventeenth century,
other musicians composed the similar theme such
as, Marc-Antoine Charpentier (1643–1704),
Francesco Cavalli (1602–1676), Giovanni Legrenzi
(1626–1690), Jean-Baptiste Lully (1632–1687),
Agostino Steffani (1654–1728) (Table  8.1).
Classical works also interest the composers of the
eighteenth century such as, Antonio Vivaldi (1678–
1741), George Frideric Haendel (1685–1759),
Franz Joseph Haydn (1732–1809), Christoph
Willibald Gluck (1714–1787) and the Italian
Niccolò Piccinni (1728–1800) (Table  8.1).
Baldassarre Galuppi (1706–1793), in his opera
buffa entitled Arcifanfano-Re dei Matti
(Arcifanfano-The King of Fools, 1749) deals with
the problem of lunatic asylums [49]. In this period,
83
thanks to sociocultural changes, madness is
charged with new meaning that causes a form of
social fear normally linked to medical conditions
but also to a moral dimension. The disease that
impregnates the soul of fools is linked to exagger-
ated passion that in turn leads to sin, manifesting
itself as a punishment for such excesses. Towards
the end of the eighteenth century, the enlighten-
ment and a new sensibility promoted new
approaches to madness [50].
The melodramatic texts were in uenced by a
classicism, connected a romantic atmosphere as
in The Ephesian Matron (1769) by the English
composer Charles Dibdin (1745–1814), with
Wolfgang Amadeus Mozart (1756–1791), La
nta giardiniera and Giovanni Paisiello (1740–
1816), Nina, o sia La pazza per amore (1786).
These works are also a collaboration with the
commedia dell’arte and therefore they are part of
the comic genre that generally tended to repre-
sent heroines with a mind that was disturbed by
the adversities of destiny. They were also occa-
sions to show off the virtuosity of the protago-
nists of the melodrama, especially if the typical
delirium present is madness. In the following
century, the category of the ‘folles par amour’
became more established as scenes depicting
madness are entrusted to female protagonists,
who have lost their minds after a disillusionment
in love [48]. There are rare examples of madness
caused by remorse due to criminal acts, which
are the prerogative of guilt ridden men, as in
Semiramide (1823) by Gioacchino Rossini
(1792–1868), Gaetano Donizetti (1797–1848) in
L’esule di Roma (1828), Giuseppe Verdi (1813–
1901) in Masnadieri (1847), Verdi also repre-
sents delirium in Nabucco (1842), Don Carlo
(1867) and also in La Traviata (1853) [51].
Completing representations of male madness we
remember the Russian composer Petrovič Modest
Musorgsky (1839–1881) in Boris Godunov
(1869, revised 1872). Another form of insanity is
that caused by external agents that cloud the
mind and are at the base of delusional manifesta-
tions such as: Masaniello, ou La Muette de
Portici (1828) by Daniel Auber (1782–1871),
Vincenzo Bellini (1801–1835) in Il pirata (1827)
and lastly there’s feigned madness as in Pazzi per
84
Table 8.1 Madness in opera
Theme Opera
Classic madness La nta pazza Licori (1627)
(seventeenth century and Il ritorno di Ulisse in patria (1640)
eighteenth century) La nta pazza (1641)
(Refs. [38, 40, 41, 48]) La Didone (1641)
L’Egisto (1643)
Totila (1677)
Atys (1676)
Roland (1685)
Orlando Generoso (1691)
Mèdée (1693)
Orlando furioso (1713)
Orlando nto Pazzo (1714)
Orlando (1733)
Roland (1778)
Iphigénie en Tauride (1779)
Orlando paladino (1782)
Romantic madness The Ephesian Matron (1769)
(eighteenth century and La nta giardiniera (1775)
nineteenth century) Nina, o sia la Pazza per amore (1786)
(Refs. [38, 40, 48]) Anna Bolena (1830)
Woman Gemma Vergy (1834)
Man Lucia di Lammermoor (1835)
Linda di Chamounix (1842)
Il Pirata (1827)
I Puritani (1835)
Étoile du nord (1854)
Ruddigore or the Witch’s Curse (1887)
Semiramide (1823)
L’esule di Roma (1828)
Torquatto Tasso (1833)
Il furioso all’isola di San Domenico (1833)
Maria Padilla (1841)
Nabucco (1842)
Masnadieri (1847)
Don Carlo (1867)
Boris Godunov (1869)
progetto (1830) by Donizetti or the Rossini’
Italiana in Algeri (1813). This is the amorous
madness that imposes itself in the nineteenth-
century scene with a scheme, the so-called scene
of madness, which was well codi ed and recog-
nizable by the public of the time, and set out in
various works like Anna Bolena (1830), Gemma
di Vergy (1834), Lucia di Lammermoor (1835),
Linda di Chamounix (1842) by Donizetti.
Donizetti, also represented male roles in Maria
Padilla (1841), Torquato Tasso (1833) and in the
same year Il furioso all’isola di San Domenico,
which is characterized with conversion disorder
L. Lorusso and A. Porro
Composer
Monteverdi Claudio
Sacrati Francesco
Cavalli Francesco
Legrenzi Giovanni
Lully Jean-Baptiste
Steffani Agostino
Charpentier Marc-Antoine
Vivaldi Antonio
Handel George Frideric
Piccinni Niccolò
Gluck Christopher Willibald
Haydn Franz Joseph
Dibdin Charles
Mozart Wolfgang Amadeus
Paisiello Giovanni
Donizetti Gaetano
Bellini Vincenzo
Meyerbeer Giacomo
Sullivan Arthur
Rossini Gioachino
Donizetti Gaetano
Verdi Giuseppe
Musorgsky Petrovič Modest
represented by hysterical blindness. Continuing
with female madness we can recall other opera
by Vincenzo Bellini, Giacomo Meyerbeer (1791–
1864) and Arthur Sullivan (1842–1900) among
others ([38, 40, 48]; Table 8.1).
Towards the end of the nineteenth century, the
representation of madness lost its romantic charac-
terization to take on a pathological connotation, in
a neuropsychiatric vein, already present in some
works by Donizetti, such as: Lucia di Lammermoor
and Anna Bolena, the author himself suffered from
a form of paralytic dementia. The development of
neuropsychiatry, beginning with the physicians
8 Opera and Neuroscience: A Historical Approach and Its Relevance Today 85

Jean Etienne Dominique Esquirol (1772–1840), 1859), the Tuscan, Carlo Valentini (1790–1853) with
Philippe Pinel (1745–1826) and above all the Il sonnambulo (1834), O sonámbulo (1835) by Luis
founder of neurology Jean-Martin Charcot (1825– António Miró (1815–1853), and later with Der Prinz
1893), profoundly in uenced the neuroscienti c von Homburg (1935) respectively, in two different
progress of the second half of the nineteenth cen- versions by the German composers: Paul Graener
tury, with the various studies on neurosis and on (1872–1944) and Hans Werner Henze (1926–2012)
the de nition of emerging neurological patholo- (1958, new version, 1991) ([41, 52–54]; Table 8.2).
gies [40]. The melodrama absorbed this spread of
new neuropsychological theories and some works
represented patients suffering from neurological
pathologies such as somnambulism, la Sonnambula
(1831) by Bellini (Fig.  8.1), Macbeth (original
version 1847, revised 1865) by Verdi, which were
in uenced by the contribution of the theories of
animal magnetism or mesmerism, of the German
physician Franz Anton Mesmer (1734–1815).
Other works put emphasis on this theme of sleep-
walking such as those of Luigi Alessandro or
Lodovico Piccinni (1779–1850), son of the most
famous Niccolò, author of Sonnambula (1796), by
Ferdinando Paër (1771–1839) with Sonnambula
(1800), both considered amusing as works, the
Berliner Karl Blum (1786–1844) with Die
Nachtwandlerin (1822), Il fantasma (1842) by the
Sicillian Salvatore Agnelli (1817–1874), again with
the same title Il fantasma (1843) by Giuseppe
Persiani (1799–1869). There are also so-called male
versions: Il matrimonio segreto (1791) by Domenico
Cimarosa (1749–1801), Il sonnambulo (1824) by
Michele Carafa (1787–1872), the German, Heinrich
August Marschner (1795–1861) with Der Vampyr Fig. 8.1 Jenny Lind (1820–1887) in La Sonnambula,
(1828), Il sonnambulo (1829) by Luigi Ricci (1805– 1831 (Copyright Wikipedia)

Table 8.2 Sleepwalking

Eighteenth century and nineteenth
century [41, 52, 54] Opera Composer
Woman sleepwalker Sonnambula (1796) Luigi Alessandro or Lodovico Piccinni
Man sleepwalker Sonnambula (1800) Paër Ferdinando
Die Nachtwandlerin (1822) Blum Karl
Il fantasma (1842) Agnelli Salvatore
Il fantasma (1843) Persiani Giuseppe
Il matrimonio segreto (1791) Cimarosa Domenico
Il sonnambulo (1824) Carafa Michele
Der Vampyr (1828) Marschner Heinrich August
Il sonnambulo (1829) Ricci Luigi
Il sonnambulo (1834) Valentini Carlo
O’ sonámbulo Miró Luis António
Der Prinz von Homburg (1935) Graener Paul
Der Prinz von Homburg (1958, Henze Werner Hans
new version 1991)
86
Other neuropathologies in melodrama such as
epilepsy were presented in Ivan IV (1862–1865,
rst performance 1946) by Georges Bizet (1838–
1875), Otello (1887) by Verdi and probably
Pagliacci (1892) by Ruggero Leoncavallo (1857–
1919) [40, 41]. Migraine is presented the already
mentioned, Il matrimonio segreto by Cimarosa,
or headache again in Otello by Verdi and later,
migraine again in L’amore delle tre melarance o
Love for three oranges (Ljubov k trëm apel’sinam)
di Sergej Sergeevič Prokof’ev (1891–1953) in
Siegfried (1876) of Richard Wagner (1813–1883)
who suffered of a migraine with aura [55, 56].
Generally, the most widespread, and easily
diagnosed, neurological diseases of the age are
all represented. The transition to the twentieth
and twenty- rst century with psychoanalysis and
scienti c positivism holds more precise diagnos-
tic-clinical de nitions and the relationships
between doctors and patients and the limits of
medical practice are scienti cally highlighted in
works such as Proko ev’s. The in uence of the
theories of Sigmund Freud (1856–1939) is well
evident in: Salome (1905) and Elektra (1909) by
Richard Strauss (1864–1949) with characters
who have personality disorders in works by the
Czech composer Leoš Janáček (1854–1928)
Kát’a Kabanová (1921) and Osud (1907/1934),
the Austrian composer Schoenberg (1874–1951)
in Erwartung (1924), La cena delle beffe (1924)
by Umberto Giordano (1867–1948). In Wozzeck
(1925), by the Austrian Alban Berg (1885–1935),
apart from psychiatric-related problems, there is
also a description of risk factors relating to stroke.
Subsequently, neuropsychiatric diseases are pre-
sented through well-de ned clinical connotations
based on the progress made in medical and scien-
ti c knowledge. Igor Stravinsky (1882–1971)
with The Rake’s Progress (1951) shows a form of
secondary madness related to tertiary syphilis.
The works, Peter Grimes (1945), The rape of
Lucretia (1946), Midsummer Night’s Dream
(1960), Curlew River (1964) and The Burning
Fiery Furna (1966) by Benjamin Britten (1913–
1976) all show different clinical pictures of
patients affected by psychological disorders [57].
Hans Werner Henze, cited for Der Prinz von
Homburg (1958, revised 1991), in Boulevard
L. Lorusso and A. Porro
Solitude (1952), Elegy for Young Lovers (1961),
Die Bassariden (1966) underlines the con icts
that the progress of society, and related psycho-
logical reactions pose. The result was a demon-
stration of contemporary mental disorders such
as, in Wir erreichen den Fluss (We Come to the
River, 1976) where we see a patient being com-
mitted to a psychiatric clinic affected by a pro-
gressive blindness, this psychological blindness
is widely represented in various lyrical works,
such as Richard Coeur de Lion (1784) by the
Belgian composer André Ernest Modeste Grétry
(1741–1813), Le Deux Aveugles (The two blind
men, 1855) by Jacques Offenbach (1819–1880)
and Opéra d’Aran (1962) by Gilbert Bécaud and
has strong symbolic connotations (1927–2001)
[58]. Again in the eld of psychiatry, depression
in Jakob Lenz (1977–1978) and the con ict
between sexual impulse and hysteria Das Gehege
(La Gabbia, 2006) are presented in works by the
German composer Wolfang Rhim. The English
composer Peter Maxwell Davies (1934–2016),
with Eight songs for a Mad King (1969), the
Swede Livlægens Besøg with The visit of the
Royal Physician (2008), and the German Detlev
Glanert with Nijinskys Tagebuch (2008) deal with
problems related to schizophrenia. There is no
shortage of recent work related to neuroscienti c
problems, such as those of the English composer
Michael Nyman with The Man Who Mistook His
Wife for a Hat (1986), from an adaptation of a
book by the neurologist Oliver Sacks (1933–
2015) that deals with the theme of prosopagno-
sia. Nyman himself, with Facing Goya (2000),
refers to a biological theme between innate and
acquired traits such as craniology or craniometry,
that is, to try to prove if the characteristics of
genius are related to the dimensions of the skull,
as in this case of Goya. The theme is closely
linked to a work, by the Italian, Fabrizio de Rossi
Re, entitled: Cesare Lombroso o il corpo come
principio morale (2001), inspired by the founder
of criminal anthropology and the author of theo-
ries much discussed within and outside the neu-
roscienti c eld. Another widespread
neurological pathology, linked to an increase in
life expectancy, is that of cognitive de cit or
dementia and has been represented at the operatic
8 Opera and Neuroscience: A Historical Approach and Its Relevance Today 87

level: Macbeth by Verdi, Shakspeare’s King Lear,

probably a Lewy form of dementia, which has
been readapted for melodrama by several com-
posers. We can also mention the English com-
poser, William Thomas Moncrieff (1794–1857),
in 1820, with the title of The Lear or Private Life;
the Italian composer Antonio Cagnoni (1828–
1896) in 2009, as a posthumous work, with the
title, King Lear and the German Aribert Reimann
with the title of Lear (1978). In more recent
times, we again see dementia: The Lion’s Face
(2010) by the English composers Elena Langer
and Glyn Maxwell, and Love Hurts (2016) by
Nicola Moro, on the hospitalization for ‘demen-
tia libertine’ by the Marquis De Sade [Donatien-
Alphonse-François de Sade (1740–1814)], who
took part as an actor in theatrical performances
organized by the asylum [40, 52, 59–61].

8.3 Opera, Dementia and Traces

of the Application
of Operatic Music Therapy
The contribution of music in healing was already
known in the ancient world and the classical
period, and especially notable was Apollo, father
of Asclepius, being considered the protector of
Medicine and Music. Various philosophers such
as Pythagoras, Plato and Aristotle emphasized
the effect of music on the psyche, and the body,
for its relaxing and invigorating effects. While
during the Middle Ages and the Renaissance, the
use of music for different psychological effect
was prevalent in its various forms. The birth of
music therapy as a scienti c discipline dates back
to the rst half of the eighteenth century, with the
rst treaty of music therapy written by the
London musician and doctor Richard Brocklesby
[62] (Fig. 8.2). Brocklesby cited the philosopher
Marsilio Ficino (1433–1499) from his
Commentary on Plato supporting the bene t of
music on mental activities [63].
In 1758, another important contribution by the
French physician Louis Roger was the applica-
tion of music in curing various diseases, with a
particular emphasis and effect on mood. He
believed that it must form an integral part of the
Fig. 8.2 Richard Brocklesby’s portrait (1722–1797)
(Copyright The National Library of Medicine,
Washington, USA)
therapeutic approaches being used by various
physicians [64]. Scienti c publications had
already been written in the seventeenth and eigh-
teenth centuries by René Descartes (1596–1650),
Athanasius Kircher (1602–1680) [65] and Franz
Anton Mesmer, the latter was friend of musicians
such as Wolfgang Amadeus Mozart, Christoph
Willibald Gluck (1714–1787) and Franz Joseph
Haydn (1732–1809), and applied the rst experi-
ment of hypnotic suggestion using music. Mozart
in the comic opera ‘Così fan tutte’ (1790) refers
to Mesmerism [66]. Another doctor who had
close contact with the Mozart family was the
Austrian Peter Lichtenthal (1780–1853), who
spent most of his life in Milan, northern Italy [67,
68], he became a close friend of Karl Thomas
Mozart (1874–1858), who also lived in Milan,
and of the whole Mozart family. Although
Lichtenthal did not compose fully comprehen-
sive works for musical theatre, as a physician he
was in a position to come into contact with a wide
range of psychiatric pathologies, which we nd
in some of his ballet works composed for the
88
Teatro alla Scala in Milan [69]. Although still in
a qualitative dimension of the nineteenth century,
the doctor-musician wrote the essay Der musika-
lische Artz (The Musical Doctor) published in
Vienna in 1807 [70] and in his Treatise on the
In uence of Music on the Human Body [71], he
proposed a music therapy analysis in relation to
precise medical nosologies. He identi ed two
broad nosological categories for music therapy:
fevers and chronic diseases: fevers were subdi-
vided into acute and intermittent; chronic dis-
eases into four categories (convulsions and
spasms, illnesses of weakness, pains, mental ill-
nesses). In his historical reconstruction of the
relationship between music and medicine,
Lichtenthal emphasized the coexistence of medi-
cal and musical skills, which have often merged
in the priestly and religious elds since remote
times. He also quoted scene V of Act I of the
Merchant of Venice by William Shakespeare
(1564–1616), to demonstrate the music therapy
dimension:
Since nough so stockish, hard and full of rage,
But musick for the time doth change his nature:
The man that hath no musick in himself,
Nor is not mov’d with concord of sweet sounds,
Is t for treasons, stratagems, and spoils;
The motions of his spirit are dull as night,
And his affections dark as Erebus:
Let no such man be trusted… [71]
This quote by Shakespeare also allows us to
begin to introduce the theme of dementia, since it
can be assumed that the English author also had
in mind the medical aspects of dementia gene
pathologies [72]. Returning to Lichtenthal, he
offers us another incidental quote of great inter-
est, when he refers to the value to public health of
the musical element, attributing it to Johann
Peter Frank (1745–1821), the reformer of public
health in Austrian Lombardy and the Empire. In
fact, the Italian edition of his ‘System einen voll-
ständigen medicinischen Polizey’ [73] was pub-
lished in this period. Although Lichtenthal does
not explicitly propose the use of music therapy in
the context of certain pathologies, which we now
de ne as dementia, he stated the usefulness of
music in the eld of mental illnesses, placing
himself close to the topic of our interest.
L. Lorusso and A. Porro
Lichtenthal’s music therapy proposal is based on
a precise choice of pieces, which takes into
account the characteristics of the patient, their
musical knowledge and integration with other
therapeutic tools. The suggestion is to choose
harmonious, but not too learned, pieces [71]. In
the appendix to his Treatise, Lichtenthal pro-
poses some correlations with the theories of
colours [Isaac Newton (1642–1727) 74] is
explicitly mentioned]: this allows us to broaden
our analysis by correlating it to the physiological
data, and to that of synaesthesia [75, 76]. Here
too, we can nd scientists who have combined
medical and musical characteristics. One thinks
of Carlo Botta (1766–1837) [77] and his work of
1801, concerning the possibility of associating
sounds and colours [78], based on Newton’s
colour theory, and towards the end of the nine-
teenth century, Filippo Lussana (1820–1897):
physician, physiologist, musician [79, 80] who
dealt with the so-called audition colorée [81].
Also in Italy, there were the rst experiments in
mental hospitals in Aversa and Palermo in the
Casa dei Matti, with the participation of patients
in representations based on the commedia
dell’arte with Opera buffa [61]. Remaining in the
nineteenth century, we can see the contribution
of positivism to music therapy by Hermann von
Helmholtz (1821–1894), Karl Stumpf (1848–
1936) and Bernhard Riemann (1826–1866), who
are considered the founders of modern music
therapy. Helmholtz pointed out that parts of the
inner ear are specialized in the analysis of differ-
ent types of sounds [82]. Another scientist, the
US neurologist James Leonard Corning (1855–
1923), conducted a series of experiments in
patients with behavioural and sleep disorders,
during the phase of falling asleep, preferring lyri-
cal works by Richard Wagner and other composi-
tions of the romantic period which were rich in
harmony and contained a predominance of
arpeggiated minor chord [83, 84]. In the twenti-
eth century, in the Anglo-Saxon world, system-
atic research was conducted on the use of music
therapy during World War I for what we now call
post-traumatic stress disorder (shellshock), using
musical pieces that were known to the patient in
such a way as to restore the musical memory and
8 Opera and Neuroscience: A Historical Approach and Its Relevance Today
then allow recovery of other personal memories.
The concept of taking the musical preferences of
patients into account is the cornerstone of music
therapy in the various treatments of diseases, not
and just in the neuropsychiatric eld [85, 86].
The positive effects of music therapy for neuro-
psychiatric diseases lead the US government,
under the Franklin D.  Roosevelt (1882–1945)
and involving the musician Nikolai Sokoloff
(1886–1965), to apply it during the great depres-
sion. The programme, called the Federal Music
Project (FMP), focused on rural and urban cen-
tres. These events were aimed at people of differ-
ent ages and with different disorders, especially
neuropsychiatric in nature, and under the super-
vision of professionals in the medical and musi-
cal elds. The FMP used different musical
genres, including melodrama in its forms of
‘Grand Opera, Operetta, Opera Comics and
Chamber Opera’ [87], that drew out a wide range
of sensations from subjects such as: peaceful,
contented, sad, soothing, happy, exciting, spir-
ited, gay, restless, awesome, uncanny, oppres-
sive, religious, melancholy, love and pleasant
with a ‘tendency of constancy of mental imag-
ery’ [88, 89].
Interest in the results of the application of the
music therapy created the conditions for the birth
of the rst university courses in the subject in
1919 at Columbia University and in 1944  in
Michigan. The foundations were laid for associa-
tions such as the National Association for Music
Therapy in 1950, and later in 1970 and maga-
zines dedicated to the results of the application of
music therapy in various medical contexts, such
as the Journal of Music Therapy, in 1964 [90].
Awareness of the close relationship between the
two disciplines spread with the use of this type of
therapeutic approach to various neuropsychiatric
pathologies [37, 91]. Different studies have high-
lighted the role of classical music in the treatment
of various diseases, showing how the music com-
posed by Bach, Mozart and Italian composers is
the most powerful in ‘treating’ patients [85, 92–
94]. There are few studies on the bene t of melo-
drama in medicine, despite the musical effects on
the emotional component and changes at the
encephalic level, especially among lyrical singers
89
[95–97]. An interesting study, con rming the
previously mentioned data, was conducted by
Bernardi et al. on 24 young healthy subjects. The
sample consisted of: 12 musicians (choristers)
and 12 non-musician control subjects, who lis-
tened (in random order) to music with vocal
(Puccini’s ‘Turandot’) or orchestral (Beethoven’s
ninth Symphony adagio) progressive crescendos,
more uniform emphasis (Bach cantata), 10-s
period (i.e. similar to Mayer waves) rhythmic
phrases (Giuseppe Verdi’s arias ‘Va pensiero’ and
‘Libiam nei lieti calici’), or silence, while heart
rate, respiration, blood pressure, middle cerebral
artery ow velocity and skin vasomotion were
recorded. Common responses were recognized
by averaging instantaneous cardiorespiratory
responses regressed against changes in music
pro les and by coherence analysis during rhyth-
mic phrases. Vocal and orchestral crescendos
produced signi cant correlations between cardio-
vascular or respiratory signals and music pro le,
particularly skin vasoconstriction and blood pres-
sure, proportional to crescendo, in contrast to
uniform emphasis, which induced skin vasodila-
tion and reduction in blood pressures. Correlations
were signi cant both in individual and group-
averaged signals. Phrases at 10-s periods by Verdi
entrained the cardiovascular autonomic variables.
No qualitative differences in recorded measure-
ments were seen between musicians and non-
musicians. These ndings helped advance our
understanding of how music can transmit emo-
tions and how it could be used to induce or
enhance speci c cardiovascular responses in
various elds, from physical training to recovery
from stroke [98]. For such effects on the auto-
nomic nervous system, at a subconscious level,
music can provide bene ts both in physiological
conditions, improving some different psycho-
physical performances. Some studies have shown
that by using the melodrama, performed in the
scholastic and academic eld. The participation
in performing, hearing and evaluating genres on
music has an effect on analysis, evaluation and
perception [99–101]. Another aspect is the ability
of music, including opera, to overcome social
and ethnic differences, between people of differ-
ent cultural backgrounds, succeeding in increas-
90
ing the awareness and adaptation to new artistic
languages with age, as reported by two articles
regarding elderly Chinese immigrants in Australia
[102, 103]. The effects of music would not have
signi cant differences, as an emotional response,
in normal and pathological subjects such as
schizophrenic patients, in a study by a Brazilian
researcher [104]. Based on these assumptions,
studies have begun that have introduced the use
of the therapy in various diseases such as, cancer
[47] and in patients with conscience disorders,
including those in a state of coma [105]. Studies
on dementia patients prove to be more detailed
and interesting, despite contradictions and uncer-
tainties, and show that the value of music therapy
in the case of dementia [106] seems to have
assumed a totally digni ed position [107].
However, from a general historical viewpoint, we
are interested in examining whether there is a
speci c role of opera in this context. Some recent
contributions have underlined the connections
with neuroscience in this particular musical eld
[40] and have also witnessed a more general revi-
sion of the issue of a medical presence in the
operatic eld [108]. In the latter case, a medical
presence was recorded in 53 works. The produc-
tions of Giuseppe Verdi stand out, represented
with nine works in which doctors and/or patients
appear [108]. In this regard, instead of the rela-
tionship between opera and pathologies from the
neuroscienti c eld, we can identify the presence
of dementia, epilepsy, headache, migraine, sleep
disorders, spinal pathologies, stroke and at least
40 representations of female insanity [40].
Usually, the world of the opera has been investi-
gated through the analysis of the problems of the
artists [109], or also of the operatic element as a
speci c pathological data, as in the case of hal-
lucinations [110]. In some cases the effective
interaction of operatic pieces (La Traviata) with
the immune system in the experimentation of
allografts was assessed [111]. The creation of a
rock opera has also been proposed as a training
vehicle in the biomedical eld [101]. The thera-
peutic use of speci c operatic pieces appears
instead to be a chimera: the attestation of the use
in music therapy of speci c operatic pieces in the
treatment of dementia is rare, and often it is char-
L. Lorusso and A. Porro
acterized by the insertion of the selected pieces in
the category of known music. This presupposes
that the patient was familiar with operatic pas-
sages in the past. The aforementioned work by
Cuddy, Sikka and Vanstone [23] proves to be par-
ticularly interesting for our discussion, because it
focuses on the preservation of musical memory
in healthy elderly people and in Alzheimer’s
patients. Can music evoke autobiographical
memories? The results of two studies conducted
by Canadian researchers con rm this possibility
in patients with Alzheimer’s disease. The useful-
ness of the re-evocation of positive autobiograph-
ical memories through music, as a therapeutic
tool, is evident. However, we are interested in
focusing on which music can be chosen, and
whether there are operatic tunes within a thera-
peutic music range. Here we come into contact
with a general problem concerning the character-
istics of universality typical of certain musical
pieces, compared with the speci c musical con-
text of reference and the passages of the local
musical culture. We must not forget that this can
in uence choice. Among the materials associated
with Cuddy, Sikka and Vanstone [23] was a list of
standardized musical pieces used in their experi-
mentation. These included 31 tracks of instru-
mental music lasting 30 s for a study related to
patients with Alzheimer’s disease. The pieces
were by Aram Ilyic Khachaturian (1903–1978),
Antonio Vivaldi (1678–1741), Glenn Miller
(1904–1944), Luigi Boccherini (1743–1805),
Paul Dukas (1865–1935), Pyotr Ilyich
Tchaikovsky (1840–1893), Werner Thomas,
Ludwig van Beethoven (1770–1827), Johann
Strauss II (1825–1899), Richard Wagner (1813–
1883), as well as a piece of traditional Irish music
and one of Mexican folk dances. The Beethoven,
Strauss and Wagner passages were used exclu-
sively for this branch of experimentation, while
the other nine were also used in the other branch,
made up of young and cognitively intact senior
citizens. Among the 12 pieces mentioned, the
only one pertaining to operas (Treulich Gefürt) is
from Wagner’s Lohengrin (1850). In experimen-
tation related to cognitively intact subjects, opera
music by Rossini and Bizet appear as excerpts
from the Ouvertures from Il Barbiere di Siviglia
8 Opera and Neuroscience: A Historical Approach and Its Relevance Today
(The Barber of Seville, 1816) and La Gazza
Ladra (Thieving Magpie, 1817) and as the suite
from Carmen. If we focus on the operatic pas-
sages, it should be highlighted that in the study
by Cuddy, Sikka and Vanstone [23] song does not
appear: this is a speci c choice so as to avoid
interference from the text. In fact, as mentioned
by some Canadian authors, in previous studies by
Janata, Tomic and Rakowski [112] performed on
young cognitively intact subjects, musical and
vocal pieces of various kinds were used.
Therefore operatic pieces do not seem to be
excluded among the music therapy instruments
where cognitive de cits are concerned, but with
the caution as mentioned above.
8.4 Conclusions
Despite the lack of interest in the role opera ther-
apy has had, from the historical point of view, a
certain importance in the practice of music ther-
apy exists in recent studies that try to emphasize
its most complete effects. Opera provokes an
emotional participation because, compared to
other musical genres, it is all encompassing from
a physical and psychic standpoint.
Neuropsychiatric pathologies are the main disor-
ders subject to experimentation, this has been
con rmed by the creation of associations, espe-
cially in Anglo-Saxon countries, which are dedi-
cated to the use and application of the melodrama.
We will need more studies to better understand
which operas are more effective in which dis-
eases. Opera therapy will be simply another form
of art that can provide an improvement and relief
in the treatment of patients’ suffering.
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 Cinema and Neurology:
From History to Therapy
Lorenzo Lorusso and Simone Venturini
9.1 Introduction
The neurologist, and by extension the entire eld of
neuroscience, uses direct observation during the
patients’ examination, and instrumental observa-
tions such as brain visualization techniques are the
principal semiotic tools in clinical practice or in bio-
medical research. Mediated observation in clinical
and laboratory environments (using devices and
imaging techniques) is not such a recent phenome-
non and has been part of neurological practices
from its onset as a scienti c-discipline.
In particular, in medicine, anatomy, physiol-
ogy and clinical areas, iconographic sources have
always played an important role in understanding
the development of scienti c knowledge.
Visualization techniques and visual evidences
have been fundamental for science and medicine
since the Renaissance and have undergone sev-
eral transformations in the last two centuries,
contributing to the establishment of speci c pro-
tocols of observation [1].
Modern neurology, between the second half
of the nineteenth century and the beginning of
the twentieth century, was modelled and estab-
L. Lorusso (*)
Neurology Unit, Neuroscience Department,
ASST-Lecco, Merate, Italy
S. Venturini
Dipartimento di Studi umanistici e del patrimonio
culturale, Università degli Studi di Udine,
Udine, Italy
© Springer Nature Switzerland AG 2020
B. Colombo (ed.), Brain and Art, https://doi.org/10.1007/978-3-030-23580-2_9
9
lished in contact with optical media [2] such as
photography, cinematography and other
‘mechanical’ tools. Neurology progressed along
with the other sciences, evolving during positiv-
ism with its own speci c moral and disciplinary
ideals embodied in concrete apparatuses of visu-
alization, learning, analysis and evaluation of the
observed phenomena. In other words, every sci-
enti c observation has its own history [3]. At the
beginning of the nineteenth century, the relation-
ship between observation and scienti c experi-
mentation took a turn. The direction changed to a
moral distinction between the subjectivity of
observation (and therefore the fallacy of the cog-
nitive premise) and the objectivity of the experi-
ment, towards the reception of an observation
that was either completely open or carefully
stripped of all previous knowledge and compe-
tences. This resulted in the recording of phenom-
enal data as objectively as possible. The epistemic
virtue inherent in the paradigm of ‘mechanical
objectivity’ [4] is thus found in the origins of
nineteenth-century physiological thought which
was devoted to mechanical and automatic record-
ing [5]. This echoed the words of the father of
modern neurology, Jean- Martin Charcot who, to
reclaim the immediacy and objectivity of his
observation techniques, appealed to the photo-
graphic process: ‘I register what I see […] I am
not inventing, because I take things for what they
are, I photograph them’ [6]. It is thus essential to
trace the correlated development of disciplines
like neurology along with cinematic devices
95
96
such as chrono-photography and cinematogra-
phy to the roots of physiology or rather, to the
study of movement of humans and other living
beings and speci cally the recording and analy-
sis of motion. In particular, it is necessary to
place them in the wake of a search for a standard-
ization, and uni cation of scienti c methods
such as that found in Marey’s Institute of
Physiology, which was a rst in attempting the
above at the beginning of the twentieth century.
More generally, historical and epistemologi-
cal studies on movement have found a common
root in the mechanical principles applied to the
human and animal body with the arti cial repro-
duction of movement and therefore in automatic
locomotion from the late seventeenth century
onwards [7, 8]. In this way, chrono-photography
and cinematography are prismatic apparatuses
that allow for a new clearer understanding, as
modern technical media, artistic and cultural
environments and scienti c research enter into
competition and intertwine with each other.
Instead, when we look at the above in perspec-
tive, that is to say, the transition of positivist sci-
ence towards the twentieth century, it is
increasingly dif cult to clearly isolate disciplin-
ary practices from others. Especially at the turn
of the last century, ‘the truly critical and problem-
atic inheritance of nineteenth-century positivism
was in fact the real cultural and ideological koinè
that united a scienti c community in a shared
epistemological horizon. A community of schol-
ars from different backgrounds (physiology,
early experimental psychology, the even younger
criminal anthropology, forensic medicine, neu-
rology, psychiatry, biology, etc.) […] aimed in
one hand to create dialogue between knowledge,
while on the other were engaged in a erce battle,
including academic, for the legitimization or
strengthening of their autonomy’ [9]. Thus,
between the nineteenth and twentieth centuries,
chrono-photography and cinematography were
part of an epistemic and pragmatic apparatus
aimed at the recording, analysis, visualization,
validation and dissemination of results. The ideal
of an objective recording embodied by photogra-
phy was articulated in the experimental and clini-
cal pragmatics in an environment ‘inhabited’ by
L. Lorusso and S. Venturini
different agencies: together with scientists, the
‘instruments’ (such as chronophotographic and
cinematographic devices) acted as ‘participants’
or active subjects of change in the elds of physi-
ology, psychology, life sciences, anthropology,
social sciences and philosophy.
Visualization techniques and technologies
did not, therefore, ful l a pure prosthetic or
instrumental function: ‘technologies are not
mere exterior aids but also interior transforma-
tions of consciousness’ [10]. In other words,
technical media proved to be equipped with
their own modelling, interactive and performa-
tive forces [11].
Similarly, neurological iconography is not an
objective expression of what one observes, but
the result of transformations of the visual evi-
dences initially recorded along several appara-
tuses and media. The ‘rise of objectivity did not
eradicate other epistemic forms’ [12] and
between the nineteenth and twentieth century,
neurology and psychiatry employ different visu-
alization techniques and practices, some with a
long tradition, such as etching, others, such as
cinematography, are rather more recent with
often surprising effects and mutual in uences in
connected artistic and cultural elds. Between
the late nineteenth and early twentieth century,
cinematography—highlighted by the positivist
belief of recording data and documents and the
modern belief in the superiority of the new
medium [13]—worked in synergy with other
visual media such as artistic and anatomical
drawing, illustration, engraving and photography.
During this period, cinema acted as a key compo-
nent of a wider ‘discursive network’ [2] or rather
as a set of institutions, technologies, discourses
and clinical practices. Furthermore, from their
inception, chrono-photographic and cinemato-
graphic devices and apparatuses were ‘as much a
technology of movement as a method of repre-
sentation’ [14–16].
The study of the use of cinematic media thus
establishes a privileged perspective for the fram-
ing and understanding of a broader ‘cinematic
scienti c apparatus’ [14] aimed at experimental
scienti c observation. A ‘cinematic method’ of
science [17] associated with the emergence of a
9 Cinema and Neurology: From History to Therapy
‘homo cinematicus’ [18, 19] was inseparable
from the development of life sciences and mod-
ern visual cultures.
The rst aim of this chapter is to outline the
historical and cultural conditions that have con-
nected the cinematographic medium and neuro-
sciences between the late nineteenth and early
twentieth centuries. Perspectives from both clini-
cal and therapeutic points of view and educa-
tional and didactic scope will also be looked at.
Secondly, the aim is to map seminal experiences
in the use of cinematography in the neurological
eld and ultimately to deal with some speci c
experiences and application lines, such as the
therapeutic use of cinematography and moving
images in the eld of sciences of the mind. A his-
torical study of the relationship between cinema-
tography and neuropsychiatric disciplines
represents an opportunity to reiterate ‘the impor-
tance of history in the training of neuroscientists’
[20]. It also gures as a contribution to achieve an
‘archaeological’ [21] and ‘media-archaeological’
[22] gaze on speci c aspects of contemporary
identities, shaped by historical neuropsychiatry
and media and technical innovations. If it is true
that the entire spectrum of medical-scienti c dis-
ciplines have been engaged and in uenced by
modern technical media, and more generally the
application of technological innovations, then
neurology and neuropsychiatry, in particular,
were the rst disciplines capable of incorporating
and widely using the new cinematic media in
their experimental practices and their visual
cultures.
9.2 From Chrono-Photography
to Cinematography
Beginning in the mid-nineteenth century, the
rst applications of graphic and photographic
time-based devices (myography, chronography,
pneumography, chronophotography and cinema-
tography) for recording and analysis in the eld
of human and animal physiology, proved useful
in xing and measuring the movement of various
organs. This was done by recording their various
activities, such as heart rate in various physio-
97
logical conditions or the movement of other vari-
ous parts of the body under the in uence of the
sense organs. The use of chrono-photography in
the physiology of human and animal movement
followed its application to observe and study
various pathological conditions, in particular in
the neuropsychiatric eld. While it was at the
end of the nineteenth century, cinematography
would ful ll this function [23, 24].
During the late nineteenth century, scientists
working in both America and in Europe sensed
the potential of chronophotographic image for
the study of subjects suffering from psychiatric
and neurological pathologies. Pioneering this
was the research conducted in the United States,
in Philadelphia, by the neurologists Francis
Xavier Dercum (1856–1931), in collaboration
with the Anglo-American photographer Edward
Muybridge [25–27] along with Theodore
Weisenburg [28] and Walter Greenough Chase in
Boston [29].
In 1885, Dercum, in collaboration with
Muybridge produced the rst applications of
motion pictures of neurological disorders ([25–
27, 30]). As Lanska states, patients come from
Dercum’s own clinical practice and ‘from the
practices of colleagues, including Mitchell,
Pepper, Wood, James Hendrie Lloyd (1853–
1932), and Charles Karsner Mills (1845–1930)’
[27]. Thanks to the apprentice spent beside
Muybridge, Dercum reached the aim to record
through the chrono-photographic apparatus
some of the rst neurological disorders ever
lmed: ‘[At] my request, [Muybridge] photo-
graphed for me quite a large number of patients
both from the nervous clinic of the University
Hospital, of which I was then the chief, and also
quite a number of patients from the Philadelphia
Hospital’ [31]. The neurological cases (included
in Volume 8 of Muybridge’s Animal Locomotion)
comprise collectively 592 separate images on 22
plates of 20 subjects, with 12–47 images per
plate [27, 32, 33].
Lanska in his paper on Dercum wrote that the
majority of these photographic plates concern
various pathologic gaits (18 plates of 18 sub-
jects), usually of men (14 plates of 14 subjects).
Three of the subjects with pathologic gaits due
98
to neurological conditions were partially clothed
(two females and one male), but the rest were
nude. There were also several cases of abnormal
gaits related to non-neurological conditions
such as amputations, scoliosis and morbid obe-
sity. Dercum was able to graphically represent
the trajectories of different body parts during
ambulation and then to compare these trajecto-
ries with normal and abnormal gaits. He noted
that with the normal gait: ‘It is seen at a glance
that this curve [of the trajectory of the lateral
malleolus as viewed from the side] is made up
of a number of elements’ [25, 26]. Among the
Dercum-Muybridge sequences of pathologic
gaits, ‘the most common diagnosis was locomo-
tor ataxia’. Followed by spastic gaits that
includes cases of hemiparesis, quadriparesis and
paraparesis [27]. Moreover, ‘Dercum noted that
sequential photography allowed a more careful
analysis of a sequence of movement than was
possible with visual observation’ [25–27]. In
1910, Dercum was invited by the founder of the
Lubin Manufacturing Film Company, Sigmund
Lubin (1851–1923) to update the Dercum/
Muybridge locomotion study of nerve disease
by using the latest motion picture technology.
The neurologist accepted and he proved enthu-
siastic about the result: ‘The life motion cam-
era has superseded the old battery of camera
used by Muybridge and is far more effective.
These pictures that are being made by Lubin
[…] are of the immense bene t to the medical
fraternity’ [34].
In Europe, during the same period, the French
physiologist Étienne-Jules Marey (1830–1904),
author of fundamental texts for the study of
dynamic phenomena and organized movement
[35, 36], conceived and created the rst chrono-
photographic instruments. In 1882, in the Bois de
Boulogne, near Paris, Marey was able to build the
Station Physiologique [37, 38], established
thanks to funds approved in December 1881 by
the IV Commission for Public Instruction of the
Municipal Council of Paris together with nanc-
ing from the Ministry of Education and War. The
Station assumed as reference models other insti-
tutions and devices dedicated to observation and
experimental study, in particular zoological.
L. Lorusso and S. Venturini
Marey brought the study of movement in
physiology to the fore, and this happened through
his graphic method that led to an ‘external’ non-
invasive, and not necessarily, visual approach in
didascalic-reproductive terms [39]. This carried
out through instrumental analysis of the body and
then a review of instruments originally used in
the vivisection of the organic stasis of the physi-
ological body [35, 40]. Thanks to the systematic
application of the graphic method—starting from
the works of Muybridge and using the collabora-
tion of Georges Demenÿ (1850–1917)—the
French physiologist experimented with different
chrono-photographic tools such as the photo-
graphic ri e and, later, chrono-photography on
xed plates and sensitive lm [41].
Marey and Demenÿ drew important conclu-
sions from their studies on human gait. For exam-
ple, they recognized that a slow pace always
occurs with a lengthening of the joints: the per-
son stretches the knee with force and, with as
much energy possible, rests the heel on the
ground [42]. The study of dynamic phenomena,
and in particular of the physiology of movement,
led Marey to collaborate, not only with the future
pioneer of cinematography Demenÿ, but also
with Charles-Émile François-Franck (1849–
1921). Later he was to collaborate with others
such as Lucien Bull (1876–1972), Pierre Nogues
(1878–1961) and Joachim-Léon Carvallo (1869–
1936) [43]. In 1901 [44], Marey created his own
institute where he included the application of cin-
ematography in carrying out his research [45].
He also collaborated with the medical researcher
and photographer Albert Londe (1858–1917),
working at the Salpêtrière Hospital, in Paris [46],
where, since 1875, the founder of neurology,
Jean-Martin Charcot (1825–1893), with the col-
laboration of Désiré-Magloire Bourneville
(1840–1909) and Paul Regnard (1850–1927),
introduced photography for the study of the phe-
nomenon of hysteria [47]. For Charcot, photogra-
phy was an ‘experimental procedure (a laboratory
tool), a museological procedure (scienti c
archive) and a teaching method (a tool of trans-
mission)’ [6]. During the 1880s, Albert Londe,
skilled in the new silver bromide dry emulsion,
reorganized photographic services in a modern
9 Cinema and Neurology: From History to Therapy
laboratory using more new technologies. In 1883,
by modifying his photographic camera and using
commercial photographic plates he created a
nine-lens photo-electric device that worked as
sequential photography, and this was inspired by
the work of Muybridge and Marey [5]. Ten years
later, he built an open-space station, similar to the
Marey’s, to investigate and develop a larger
12-lens camera (1893).
From the end of the nineteenth century to the
1920s, the use of cinematic media and moving
images had spread into different medical elds,
such as cardiology, neurology, psychiatry, sur-
gery and otorhinolaryngology with different
technical improvements and con gurations
applied in various European institutions. Also at
the beginning of twentieth century, the surgeon
Eugène-Louis Doyen (1859–1916), with a keen
interest in cinematography, microcinematogra-
phy, stereoscopic lm and photography, pro-
duced several lms, documenting surgical
operations. These included, craniotomy, abdomi-
nal hysterectomy and, in 1902, the famous sepa-
ration of conjoined twins, Doodica and Radica,
connected at the xiphoid area of the sternum
(Séparation des sœurs xyphopages Doodica et
Radica) [Separation of sisters xyphopages
Doodica and Radica] [48, 49].
Another important development was the appli-
cation of moving images in studying the invisible
or unseen parts of the body, following the discov-
ery of X-ray by Wilhelm Röntgen (1845–1923)
and the ‘ultramicroscope (also called black-
backdrop microscope) that was created by the
German optical company, Zeiss’ [50].
Initially, microphotography used only single
images and micro-cinematography recordings
were applied by Charles Émile François-Franck
(1849–1921) at the beginning of the 1900s,
developing one single and continuous image
sequence [51]. As Landecker states, ‘early
micro-cinematographic lms simultaneously
used the lm camera to investigate the properties
of living things and used these life science
experiments to investigate the properties of the
new medium of cinema, particularly its temporal
characteristics’. In this way, innovative analyti-
cal techniques, that joined together early life sci-
99
ences and early cinematography, were
‘generative simultaneously of theories of life
and theories of lm’ [52].
Marey’s pupil and successor François-Franck
enhanced his micro-cinematography application
by introducing slow combustion in the form of a
mixture of magnesium as a light source (1907)
and began to apply the grapho-photographic (or
grapho-photocinematographic) procedure that
allowed for a vision of an organ in movement
and, at the same time, a graphic recording of its
activity (1904). The experimental setting of
François-Franck’s ‘grapho-photocinematographic’
procedure is emblematic of what Cartwright [14]
and Curtis [17] have written on combined battery
or mix-media use of cinematography in others
tools and technical media. Graphic, photographic,
and cinematographic techniques were frequently
used together by physiologists and neurologists
to investigate, measure and document speci c
phenomena [53]. The ‘grapho-photocinemato-
graphic’ method employed the simultaneous
lming of a sequence of moving images along
with the graphical curve recording of the changes
in the state of the organs being analysed [54].
In 1904, a well-known article (Application de
la methode grapho-photographique a l’étude des
re exes téndineux chez l’homme et chez les ani-
maux) aimed to study the tendon re ex in a dog,
François–Franck used and ‘represented’ myo-
graph, kymograph, chronograph and the cinemat-
ograph itself at the same time and in the same
iconic ‘frame’ [55]. Differently to Cartwright,
who analysed this setting in a bio-political and
Foucaultian sense, here we can highlight how
cinematography remediated [56] other graphical
tools, or rather, how the lmstrip and lm frames
reproduced by François–Franck show a eld of
media forces embodied by different techno-
scienti c media committed in an intermedial
competition between different reading (and writ-
ing) practices [57].
Among the different medical sciences, psy-
chiatry and neurology were the medical elds
that rst cooperated with cinematography [38,
58, 59]. Starting from the experiences of Paris in
‘medical-surgery cinematography’ [42, 50, 60]
and in particular the Paris Pitié-Salpêtrière and
100
Bicêtre, other major centres and individual neu-
rologists across Europe gradually established a
scienti c-disciplinary network of great interest to
scienti c, cultural and visual modernity at the
end of the nineteenth century and up to the 1930s.
At the cusp of the nineteenth and twentieth centu-
ries, Charcot’s pupils, such as Joseph Babinski
(1857–1933) and Pierre Marie (1853–1940),
understood the importance of recording moving
images in a clinical environment, supporting
their use and dissemination. In turn, these stu-
dents had gathered their collaborators and pupils
who were interested in using lm in their
research.
Initially, at the end of the nineteenth century,
the rst European applications of motion pictures
in neuropsychiatric elds were performed in a
few countries. Since 1898, Gheorghe Marinescu
(1863–1938) of Bucharest, a former student of
Charcot, had been undertaking thorough cine-
matographic studies on normal gait, followed by
organic hemiplegia, hysteric hemiplegia, paraple-
gias, progressive locomotor ataxia and myopa-
thies. He also studied various movement disorders
(Parkinson’s diseases, chorea, athetosis, cerebel-
lar ataxia and dystonia). He was probably the rst
to go beyond a single recording of a clinical case,
using the cinematographic camera to follow the
course of the disease and also to record therapeu-
tic applications. He was surprised at the wealth of
‘absolutely new facts’ which careful analysis of
the lms revealed to him. This kind of a ‘discov-
ery shock’ [4] provoked by the results of a photo-
graphic sequence recording of a dynamic
phenomenon, was similar to that experienced by
the English physician Arthur Mason Worthington
(1852–1916) a few years before, by recording for
the rst time, through high-speed photography, a
splashing liquid drop [61].
Marinescu also used these lms to train his
students, and his works between 1898 and 1902
remain an important contribution to clinical neu-
rology and an example of the application of cin-
ematographic technology to neuroscience
[62–64]. Marinescu’s original lms are cata-
logued in the Romanian National Film Archive in
Bucharest together with their reprocessed
versions.
L. Lorusso and S. Venturini
In 1898 in Paris, the Polish photographer and
cinematographer, Bolesław Matuszewski, pub-
lished two pioneering essays that highlight, like
Worthington and Marinescu, the ground-breaking
nature of the new medium: Une Nouvelle Source
de l’Histoire and La photographie animée [13,
65]. Matuszewski’s ‘animated photography’
becomes a new source for history and a time-
based recording medium shaped by instantaneous
photography to be used for historical, archival
and analytical purposes. Following Matuszewki,
not only did it allow the viewer to examine both
the instant and the duration (extending, therefore,
the researcher’s analytical possibilities), but
thanks to the multiplication of the images scat-
tered in a long sequence of frames it is physically
much more dif cult to counterfeit when com-
pared to photography: ‘animated photography’ is
a gift of ‘authenticity, accuracy and a precision
belonging to it. It is the true and infallible eyewit-
ness’ [13]. Cinematography had hence a double
value. On the one hand, it is evidence, because
the recorded images, based on the photographic
indexical process, are without ‘mediacy’ testify-
ing how things have gone. On the other hand,
‘animated photography’ is also an instrument,
because it technically enhances—through poten-
tial space and time manipulation: slower, faster
and closer—the possibilities of human senses.
Furthermore, in the oscillation between evi-
dence and tool, like still photography, ‘animated
photography’ is the result of a multi-layered
labour-process that suspends cinematographic
technology between the ideal of a mechanical
objectivity and the pragmatics of image produc-
tion processes [66].
The ‘animated photograph’ belongs at the
very beginning to a speci c genealogy, although
it adds, as we will see later, more speci c quali-
ties such as time synthesis and duration. As rec-
ognized by Marey himself, Matuszewski’s
intentions were an extension of the chrono-
photography: ‘Mr. Matuszewski wants
Chronophotography to study and reproduce the
various phenomena of nervous diseases, to share
the reproduction of vivisections by recording
them once and for all, and to present to the
apprentice surgeons models of operations
9 Cinema and Neurology: From History to Therapy
extraordinarily performed by a master’ [67].
Following Marey’s tradition of graphic method,
photography and specially ‘animated photogra-
phy’ ‘looked’ as a sort of right compromise
between the mediation of the language and the
immediacy of the senses [6].
On the basis of lost lms shot at the St.
Petersburg and Warsaw Hospitals in 1897 and at
the Saint-Antoine and Pitié Hospitals in Paris
during the spring of 1898, where Matuszewski
recorded different patients suffering from neuro-
logical pathologies in collaboration with neurolo-
gists such as Gilbert Ballet (1853–1916), Édouard
Brissaud (1852–1909) and Joseph Babinski, it
appears he envisioned the use of cinematographic
recording in medical sciences [18, 19, 30, 68]. He
also assigned a special focus to neurologic appli-
cations: ‘Beginning in May 1897, in hospitals of
St. Petersburg and Warsaw, I recorded on lm-
strip the course of some important operations as
well as motor manifestations in persons affected
with nervous or mental diseases’ [65].
In Germany, two physicians were pioneers of
the use of cinematography in neurology, the rst
was Paul Schuster of Berlin, who recorded neu-
rological disorders and presented his recordings
before the 1897 meeting of the Society of
German Scientists and Physicians. Schuster’s
lms showed patients with paralysis agitans,
myoclonus, hemichorea, ataxia, spastic paresis,
hemiparesis and multiple sclerosis and
Romberg’s sign. In his accompanying paper,
Schuster emphasized that the use of lm tech-
nology was at the beginning, indicating the great
future possibilities, not only in neurology but in
all branches of medicine [59]. He had made the
lms in order to be able to illustrate his lectures,
free from the limitations of the case material of
his clinic: furthermore, the lms were designed
to overcome the dif culties of direct observation
in analysing complex situations. However,
Schuster’s attempt at frame-by-frame analysis
was not successful because many of the images
were blurred; apparently, he had not been a stu-
dent of Marey’s papers and did not know that
very brief exposures, for which his camera was
not equipped, were needed to obtain clear indi-
vidual images of rapid movements. Schuster’s
101
lms were important as a rst demonstration of
the teaching value of medical motion pictures
[69, 70]. In Giessen, the neuropsychiatrist Robert
Sommer (1864–1937) invoked Charcot’s and
Richer’s contribution to establish ‘a new stan-
dard of objectivity in neuropsychiatric observa-
tion’. Sommer ‘saw the ability of cinematography
to capture motion gave it a distinctive advantage
over photography’, and circa 1900 he soon inte-
grated it into his techniques of neuropsychiatric
examination and diagnosis, using it to help anal-
yse the movement disorders associated with epi-
lepsy, hysteria and related conditions [18].
In Austria, by 1902, the Viennese Arthur
Schüller (1874–1957) made lms of patients
with nervous gait disorders and showed them the
following year at a congress in Madrid [69, 71].
With an adaptation of Marey’s technique, the
Hungarian neurologist Ernő Jendrassik (1858–
1921) undertook a systematic study of gait in
eight normal subjects and 44 patients with vari-
ous pathological gait disorders. In 1901, he pub-
lished these observations in an extensive paper
[72–75].
9.3 From the ‘Expert Observers’
to the Institutionalizations
of Scienti c and Educational
Films
From the early twentieth century, medical-
scienti c lms in the neurological and neuropsy-
chiatric elds spread throughout Europe. Arthur
Simons in Berlin, Max Nonne in Hamburg, Emil
Kraepelin in Munich, Hans Hennes in Bonn,
Osvaldo Polimanti in Rome, Camillo Negro in
Turin, Vincenzo Neri in Paris and Bologna, Paul
Sainton and André Thomas, Jean-Athanase
Sicard, Édouard Long, Edmond Lesné, Paul
André Chailley-Bert, Jan-Joseph Gournay with
Jean Comandon in Paris, Rudolf Magnus and
Gysbertus Godefriedus Johannes Rademaker in
Utrecht and Leiden, Arthur Schüller in Vienna,
Herbert Campbell Thomson in London, Arthur
Van Gehuchten in Leuven, Tomás Maestre in
Madrid and others, used lm as an innovative
tool for their research (Fig. 9.1). Similarly, in the
102
Fig. 9.1 Cartography of the pioneers in neuro-psychiatric lms in Europe
United States, more projects and experiences
emerged that included, or were essentially based
on, their approach on cinematographic technol-
ogy and its heuristic, documentary and educa-
tional potential (Allen McLane Hamilton, Walter
Greenough Chase, Theodore H.  Weisenburg,
etc.) (Fig. 9.2).
At the same time, the rise of cinema and other
new media (popular literature, illustrated periodi-
cals, phonography, photography, etc.) shaped an
increasingly broad and detailed intellectual and
cultural landscape related to new neuro-scienti c
practices. This also played a crucial role in the
dissemination and knowledge of psychiatric and
neurological disorders as key factors for the
health and identity of individuals. By crossing
European national borders, moving images
allowed the iconography, the signs, the narrative
L. Lorusso and S. Venturini
and symbolic places of neuropsychiatry to spread
in popular culture, while at the same time giving
life to an international scienti c language.
Furthermore, as Lisa Cartwright states, refer-
ring to Marey’s attempt to establish a scienti c,
controlled and standardized method in physiol-
ogy at the beginning of twentieth century, ‘cine-
matography was not a method in itself, but was
one among a range of techniques and instru-
ments. These were to be potentially implemented
within the apparatus for the dissemination of
physiology as an effort to control not only the
living body but also the scienti c study of life’
[14]. Although, cinematography participated in a
wide movement of re ection on living and on
life [76], of recon guration and re-elaboration of
gestures [77] and of the construction of a ‘neuro-
logical gaze’ [78], at the moment of its inception
9 Cinema and Neurology: From History to Therapy
Fig. 9.2 Cartography of the pioneers in neuro-psychiatric lms in the United States
the rst neurological cinematography did not
desire to ‘expose itself’ publicly in extra-scien-
ti c contexts (except in the extreme case of sto-
len lms and the controversies surrounding the
lms of Doyen) [49, 79]. A characteristic of
original medical-scienti c cinematography was,
therefore, to express itself mainly in its own con-
text and in a ‘non-theatrical’ way [80]. Curtis
highlighted how the producer of medical-scien-
ti c cinema was in opposition to the ‘lay specta-
tor’, and was an ‘expert observer’ capable of
taking the technology ‘in their own hands’ [17]
to assemble it, adapt it and set it within techno-
logical, experimental and communicative hybrid
contexts. Downstream, the results of the experi-
mental scienti c observation performed by
means of cinematographic techniques were fun-
damentally directed to the scienti c community.
Nevertheless, neuropsychiatric cinema ‘shares a
passion for the fragmentation of the body as well
as an obsession with physiology and various ner-
vous gestures with the early cinema of attrac-
tions’ [78]. Medical cinematography shows
similarities with ‘cinema of the attractions’ [81]
and its spectacular dimension, sharing narrative
103
and spectacular tropes with it [9, 82, 83]. From
1903, the naturalist and photographer expert in
chrono-photography and microphotography,
Francis Martin Duncan and the Anglo-American
producer and distributor Charles Urban, gave
life to a series of natural science lms ‘The
Unseen World’. Duncan Urban’s work and later,
from about 1908, that of the self-taught natural-
ist and time-critique Frank Percy Smith ‘estab-
lished a gamut of subjects that other lm-makers
repeated’ [12]. The inclusion of medical-scien-
ti c lms in a narrative and pedagogical frame-
work imposed a progressive af rmation of a
specialized, scienti c-documentary genre. Jean
Comandon, unlike other neurologists who
sought collaboration with lm professionals
exclusively for the purpose of accessing the
basic apparatus using the likes of Chase and the
Mutoscope and Biograph Company in 1905;
Wiesenburg and the Lubin Manufacturing Film
Company and Campbell Thomson and Charles
Urban around 1907; Vincenzo Neri, who in
1908, Georges Mendel, Paul Sainton, who
involved Léon Gaumont, nalized his produc-
tion to distribution and made agreements with
104
Pathé, starting from 1909 (de Pastre 2012) going
on to produce an important series of neuropsy-
chiatric lms [51]. In the United States, around
1910, Lubin actively pursued a collaboration
with Dercum. While in Italy, Camillo Negro was
linked to Ambrosio Film in Turin and the profes-
sional and prominent camera operator Roberto
Omegna to realize La Neuropatologia (1908).
The same Doyen collection was sold several
times and was the subject of anthological edi-
tions at the beginning of the 1920s by Gaumont
and Pathé. The use of the cinema as a recording
and analytical medium was anked by commer-
cial production born out of the convergence of
the stable cinematographic institutions, socio-
political interests and reforms of national educa-
tional systems, which all led to the
institutionalization of educational and non-theat-
rical cinema [84]. The rst specialist academic
institutions in universities (such as the Berlin
Charité in 1923) and the rst production houses
dedicated exclusively to the production of edu-
cational lms, such as the Édition française ciné-
matographique (1922) by Jean Benoît-Lévy [85]
were created during the inter-war years. During
these years, the relationship between cinematic
media and neurosciences was re-articulated at
the intersection of the epistemic changes occur-
ring in the disciplinary eld, the rise of new
national and corporate interests and the forma-
tion of new scienti c communities. From a tech-
nological perspective, on the one hand, the
aforementioned introduction of small-gauge lm
formats, the miniaturization of technical appara-
tuses and the wide circulation of technical hand-
books signi cantly eased the contamination of
medical lms with amateur, experimental docu-
mentary cinema and modernist aesthetics; on the
other hand, the photographic and cinemato-
graphic image ushered in a series of long-term
(so far rarely considered) transitions and hybrid-
izations with electronics, such as Harold
E.  Edgerton’s work on strobe photography in
1930s. The surfacing of these new technological
and epistemic paradigms (e.g. the introduction
of electroencephalography after World War II)
would eventually lead to a drastic change in the
conception of medical imaging, as well as some
L. Lorusso and S. Venturini
of the analytical modes and scienti c objects
which are currently in use in medical practices
(e.g. motion tracking techniques). This would
suggest that some cinematic logics and epis-
temic layers inaugurated between the nineteenth
and the twentieth century persist in terms of his-
torical and phenomeno-technical vectors in the
contemporary techno-scienti c scenario, further
emphasizing the relevance of the culture heritage
in question.
9.4 Cinematography, Neurology
and Neuropsychiatry at
the Beginning
of the Twentieth Century
As already seen with photography and chrono-
photography (for Charcot and the Salpêtrière
school) [6, 86], cinematography in the neuropsy-
chiatric sciences of the early twentieth century
took on a triple function: analytical-experimen-
tal, archival-documentary and educational-peda-
gogical. These all embraced both aspects most
closely linked to clinical research and disciplin-
ary strengthening [17, 53, 87] as much as they
did documentary and commercial production, as
in the case of Comandon [88]. However, it would
be wrong to outline a simple genealogy and con-
tinuity of tradition without, at least, brie y look-
ing at the speci cities and connotations
introduced by the new medium. In particular, cin-
ematography, despite the initial insistence regard-
ing its complexity and high costs, showed from
the rst comparative experiences of Londe using
chrono-photographic and new cinematographic
devices, an ef ciency that is hugely more attrac-
tive for those (doctors, scientists) who associated
this characteristic with a certain moral virtue (see
the case of Hennes later). Moreover, cinemato-
graphic technology enhanced the key critical
concepts of synthesis, duration, repetition and the
observation of speci c pathological diseases
(think of the study of re exes by François-
Franck) [55]. It also reframed the experimental
and displaying settings and environments giving
the chance of screening documentary proof for a
wide audience or to capture the neuro-pathologi-
9 Cinema and Neurology: From History to Therapy
cal disease in an everyday setting (e.g. bedside)
with the aid of lightweight cameras and other
devices. It could enhance the duplication pro-
cesses and large scale reproduction, thus allow-
ing for a wide circulation of neurological
iconography all over Europe. This fostered the
archiving and exchanging of clinical cases and
neuropsychiatric phenomena; as described above,
bolstering the character of the new medium as a
technological attraction and highlighting the
closeness with the cinema of the attractions and
af rming itself as a scienti c-documentary genre
and as an agency and object of educational and
health reforms. On this premise, cinema moved
from being a scienti c instrument and object of
curiosity to a medium of mass culture. The spread
of the iconography and neurological and psychi-
atric imaginary, in tandem with the progressive
establishment of the documentary as an educa-
tional scienti c cinema genre, took place between
the beginning of the twentieth century and the
rst post-war period. Rather than preventing
them, it actually encouraged the neurological and
neuropsychiatric disciplines to intensify the use
of cinematographic techniques. This led to the
construction of a network of practices of signi -
cant importance for their disciplinary and histor-
ical-cultural speci city. The timely recognition
of these experiences takes on even more interest
if we consider that historically, and at least until
the early 2000s, ‘much attention has been paid to
the analytics of the movement produced by
Marey within a scienti c framework of chrono-
photography, but little to the later syntheses of
movement within a scienti c framework of cine-
matography’ [52]. The importance of using and
the presence of moving images in itself became
more common in the medical scienti c eld in
the 1910s. For example, in 1911, Robert Kutner
(1867–1913) organized a demonstration of medi-
cal lms at the Kaiserin Fridrich Haus (Empress
Frederick House) with the title ‘Cinematography
applied to the Service of Science’. Kutner [89]
explicitly refers to the importance of cinematog-
raphy, not only for teaching but also for medical
research: ‘the cinematographic lm also allows
the researcher to immerse himself, each time, in
the study of the movement processes, with the
105
process that every time, and for an unlimited
number of visions, takes place before his eyes
exactly like the rst time. For movement, recog-
nizable to the naked eye, the researcher can count
on a second phase of observation of enormous
scope, since cinema offers him the possibility to
study the movement as a whole or each single
phase, to divide it at the same time according to
its functions and to penetrate the intimate of the
propulsive forces and of the mechanics’ [89, 90].
It is therefore within this perspective that we
propose below a panorama of the practices of the
use of the lm in the neurological context up to
the interwar period in North America and Europe.
In the United States, in the early twentieth cen-
tury, the prominent New York neuropsychiatrist
Allen McLane Hamilton (1848–1919), a descen-
dant of Alexander Hamilton, lmed various gait
using a cinematographic camera [14, 29, 30, 91,
92]. In the wake of the progressive spread of
mechanical means of transport and work in
urban, rural and industrial areas, law rms were
requested to handle claims for neurological and
motorial damage caused by machinery [14].
McLane Hamilton used cinematography to sup-
port the study of numerous clinical cases, in order
to distinguish and recognize speci c pathologies
and discern possible fraudulent cases. In 1904, he
published the volume, Railway and Other
Accidents with Relation to Injury and Disease of
Nervous System. A publication used by the courts
and accompanied by explanatory tables, among
which appear some sequences of 35  mm lm
frames (with Edison/Eastman perforation)
obtained from the original lm and used as evi-
dence to illustrate cases of patients lmed on a
neutral background and claiming locomotor atax-
ias and hysterical paralysis [92].
A unique and impressive medical lm produc-
tion strategy was accomplished by Walter
Greenough Chase (1850–1919). In the summer
of 1905, Chase lmed several epileptic seizures,
thanks to the training, lm stock and lming
apparatus offered by American Mutoscope and
Biograph Company. He also referred to the ‘nec-
essary material’ (in other words, the clinical
cases) furnished by the epileptologist William
Spratling, medical superintendent at the Craig
106
Colony for Epileptics in Sonyea of New  York
[29], a modern institution organized to bring
together supervision, health and labour functions
[14]. In order to match the photographic needs of
the lm and camera equipment (light, focus,
duration of the lm stock length) with ‘the most
dif cult form of motion to photograph’, Chase
obtained ‘125 male patients from the in rmary,
assembled in a convenient spot out-of-doors on a
warm summer day. The patients’ clothes were
removed and they were patients covered only
with blankets, so that when a seizure occurred he
could be readily dropped in front of the camera at
the proper focal point, which had been previously
marked. For background I used a large dark
screen’ [29].
Nichtenhauser reported: ‘The camera was set
up in front of a large black screen, and the point
where the head and feet of the patients were to be
placed were marked on the ground so that patients
would appear in focus and within the eld of
view of the camera. As soon as a patient suffered
a seizure, attendants removed his blanket and
placed him within seconds on the marked spot’.
By means of this method, Chase obtained records
of 21 separate seizures, including a patient in sta-
tus epilepticus. In order to follow the motions of
the rising patients after they awoke form their
attack, Chase employed a ‘traveling head to the
tripod’, which was probably some kind of tilting
mechanism. This is a detail of great technological
interest because the motion picture camera of the
time was rigidly attached to the tripod and
remained so for some more years. Subsequently,
Chase lmed a rare case of double nystagmus,
two cases of athetosis and a group of idiots ‘each
with his individual motions keeping time with
music’ [69]. Chase presented his lms in front of
groups of physicians in many parts of the coun-
try. How much they impressed their audience is
vividly expressed in an editorial of the Boston
Medical and Surgical Journal of 23 November
1905, whose author probably had never seen a
medical lm before [30, 69]. He wrote: ‘Only
those who have seen the moving pictures can
appreciate the extraordinary effect produced
upon the observer by the reproduction of an epi-
leptic attack, for example, continuing from its
L. Lorusso and S. Venturini
beginning to its end. Except for those particularly
favoured in this respect, physicians of wide expe-
rience may go for many years without once
observing a complete attack, and even if they
may have the opportunity, the study of individual
movement, the succession of tonic and clonic
spasms, and the remarkable movements of an
automatic sort are lost sight of in the general
excitement. Few physicians could see such a
series of epileptic attack as Chase has been able
to reproduce without learning something of the
disease which neither his previous observation or
his study of textbooks have taught him’ [29, 93].
Chase, in his written reports on the ‘Epilepsy
Biographs’ [14], highlighted his own and the cin-
ematographic apparatus’s ability to depict and
photograph epileptic seizures and more generally
he identi ed perfectly the three scienti c func-
tions embodied by the new medium. Firstly, cin-
ematography permits to obtain several moving
image sequences and ‘recorded a series of 22,500
separate and distinct pictures of epileptic atti-
tudes. Anyone of these may be enlarged sepa-
rately or projected upon a screen, giving an
opportunity to closely study and analyze the fea-
tures any super cial muscles’ (Chase 1906). In
other words, cinematography works as an ana-
lytical method and procedure. Secondly, he
remarks on the ‘educational feature’ offered by
the cinematographic recordings: ‘By the use of
the biograph you have your illustrations at hand
for use at any time in the lecture-room, and can
run them over and over again to make your stu-
dents familiar with the motions. You may explain
time and again to the students the difference
between the motions of a patient in an attack of
chorea and epilepsy’. Thirdly, Chase points out
the documentary and archival function: ‘it is my
ambition to secure a full set of lms descriptive
of all phases of pathologic motion, and I believe
the time will come when each institute of medical
instruction will secure its own set of biograph
lms and interchange with other medical schools’
(Chase 1906; [69]).
Theodore H.  Weisenburg (1876–1934) of
Philadelphia, Professor of Clinical Neurology at
the University of Pennsylvania, carried out one of
the most methodical and extensive uses of motion
9 Cinema and Neurology: From History to Therapy
pictures in neurology and psychiatry during the
early years of cinematography. He began, in
1907, to make lms for the instruction of his stu-
dents thanks to the collaboration with the Lubin
Company and in 1910 with the advice of Dercum.
By 1912, he had, in his words, ‘practically com-
pleted my work in both these elds’ [28]. Through
a 10,000 feet of 35 mm lm recording, he cov-
ered all important functional and organic nervous
system diseases, showing the different types of
gaits, tremors, convulsions, tics, spasms, re exes
and ataxias and physical examination methods
for these conditions: psychotic patients with cata-
tonia, mania and paresis, and the physiognomic
expressions in various mental disorders. Like
Doyen, he held that clinical lms would be most
valuable as a permanent record for future genera-
tions of physicians. He hoped that an exchange
would come about of lms dealing with different
types of the same diseases occurring in different
countries. He prepared papers on rare conditions
with the aid of lms he had taken of patients,
studying them together with the case histories
and specimens. He also saw in motion pictures a
most valuable ‘new means of detection’ and
graphically described the order of appearance,
distribution and extent of the muscular twitchings
in a case of Jacksonian epilepsy, which he could
perceive on the screen but never had been able to
observe with the naked eye, due to their rapidity.
Like Marinescu, 10 years before him, Weisenburg
became so impressed with the neurological
details which the motion picture revealed to him
that he acquired ‘the habit of having all the rare
diseases and some of the commoner signs and
symptoms photographed’ [69]. It appears that the
United States was the country most active in
health education lms and Weisenburg, in his
paper, related ‘as a matter of fact, moving picture
illustrations are already employed by public
health bureaus in different states, notably in
Louisiana, where the head of that department
employed motion picture photography to show
the menace of such disease as small-pox, typhoid
fever, etc.’ [28]. Another important contribution
by Weisenburg was the role of cinema in teach-
ing: ‘To my mind no new development in recent
years for the teaching of medicine is of so much
107
value as the use of moving pictures […] in my
course in nervous disorders to medical students I
now regularly employ these pictures. If, for
example, I wish to discuss epilepsy I rst lecture
on the disease and then show the reel which con-
tains the different types of ts […] Even in the
commoner diseases, such as hemiplegia, diplegia
and the different types of spastic paralysis, etc.
examples of which can always be found in clin-
ics, there is something peculiarly impressive in
their being shown by means of motion photogra-
phy’ [28]. Weisenburg was convinced that motion
pictures could be of equal value in other branches
of medicine. ‘So far as I know’ he said, ‘no
attempt has been made to develop motion pho-
tography in the other specializations but there is
no reason why this should not be done’. This
statement makes it evident that Weisenburg, in
spite of his intensive use of cinematography, had
no information on the motion pictures produced
in Europe. He set up the rst attempt to indicate a
general medical programme; an attempt which
has been repeated from time to time, up to the
present, by other medics in a more methodical
form [30, 69].
In Europe, neuropsychiatry was also at the
foreground of clinical cinematography. From
circa 1904 until the 1920s, lms were made at the
psychiatric clinic of the Munich Medical School.
The psychiatrist Emil Kraepelin (1856–1926),
former head of the department at the University
of Heidelberg moved to Munich in 1904, where
he created a lm studio in his clinic, shooting
cases of paralysis, epilepsy, hysteria, alcoholic
delirium, chorea, mania and so on, as well as
therapeutic procedures [19]. Kraepelin was also
involved in the public sphere, due to the ‘growing
medicalization of social issues in industrialized
nations’, a major issue that would have involved
cinematography itself in terms of evaluation of
potential public health threats within the Prussian
empire lm- und kino-reform of the 1910s [17,
94]. During 1910, in Bonn, Hans Hennes lmed
the pathological movements and psychiatric
patients [69]. Hennes’ account of his experience
testi es that for the most part of the recordings he
used one of the rst amateur small format sys-
tems. This was introduced by Heinrich Ernemann,
108
one of the most well-known camera and projector
producers and designers in the cinema’s history,
based in Dresden and that some years later, in
1907, through Alexander Ernemann, optical
engineer son of Heinrich, lmed cases of catato-
nia and chorea [42, 95, 96]. Hennes showed that
a small format (instead of the main 35 mm stan-
dard) assembled and paired with high-re ective
screens could allow a large audience to watch
high-quality images. In other words, Hennes was
able to link together the aim of using cinemato-
graphic technology as an educational tool and the
request for cheaper and simpler apparatuses.
Hennes wrote that lms are ‘always cooperative’
and ‘in the mood’ [97]. The juxtaposition between
moral virtue and automatic and cinematic tech-
nology meets the common and widespread con-
cept of ‘ef ciency’, perfectly associated to the
machinery instead of the disordered and uncon-
trolled pathological movement of the human
being [17]. Furthermore, as in the case of Chase
and many others, Hennes recommended that
teaching institutions should exchange the lm
they had made, and suggested creating archives
to gather lms on the most interesting cases [17,
69, 96, 97].
World War I injuries offered many tragic oppor-
tunities to improve neurological knowledge. At the
Netley Military Hospital, Arthur Hurst (1879–
1944) shoot numerous cases of hysterical disor-
ders, including “shell shock” phenomena, af icting
soldiers invalided back from the trench warfare in
France during the World War I [98]. Arthur Simons
(1877–1942), collaborator of Hermann Oppenheim
(1858–1919) in Berlin, through at least 11 cases
recorded between 1916 and 1919 and related to
injured soldiers, studied the tonic neck re exes in
hemiplegic patients. Simons described his wartime
work as follows: ‘In the autumn 1916, I examined
a hemiplegic patient in the eld 2 months after an
injury by gunshot in the head’. The cinemato-
graphic recordings were edited after World War I
and stored in the medical lm archives of the
cultural department of the Universal Film
Aktiengesellschaft (UFA, the most important lm
production organization during the 1920s and
1930s in Europe). They were then preserved for
many years at the Bundesarchiv—Filmarchiv in
Berlin and recently discovered [99, 100], still
L. Lorusso and S. Venturini
frames from the lms were used by important neu-
rologists, such as Magnus and Rademaker, who
both used cinematography in their own studies [99,
100]. Still in Berlin, Fraenkel Joachimsthal had
been lming normal and pathological gait in the
orthopedic eld since 1904 [42, 101] and also
Friedrich Heinrich Lewy (1885–1950), a former
student of Kraepelin and Aloysius Alzheimer
(1864–1915), edited a lm (with himself on the
stage) devoted to ‘Acute Encephalitis Lethargia’
(1925). In Breslau, in the 1910s, the neurologist
and neurosurgeon Ort rd Foerster (1873–1941)
used photography and motion pictures extensively
in teaching concerning movements disorders such
as chorea and athetosis [102, 103].
In France, Paul Sainton (1868–1958), a pupil
of Pierre-Marie, in collaboration with Gaumont
Company at the beginning of his career, lmed
11 patients with movement disorders (chorea,
tics, athetosis and Parkinsonism). He pointed out
the importance of cinema as a method of scien-
ti c documentary and medical education [104,
105]. His lms are preserved at Gaumont in
Paris. An important contribution for the spread of
cinematography in clinical routine was made by
Jean Comandon (1877–1970), who throughout
his entire cinematographic activity produced
about 426 scienti c lms, 103 of which were on
neuroscienti c topics with different objectives
[106]. They included the description of clinical
neurological syndromes associated to education,
aimed at semeiotics on various neurological clin-
ical manifestations and as a research aim for
describing mechanisms of neurophysiology [88].
These lms were recorded in different Parisian
hospitals, such as La Salpêtrière and l’hôpital
Trousseau, involving French and Swiss neurolo-
gists who attended their neurology clinics.
Comandon’s collaboration lasted from 1918 to
1924 and had an important role for physicians
interested in neurology, starting with André
Thomas (1867–1963) who was laboratory direc-
tor and a pupil of Jules Dejerine (1849–1917) at
La Salpêtrière. Dejerine and Thomas had given a
detailed description of a chronic ataxia, charac-
terized by progressive cerebellar atrophy or
olivo-ponto-cerebellar atrophy. Comandon cre-
ated the majority of the neurological lms (pre-
served at the Centre National du cinéma et de
9 Cinema and Neurology: From History to Therapy
l’image animée in Paris) with Jean-Athanase
Sicard (1872–1929), a radiologist and neurologist,
producing 20 lms regarding clinical features of
involuntary movement, disorders caused by
encephalitis infections, with such titles as Chorée
chronique, post-éncéphalitique. Another impor-
tant scienti c collaborator was the Swiss neurol-
ogist Édouard Long (1868–1929) who produced
12 lms with Comandon, dealing especially with
children. Comandon carried out his nal collabo-
ration with two physiologists who were studying
neurophysiopathological mechanisms: Jean
Joseph Gournay and Paul André Chailley-Bert
(1890–1973) produced a total of nine lms [51].
In 1907  in the United Kingdom, The Lancet
journal published a short article regarding the
Kinematograph in Medicine: ‘at the opening
meeting of the Middlesex Hospital Medical
Society on Nov. 7th Dr Herbert Campbell
Thomson showed an interesting series of kine-
matograph pictures illustrating different points in
the diagnosis and examination of patients in ner-
vous diseases. Dr Thomson observed that the kin-
ematograph would be of considerable assistance
in medical education (…) then proceeded to give
a practical demonstration of the utility of the
method in the teaching of clinical medicine by
means of living pictures of patients showing typi-
cal diagnostic symptoms in disseminated sclero-
sis, Friedreich’s disease, pseudo-hypertrophic
paralysis, and paralysis agitans. The particularly
striking instance of the value of this method were
the reproductions of the different forms of nys-
tagmus and the representation of the mask-like
face in paralysis agitans. In replying to a vote of
thanks, Dr Thomson acknowledged the help
which he had received from Mr Charles Urban of
the Urban Animated Photography Trading
Company’ [107]. Herbert Campbell Thomson
(1870–1940) was appointed ‘as physician and
lecturer of Neurology’ of the new Department of
Diseases of nervous system within the Middlesex
Hospital in London in 1912 and was Dean of the
Medical School till 1919 [108]. The name of the
Department comes mainly from a book with the
same title by Thomson for medical school stu-
dents and published for the rst time in 1908. In
the preface of the rst edition, the author declares
his debts to the French neurologist Pierre Marie,
109
who gave him many photographic illustrations.
Furthermore, as a clear example of dissemination
and the educational use of cinematographic tech-
nique, already shown during the opening meeting
of 1907 quoted above, Thomson declared that
‘for the taking of the instantaneous photographs
reproduced in four plates I am indebted to Mr.
Charles Urban’ [109]. Thomson used the term
‘instantaneous photographs’ to identify single or
multiple frames or partial frames reproduced
from cinematographic recordings and inserted as
plates in the handbook in order to illustrate spe-
ci c sign and key-moments of the nervous dis-
eases to the bene ts of the students.
At the beginning of the twentieth century, in
Leuven, Belgium, Arthur Van Gehuchten (1861–
1914) starts to use cinematography for analytical
and teaching purposes. Aubert reported that the
rst statement dates back to 1907: ‘Van
Gehuchten published his rst paper illustrated
with lms in Le Névraxe, the journal that he had
founded in 1900’. He described the ‘physiopath-
ologic study of a patient with a complex trau-
matic lesion of the spinal cord. He explained that
for 2 years he had been using cinematography in
neurology’. As Aubert states, ‘Van Gehuchten
used motion pictures to demonstrate neurologic
semiology, to illustrate various neurologic [dis-
eases], and to document the evolution of disease
or functional recovery following surgery’. His
lms ‘varied with regard to patients’ ages and
clinical material, gait and movement disorders,
neuromuscular diseases, epileptic and hysteric
seizures’. Van Gehuchten made broad use of cin-
ematographic screenings during ‘his lectures for
medical students, or at scienti c meetings’. The
original lms contain several short sequences
including later duplicates on small-gauge lm
format that keep unedited sequences and pre-
served at the Royal Belgian Film Archive in
Brussels [72, 73].
In 2010, at the Haghe Film laboratory in
Amsterdam and at the nitrate vaults of Nederlands
Instituut voor Beeld en Geluid [Netherlands
Institute for Sound and Vision] in the dunes near
The Hague, the authors of this chapter identi ed
the medical lms of Rudolf Magnus (1873–1927)
and Gijsbertus Rademaker (1887–1957) of the
Physiological Laboratory of Leiden University
110
[110]. These lms were produced between 1909
and 1940 and they were made both for educa-
tional and scienti c purposes. The lm materials
ascribable to Magnus include ‘children, animals
after surgery (cerebellum, striatum, hemi-
spheres), pharmacological experiments, and a
copy of a lm made by the Berlin physician
Arthur Simons’. The cinematographic shootings
‘show movement and position re exes in normal
infants and children, neck re exes in infants, and
animals without a cerebellum’. Similarly the
materials attributable to Rademaker show experi-
ments on ‘animals without labyrinth or a cerebel-
lum’ along with ‘procedures necessary to
investigate essential structures in standing and
walking’, and people ‘without labyrinth (congen-
itally) […] without a cerebellum (postopera-
tively, operated for tumors), and spastic children’
[111].
In Spain, circa 1915, Tomás Pérez Maestre
(1857–1936), physician and professor of forensic
medicine at the University of Madrid, Institute of
Legal Medicine Toxicology and Psychiatry,
lmed some ‘scienti c excursions’ to different
insane asylums (at least two insane asylums are
identi able Toledo and Ciempozuelos). He shot
the lms mainly through 28  mm format (with
additional 35 mm negative and positive materials
and are preserved at the Filmoteca Española in
Madrid). The lms contain two discursive texts
with two different strategies: the rst part works
as a documentation of Dr. Maestre’s practical les-
son among patients and in front of his students
and colleagues; the second part as a scienti c
recording of clinical cases (agitated mania, mel-
ancholic, manic depressive disorder, progressive
general paralysis, highly expansive elated mania,
catatonia, agitated paralysis, chorea and melan-
choly). It seems certain that Dr. Maestre ‘never
intended to give his lmed material any great
academic signi cance, whether this meant for
research, education or for making scienti c
knowledge available’. Due to their ‘fragmentary,
inconclusive, evanescent, non- lmlike quality’, it
seemed that they should inevitably be combined
with live lectures by Dr Maestre or other special-
ists able to explain the visual content. At the time
at least some of this footage were shot, in 1915,
L. Lorusso and S. Venturini
he had completely rejected the concept of ‘neuro-
pathology’ in the case of ailments associated
with hysteria. Instead, Maestre championed the
older concept of ‘degeneration’, in keeping with
Cesare Lombroso, whom he admired. According
to Maestre’s interpretation, degeneration was a
hereditary illness made up of four stages [112].
An attempt to introduce motion pictures as a
routine scienti c method was also made by the
Italian physiologist Osvaldo Polimanti (1869–
1947). In 1905, he lmed the development of
pathological movements in a dog whose cerebel-
lum had been extirpated in stages. Subsequently,
he employed motion pictures extensively for the
analysis and recording of forced movements and
other pathological phenomena occurring in dogs
after extirpation of different brain regions. The
lming was done with the assistance of the pro-
fessional cinematographer Filoteo Alberini
(1867–1937). Polimanti held cinematography
indispensable for the study of complex and rapid
movements. In addition, he emphasized that
motion pictures of such movements were clearer
than even lengthy and precise description and, by
providing documentary evidence they helped to
eliminate the frequent controversies as to whether
or not the observations and interpretations of the
investigator had been correct [24, 101].
Polimanti’s experiences had shortly preceded the
birth of the Italian Society of Neurology in 1907.
Although not to be interpreted as a division
desired by neuropathologists, in fact, the choice
‘breaks the unity with the psychiatrists estab-
lished by the constitution, in 1873, of the Society
Freniatrica Italiana’ [9]. In synchrony and sub-
stantial harmony with other European situations,
starting from about 1906 to 1908, some practices
and decisive experiences for the spread of the use
of cinematography in neuropathology also devel-
oped in Italy. In Turin, in 1906, Camillo Negro
(1861–1927) professor of Neurology, with the
cinematographer Roberto Omegna (1878–1948),
began lming several clinical cases. The shooting
took about 2 years, until early 1908. They shot 24
‘scenes’ that show clinical signs in patients with
different kinds of neurological diseases: includ-
ing movement disorders (tremors, ticks, dystonia
and Parkinsonism), various gait and gaze
9 Cinema and Neurology: From History to Therapy
disturbance. The association of a neurologist
with a professional cinematographer and artist,
such as Omegna, illustrates the growing interest
in scienti c and medical cinematography around
1905–1910, with the emergence of a professional
and institutionalized practice. The lms show an
‘anthological vocation’: ‘cinematograhic
sequences of Negro and Omegna, dedicated to
patients suffering from different syndromes,
were conceived as exemplary sequences valid
also in themselves, whose montage could vary
according to the needs of the presentation by the
hand of their own authors. We can suppose that in
the university context the projections were
divided into lessons adapting to teaching’ [113].
La neuropatologia (Negro, Omegna, 1906–1908,
‘Neuropathology’) was presented for the rst
time in Turin and in April 1908 at the rst meet-
ing of the Italian Neurological Society held in
Naples [23, 24, 30, 114]. Recently, thanks to the
‘critical edition’ of the Negro Collection pro-
posed by the National Museum of Cinema in
Turin, scholars could have access to a high-
quality restored copy and can watch the ‘war
trauma’ and shell-shock sequences that Negro
recorded during World War I correctly disposed
out and after the sequences that composed the
1906–1908 shootings [113]. In Bologna, the neu-
rologist Vincenzo Neri (1880–1961), the most
important of Babinski’s Italian pupils, used the
cinematographic medium for his own scienti c
researches for almost 50 years, starting with his
early clinical experience in Paris, in 1907–1908
[115]. He lmed patients from the Bicêtre, and
Pitié-Salpêtrière clinics in Paris—including
patients who had already been analysed by
famous neurologists such as Pierre-Marie, Jules
J. Dejerine (1837–1915) and Joseph Babinski, an
example of this approach is the case of Henri
Mouninou, whose cerebellar symptoms had
already been described by Babinski [116]
(Fig. 9.3).
At the same time, Neri’s patients were also
lmed by other Parisian colleagues, such as Paul
Sainton (1868–1958), demonstrating a real col-
laboration and research network between neu-
rologists interested in using cinematography for
clinical research. Neri continued to lm patients
111
and new techniques in his private neurological
clinic (Villa Baruzziana Clinic for Nervous
Diseases) and as a consultant neurologist at the
Istituto Ortopedico Rizzoli in Bologna. Since
starting his studies, Neri gave great attention to
neurological semeiotics. The symptoms of the
diseases that he isolated and described (‘Neri’s
signs’) can be seen in the frames and photos that
came from his clinical studies and were quoted
and used in important research publications of
the time [117]. In 1910, he published his rst
monograph, Le disbasie psichiche [Psychic
Dysbasia], which was the result of research car-
ried out in both Paris and Bologna. Here, he paid
particular attention to those signs that allowed
him to note differences between functional and
pathological walking or gait [118].
Cinematographic, chrono-photographic and pho-
tographic methods characterized the entirety of
Neri’s research. For analytical purpose, and to
create a wider scienti c archive, he conjoined
Babinski’s semeiotics to Etienne-Jules Marey’s
practices, using graphs, schemes, photos and
lms. The complex articulation of all of these dif-
ferent practices led to the construction of an
extremely heterogeneous archive, founded in
Bologna in 2008. Thousands of items of materi-
als of great historical value were found inside
Neri’s cabinet (photographic plates, including
stereoscopic samples, X-rays, prints, typo-
graphic clichés, cinematographic shot in 35 and
16  mm, diagrams, paper prints of additional
cinematographic marked Léon Gaumont and
lost sequences that were lmed in 17.5  mm)
(Fig.  9.4). The cinematographic material that
survived, excluding two 16 mm edited elements
dating back to the end of 1940s, is almost
totally composed of unedited units. In a few
cases, the sequences show evidence of editing,
which was used to show an elementary sequence
of cases and the steps involved in the clinical
lming protocol for scienti c dissemination
and educational purposes. His lms are pre-
served at the Home Movies National Film
Archive in Bologna [87].
It is also interesting to mention that in Italy the
neurologist Giuseppe D’Abundo (1860–1926)
and the psychologist Mario Ponzo (1882–1960)
112 L. Lorusso and S. Venturini

Fig. 9.3 Vincenzo Neri’s frames concerning the cerebellar symptoms of Henri Mouninou, a patient described by
Joseph Babinski in 1899 (Vincenzo Neri’s collection)

reported in 1911 the rst psychological reaction
in normal and in neurasthenic patients that
attended at the lm projections [119, 120]. The
pioneering theoretical contribution of D’Abundo
and Ponzo is an example that opens up the use of
cinematography in the neurological eld to the
concept of an embodied mind and more precisely
to the analysis of the physiological, psychologi-
cal and also philosophical relationship between
the cinematographic, the human subject and its
therapeutic application since the early twentieth
century.
9 Cinema and Neurology: From History to Therapy
Fig. 9.4 The collaboration between the doctor Vincenzo Neri with the cinematographer Georges Mendel (around
1908) (Vincenzo Neri’s collection)
9.5 Cinema as Educational
and Therapeutical Tools
Since its early days, cinema has been recognized
as having profound cultural value and as an
important source of education, shaping social and
professional attitudes and more generally con-
tributing to the cultural sensitivity of the contem-
porary world [121]. In the last three decades, lm
has become increasingly used as an educational
tool in teaching medical subjects and as a peda-
gogical tool thanks to its therapeutic capacity, as
in neuropsychiatric training and the development
of ‘Cinematherapy’ ([122–125]). Film can offer
new perspectives for introducing medical stu-
dents to their future professional activity [126–
128]. The representation of clinical symptoms
through lm provides an alternative to a narrative
procedure, thus facilitating the development of
empathy as an emotional impact on psychopatho-
logical symptoms [129]. This method serves as
an important interpersonal skill in medical train-
ing as it allows for greater humanization in clini-
cal practice [130, 131]. By watching a lm, the
viewer can experience transformations of per-
sonal meaning in his relationship with the world
and gain deeper access to subjective experiences
that often prove dif cult to interpret. This type of
113
approach is called ‘Cinemaeducation’ and can
act as an important instrument for promoting
essential components of subjective understand-
ing such as ‘an ability to perceive and express
emotions, understand and reason with emotion,
and regulate emotions in oneself and in others’
([120, 124, 132]). The usefulness of lm in illus-
trating the psychological and sociological con-
icts of medical practice is widely recognized
[133]; however, its use in medical sciences, such
as pharmacology and other elds is rare, but has
been spreading more recently. Several authors
have con rmed ‘ lm can increase students’ moti-
vation to understand clinical principles and
become a driving force to stimulate learning’
([133–135]). In the clinical setting, the use of cin-
ema in neuropsychiatry, concerning a variety of
complex psychological disorders, can be com-
prehensively characterized and empathically
made available to the viewer. Psychiatric patients
who can also bene t from this approach, as was
shown in the studies pioneered by D’Abundo and
Ponzo [119, 120]. The application of lm in neu-
ropsychiatry dates back to the early 1920s ([119,
136–139]) and one of the rst pioneers of lm
therapy was Electra Sparks (the real name Mary
Lawton Metcalfe) (1859–1949). Sparks theo-
rized that: ‘the moving image represented a meta-
114
phor for the mechanisms of the mind’. Sparks
proposed a relationship between vision and cog-
nitive functions, stating: ‘through the lens of the
human eye, a camera of the faculties of conscious
observations, located in the brain, we create
images and scenes, with different emotional con-
tent, that is imprinted by the various objects we
watch’[138]. Regarding this metaphor, Ellis
pointed out that: ‘just as the retina of the eye was
therefore considered sensitive to light, in the
same way as the Kodak camera, the mind, for
Sparks, worked like a moving image… the media
of choice for the mind is the computer, in 1911, it
was the moving image ‘[139]. Several theorists
of classical cinema made a comparison between
mind and lm. One of them was the German phi-
losopher and psychologist Hugo Münsterberg
(1863–1916), who opened the way to the study of
cinema. At the beginning of the spread of cinema,
he founded a laboratory in Boston at Harvard
University allowed for a multidisciplinary explo-
ration of the ways in which psychology and aes-
thetics intertwine with visual representation, and
in what ways moving images could be included
in a cultural context. He also succeeded in incor-
porating the cinematographic instrument into
physiological and psychological investigations
and the role played in the reorganization of the
relationships between physiology, psychology
and philosophy [140–144]. Cartwright and
Landecker’s articles show how the relationship
between philosophical and scienti c investiga-
tion, at the beginning of the rst decades of the
twentieth century, had been in uenced by consid-
erations and experiments which used lm devices
[14, 52]. In Münsterberg’ s laboratory of repre-
sentative apparatuses, scienti c research on men-
tal processes and the emotional component was
linked to image technology as well as art and the
lm industry [140, 144, 145]. Therefore, the
lms used in neuropsychiatry had the character-
istics of technology usually associated with the
‘graphic method’ as they ‘produced a visual
record related to speci c types of otherwise
imperceptible movement’ [144]. The successive
developments in the application of lm to various
neuropsychiatric disorders held differing func-
tions, according to the theories of the pioneers of
L. Lorusso and S. Venturini
cinematherapy. Today, con rmation of the use of
lm in this medical eld is demonstrated in a
study conducted on the use of cinematherapy
with 500 patients in a psychiatric clinic on
Koacaeli, Turkey, which carried out a programme
called ‘Watching Cinema Group Therapy’. In
1 year, patients watched the screening of lms to
encourage them to express ‘their beliefs, thoughts
and feelings’ while discussing the stories and
characters on screen. In this way, a therapeutic
alliance is created with the doctor favoured by the
cinematographic vision [146]. In clinical prac-
tice, there are dif culties in recognizing emotions
in various psychiatric and neurological disorders
and cinematherapy could help in recognizing and
interpreting these emotions. A study conducted
by Goodkind et  al. focused on the inability of
patients with dementia to recognize emotional
expressions when looking at static images, such
as photographs, with respect to dynamic ones,
shown as short sequences lms. Photographs rep-
resent only one mode of emotional information
(visual) and are absent of social context, while
lms allow for the recognition of varied emo-
tional information in a real setting. The authors
sought to identify emotional reactions in patients
with frontotemporal dementia, compared to those
with Alzheimer’s disease and normal subjects.
This frontotemporal dementia shows a disease
that negatively affects socio-emotional function-
ing, creating profound social and interpersonal
dif culties for families and healthcare staff. The
ability to recognize the emotions of others is fun-
damental for interpersonal relationships and for
the maintenance of intimate bonds. Patients who
are unable to recognize the emotions of others
will not be able to use these sources of social
information as a guide to help monitor, adjust and
correct their behaviour. Unlike patients with
Alzheimer’s disease (especially in the early
stage), patients with frontotemporal dementia are
unable to recognize these emotions, It has been
shown there is a preserved functioning area that
can be exploited in ways to improve interactions
with loved ones and help preserve quality of life
for these patients and their families for as long as
possible. The authors conclude that lm could be
useful for neuro-psychiatric patient groups to
9 Cinema and Neurology: From History to Therapy
help characterize areas of impaired and con-
served functioning in the eld of emotion recog-
nition. Moreover, lm could be of help in keeping
these areas preserved for the recognition of con-
tinually active emotions [147]. Alzheimer’s
patients can easily recall memories if they watch
lms related to places they had known in their
early lives. Capistick and Ludwin, followed ten
patients with Alzheimer’s disease showing lms
that referred to places they frequented at a young
age and that were linked to important life events
and still contained a strong emotional compo-
nent. Participants continued to make sense of
today by referring to similar places and events in
the past and identi ed strategies to overcome the
emotional demands placed on them by care
regimes and group care arrangements that were
not of their choice [148, 149]. Capistick and
Ludwin also pointed out that personalized social
history and archive research can be more useful
in maintaining a sense of identity and action, than
generic reminiscence aids. Care must be taken
that the use of lm could set off environmental
triggers thus reactivating traumatic memories
[148]. In conclusion, lms can be important in
this temporal journey to the past because through
analysing the lm content, dementia patients, or
the very elderly, improve memory which in turn
represents an important component of a system
that combines perception, thought and action
[150–152]. Continuing on the emotional content
linked to memories of speci c events, several
studies have sought to nd therapeutic solutions
for post-traumatic stress disorder (PTSD). The
incidence of PTSD in returning military person-
nel is creating a signi cant health challenge,
especially in the United States, and has been a
motivator for research on how to develop and bet-
ter spread treatments based on the use of virtual
reality, an approach that seems to provide posi-
tive results [153, 154]. Among Vietnam veterans,
the use of virtual reality is one of the studied
treatments for PTSD, to provide individual
‘exposure therapy that requires the patient to
repeatedly face the memory of traumatic events
by describing them in a supportive environment’
[155, 156]. Another important use of virtual real-
ity and interactive videogames, since the mid-
115
1990s, is for rehabilitation in stroke patients
[157, 158]. Stroke is one of the leading causes of
death and disability worldwide and the applica-
tion of virtual video, including telemedicine,
could be useful as an advanced visualization tool
for diagnosis of physical disability and for reha-
bilitation purposes [159–161]. A Cochrane
Systematic review, by Laver and colleagues, con-
cluded that: ‘virtual reality and interactive video
games were no more bene cial than conventional
therapeutic approaches in improving the function
of the upper limbs. Virtual reality can be useful in
improving the function and activities of upper
limb in everyday life when used in addition to
daily care. There is not enough evidence to reach
conclusions on the effects of virtual reality and
interactive video games on the speed of gait, bal-
ance, participation or quality of life (…). There
was also a trend that suggested that higher doses
(more than 15 h of total interventions) were pre-
ferred, such as personalized virtual reality pro-
grams, but these results were not statistically
signi cant’ [162]. Other studies have applied vir-
tual reality in subjects with severe levels of intel-
lectual and developmental disabilities, particularly
those with lower motivation and more reduced
access to healthcare compared to the general popu-
lation, including patients with autism spectrum dis-
orders [163, 164]. When virtual reality is applied, it
is important to keep in mind that every movement
implies a particular form of physical relationship
between the audience and the lm. This is because
lm techniques can activate different areas of motor
cognition or cerebral motor areas, including the
involvement of mirror neurons, as reported by sev-
eral studies [165–167]. Another application of video
games or virtual reality is in the eld of neurodegen-
erative pathology, as in Parkinson’s disease, which
is effective if the patient has a good cognitive level
[168]. The use of telehealth or video connection, in
following patients suffering from chronic neurode-
generative disorders turns out to be feasible and
does not signi cantly alter quality of life, compared
to personal outpatient visits. Virtual calls have
aroused great interest and provided substantial con-
venience as con rmed by a randomized controlled
national study of patients with Parkinson’s disor-
ders in the United States [169].
116
9.6 Conclusions
In 1920, the physiologist Polimanti in his essay:
‘Die Anwendung der Kinematographie in den
Naturwissenschaften, der Medizin und im
Unterricht’ (‘The use of cinematography in sci-
ence, medicine and teaching’) wrote: ‘I wonder if
one day it will not be possible to diagnose neuro-
logical diseases at a distance by seeing images of
pathology on lm, and determine the location of
experimental nerve injuries? It would be easily
possible’. This was a prediction or foresight of the
remote transmission of black and white images,
the application of virtual reality or telemedicine in
its various forms that is widely used today in clin-
ical routine by doctors [42, 101]. The bene t of
moving images in various neuropsychiatric
pathologies within diagnostics and therapeutic
elds is undeniable, as mentioned in the following
essay, and is the result of a long historical journey
that has in uenced the patient–doctor relation-
ship. We can say, still remembering Polimanti,
that moving images will determine further
changes and will be fundamental in the manage-
ment of neuropsychiatric diseases by replacing
that human component that is still error-prone.
Acknowledgements We are grateful to Patrizia Pilan for
the realization of Figs.  9.1 and 9.2. Our nal thanks to
David Noonan for his revision of our English. This chap-
ter was thought out and structured by the two authors
together. For practical purposes, the section 9.1 was writ-
ten by Simone Venturini; 9.2, 9.3, 9.4, and 9.6 were writ-
tern by the two authors together; while 9.5 is by Lorenzo
Lorusso.
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 A Neuroscience of Dance: Potential
for Therapeusis in Neurology
Gerry Leisman and Vered Aviv
10.1 A Neuroscience of Dance
and Exercise
Many individuals dance either professionally or
recreationally. Dance, in fact, has such favorable
effects on the brain and its ability to form connec-
tions as well as in its ability to stimulate sub-
stances that support neuroplasticity, which is now
being used to treat individuals with many forms
of neurodegenerative conditions such as
Parkinson’s disease (PD), a progressive neuro-
logical movement disorder that, in part, concerns
the integratory function of movement and cogni-
tion [1, 2].
Researchers have given little thought to the
neurological effects of dance until relatively
recently, when studies of the complex coordi-
nated movement in dance and its attendant cogni-
tive components began to be examined. Brown
and Parsons [3], in an article in Scienti c
American, indicated that the synchronization of
music and movement (the dance) fundamentally
G. Leisman (*)
Faculty of Health Sciences, University of Haifa,
Haifa, Israel
e-mail: g.leisman@edu.haifa.ac.il
National Institute for Brain and Rehabilitation
Sciences, Nazareth, Israel
Faculty ‘Manuel Fajardo’, University of the Medical
Sciences, Havana, Cuba
V. Aviv
The Jerusalem Academy of Music and Dance,
Jerusalem, Israel
© Springer Nature Switzerland AG 2020
B. Colombo (ed.), Brain and Art, https://doi.org/10.1007/978-3-030-23580-2_10
10
creates “double pleasure” as music stimulates the
brain’s reward centers, while dance activates its
sensory and motor circuits.
Positron emission tomography (PET) imaging
has identi ed brain regions that support the learn-
ing of dance moves [4]. These regions obviously
comprise the motor cortex as well as the somato-
sensory cortex, basal ganglia, and cerebellum.
The motor cortex is involved in planning, control
and execution of voluntary movements. The
somatosensory cortex is concerned with motor
control and similarly provides control of eye–
hand coordination. The basal ganglia together
with supplementary brain regions endeavors to
control the smoothness of movement, while the
cerebellum combines input from the brain and
spinal cord and helps in the planning of ne and
complex motor actions [5, 6]. While some imag-
ing studies have illustrated the nature of dance
activated brain regions [4], others have investi-
gated how the expressive and physical aspects of
dance modify brain function. For example, much
of the research on the bene ts of the physical
activity associated with dance links with those
gained from physical exercise bene ts ([7, 8]),
bene ts that range from memory improvement to
strengthened neuronal connections.
Numerous complex sensorimotor behaviors
involve the combination of spatial pattern,
rhythm, and synchronization to external stimuli
and coordination of the whole body. Such activi-
ties include primordial adaptations such as
hunting, ghting, and play, as well as more con-
121
122
temporary adaptations such as marching, group
physical labor, group musical performance, and
sport. Neuroimaging studies have examined
some constituents of these multifaceted actions,
such as the entrainment of movement to external
timekeepers or spatial patterning of limb move-
ment. However, this research has typically stud-
ied fundamental processes such as nger tapping
or ankle rotation [9–12]. A central issue is
whether the neural systems implicated in these
elementary processes “scale up” and “scale out”
to complex ecological activities. Are the means
that regulate complex sensorimotor processes the
same as those that trigger elementary processes
such as nger tapping or ankle rotation or are
new and different mechanisms recruited?
Dance is a universal human behavior related
to group rituals [13, 14]. Although portrayed in
cave art dating back over 20,000  years [15],
dance may actually be much older. Dance may
actually be as old as human capacities for bipedal
walking and running, dating back 2–5  mil-
lion years [6, 16, 17]. A major aspect of dance is
that body movements are structured into spatial
patterns. This patterning of movement incorpo-
rates a map of the trajectories of the body in exo-
centric space [18] as well as visual and kinesthetic
maps of body schema in egocentric space [19].
The displacement con gurations of dance can
involve any body part; every dance can be cate-
gorized by the identity and number of its contrib-
uting movement-units. Furthermore, dances tend
to possess a modular organization comprised of
distinct sections that are interwoven with one
another cyclically. Due to this combinatory orga-
nization, dances are amenable to grammatical
analysis and description [20].
Another aspect of the dance involves move-
ment synchronization that in turn is based on
metronomic or musical beats, a capacity nomi-
nally speci c to human beings. Essentially all
dancing is performed to musical rhythms, thus
allowing temporal synchronization between
dancers. Dance movement generally emulates the
graded arrangement of strong and weak beats
evident in musical rhythm patterns. In the waltz,
the rst beat is emphasized with weaker second
and third beats; in parallel in waltz movements,
G. Leisman and V. Aviv
the rst step is the most emphasized with shorter
and weaker second and third steps. Therefore, the
music and dance entrainment involves both syn-
chronization in time and a spatial component
related to the equating of hierarchies in the motor
pattern with those in the musical rhythm.
Positron emission tomography (PET) studies
were performed with amateur dancers executing
small-scale, bipedal dance steps on an inclined
surface, as compared to auditory, motor, and
rhythmic control tasks [21]. Brown and col-
leagues attempted to develop a systems-level
view of complex sensorimotor processes involved
in dance, by attempting to isolate and identify the
brain areas involved in the voluntary control of
metric movements (i.e., dance steps occurring in
an equal-time-interval rhythm).
Brown et  al.’s [21] ndings exemplify the
coordination of distributed neural systems asso-
ciated with reiterated dance steps entrained musi-
cal rhythm. Elements of both discrete and
rhythmic movements [22] are present in dance,
itself a gestural system. Activation patterns are
largely consistent with subcortical system activa-
tion involved in the timing and coordination of
discontinuous movements, whereas the speci c
cortical systems activated to support the control
of the continuous movements [23].
The operative neural subsystems that Brown
et al. [21] found included: the superior temporal
gyrus and superior temporal pole associated with
the melodic aspects of the music. The medial
geniculate nucleus was reported to direct input,
through brainstem nuclei that project to the ante-
rior cerebellar vermis and lobules V and VI, relat-
ing to beat information supporting the entrainment
of movement to musical beats. The basal ganglia
and putamen control the selection and organiza-
tion of action segments in particular for move-
ments with strong probability and constancy,
such as metronomic or timed movements. The
thalamus was reportedly involved in linking
somatosensory and motor parameters together
and is singularly signi cant for the performance
of novel or nonmetric rhythms.
Brown and associates have found that somato-
topic areas for the lower extremity in
supplementary motor area (SMA), premotor, and
10 A Neuroscience of Dance: Potential for Therapeusis in Neurology
motor regions of the cortex are associated with
parameters related to contractile forces, muscle
groups, initial and nal limb position, and direc-
tion of movement. A representation of involved
brain regions may be found in Fig.  10.1. The
SMA, cingulate motor area, and the cerebellum
support interhemispheric coordination of the two
limbs during cyclically repeated, bipedal motion
[21, 25, 26]. In motor sequencing, the right fron-
tal operculum is involved and the right cingulate
motor region is associated with movement inten-
tion. Brown et  al. [21] reported that the medial
superior parietal lobule subserved kinesthetically
mediated spatial guidance of leg movement dur-
ing navigation in dance.
Area 6
SMA PMC
Area 8
Prefrontal
cortex
Fig. 10.1 The motor areas of the cerebral cortex, among
them the premotor cortex (PMC), supplementary motor
areas (SMA), primary motor cortex (M1), and posterior
123
Brown and colleagues distinguished in their
2006 study the different aspects of the dance.
They analyzed: audio-motor entrainment, meter,
and movement patterning. In audio-motor
entrainment, two matched dance patterns were
performed at the same rate with one necessitating
entrainment to a rhythmic beat and the other one,
self-paced. Entrainment processing was report-
edly related to the anterior cerebellar vermis
exclusively. In their metronomic and nonmetro-
nomic support for Brown et  al.’s [21] ndings,
Debaere et  al.’s [27] functional magnetic reso-
nance imaging (fMRI) studies of right-foot
exion/extension timed to metronomic auditory
cues demonstrated similar ndings in the anterior
Area 4 Posterior
parietal cortex
M1 S1
Area 5 Area 7
Posterior cingulate
Area 24
parietal. Also, primary sensory area (S1) and the limbic
lobe including the cingulate gyrus (lower image).
(Adapted from Gazzaniga [24], with permission)
124
cerebellar vermis. Additional support of the
involvement of the anterior cerebellar vermis in
an fMRI study by Sahyoun et  al. [12] demon-
strated that with right-foot exion/extension
timed to a metronomic visual rather than auditory
cues, the anterior cerebellar vermis was also
involved.
This region was also activated by rhythmic
self-paced walking [28] as well as by nger tap-
ping without ongoing external stimuli [11]. These
similarities between self-paced walking as well
as metronomic-based dance patterns evidenced
on fMRI imply that common mechanisms are
involved in entrainment, indicating the impor-
tance of the anterior cerebellar vermis (III) for
the entrainment of movement to external timing
cues.
Brown et  al. [21] noted in their analysis of
functional activation of metronomic dance minus
passive music listening that activity in cortical
auditory areas was eliminated, with signi cant
residual signal in the right medial geniculate
nucleus as well as in posterior cerebellar lobules
V and VI. These investigators did not nd these
regions to be activated during self-paced dance
steps without music (in contradistinction to rest).
There exist signi cant reciprocal projections
between the cerebellum and the thalamic nuclei
via relays in the brainstem (cf. [29]). Furthermore,
cerebellar lobules V and VI have been explicitly
associated in neuroimaging studies of pitch and
melody discrimination, and are disconnected
from motor coordination or cortical motor activ-
ity [30, 31]. It is conceivable then that the sensory
input to the anterior cerebellar vermis for entrain-
ment processing involves auditory processed
information from subcortical sites.
It appears then that entrainment in dance has
no requirement for musical content necessarily
but rather is contingent on low-level information
about the beat, facilitated by subcortical path-
ways. This hypothesis may in part account for the
similarities of entrainment mechanisms between
dance and simple sensorimotor behaviors such as
nger tapping and ankle rotation.
There is much argument concerning the role
of the cerebellum, which has been understood as
a mechanism in motor-control and coordination
G. Leisman and V. Aviv
but not so much concerned with nonmotor pro-
cesses [6, 25, 26, 32, 33]. Cerebellar function has
been viewed differently of late by various authors.
It was Wolpert et al. [34] who contended that the
cerebellum possesses “internal forward-inverse
model pairs.” Alternatively, Ivry [35] focused on
the cerebellum’s role as involved in timing in
both movement preparation and motor response
coordination (in the anterior and vermal regions)
and the sensory perception of duration on the
order of hundreds of milliseconds (in lateral
cerebellum).
In yet another view of the function of the cer-
ebellum in the present context proposed by
Bower and Parsons [32] was that the cerebellum
functions to optimize the acquisition and control
of sensory data. In the present application related
to the dance, the cerebellum would function to
support cortical, subcortical, and peripheral neu-
ral structures in assembling optimal auditory and
somatosensory information in order to effect the
cortical motor system to synchronize the execu-
tion of movement with the auditory rhythm.
10.2 Metronomic Versus
Nonmetronomic Movement
Brown et al. [21] also found that metronomically
timed dance movement was associated with
robust bilateral activity in the putamen in general,
and the right putamen in particular.
Nonmetronomic movement associated with
dancing dance demonstrated no activity in the
putamen but rather signi cant increases in signal
strength in the right ventral thalamus. Much prior
and later researches con rm the basal ganglia’s
role in controlling metronomic movement in
rhythmic tapping tasks (e.g., [6, 11, 26, 36]) and
in piano performance of memorized musical
pieces ([37, 38]). The putamen’s contribution in
metronomic movement is supported by Sahyoun
et  al.’ [12] fMRI investigation of visually cued,
metronomic right-foot exion/extension where
the thalamus was signi cantly less active.
Similarly, in a PET study of the same task [39],
activity in the putamen, but not the thalamus, was
reported. The involvement of the ventral thala-
10 A Neuroscience of Dance: Potential for Therapeusis in Neurology
mus in nonmetric rhythms agrees with similar
ndings from an fMRI study [10] of tapping the
right index nger to a nonmetric, randomly timed
visual cue.
Generally, the feedback activity occurring
between putamen and ventral thalamus here
described proposes that for both dance and ele-
mentary movements, the basal ganglia are prefer-
entially triggered in the execution of motor
activities that have predictable and regular
rhythm and that unpredictable unfamiliar tempo-
ral con gurations employ alternative pathways.
This is also consistent with Dhamala et  al.’s
[40] ndings indicating that in fMRI, self-paced
nger tapping produces activity in the basal gan-
glia for simple rhythms and activity decrease was
noted with greater rhythmic complexity. In the
thalamus and anterior cerebellar vermis, on the
other hand, increased activation was produced
with increasing complexity.
Brown and associates’ [21] investigation dem-
onstrated moderate activity levels in both the cen-
tral thalamus and putamen for self-paced dancing
without music and for the performance of iso-
metric leg-muscle contractions to metronomic
tango music. Therefore, basal ganglia activity
appears to be moderated by limb displacement
and entrainment and by the presence or absence
of metronomic regularity.
This composite functionality implies that the
basal ganglia may be one part of the brain sensi-
tive to the interactions between entrainment, spa-
tial patterning, and meter, the constituent
elements of dance.
10.3 Dance, Somatotopy,
and Control of Lower Limbs
An additional aspect of Brown et al.’s [21] funda-
mental study of the dance emphasizes the lower
extremity’s topographic representation in the
sensory-motor cortex and in the superior parietal
lobule, cingulate motor area, cerebellum, and
putamen.
Activation of a mesial strip encompassing the
leg representation in the primary motor cortex,
somatosensory cortex, SMA, and premotor cor-
125
tex was reportedly existent for tasks involving
motor activity. Activation in similar somatotopic
cortical regions for the lower extremity have been
found in a number of reports of SPECT studies of
upright walking [28]; results of a study of near-
infrared spectroscopy of bipedal walking on a
treadmill [41]; an fMRI study of right-foot ex-
ion/extension timed to a metric auditory cue [27];
a PET study of this same task [39]; an fMRI
study of metronomic, visually cued right-foot
exion/extension [12]; an fMRI study of uni-
pedal exion/extension of either the left or right
knee joint [42]; an fMRI study of the placement
of either foot into visually presented foot pos-
tures [43]; and an fMRI study of imagined and
executed exion/extension of the toes timed to a
metronomic auditory cue [9].
The SMA, premotor, and motor regions of the
cortex probably encode parameters associated
with muscle group, contractile force, initial and
nal position, and movement direction [5, 44].
The SMA, the cingulate motor area, and possibly
the cerebellum [34, 35, 45] are likely involved in
interhemispheric coupling associated with repeti-
tive synchronization of the two homologous
limbs, as suggested by studies of bimanual coor-
dination (e.g., [10, 46]). Similar activations have
been reported for coordinated unilateral move-
ments of the hand and foot [27, 39, 47].
The right frontal operculum (represented in
Fig.  10.2) is reportedly triggered by motor pro-
duction but not by music listening, indicating that
the region possesses a role in motor sequencing
rather than in spatial patterning and metronomic
entrainment [9, 48]. Responses in the frontal
operculum have been noted in an fMRI study of
exion/extension of the toe timed to a metro-
nomic auditory cue [9] both during mental imag-
ery of movement and actual movement.
Analogous activity was also reported in an fMRI
study of visually cued metric right-foot exion/
extension [12]. In a PET study of nger tapping
timed to imitate the rhythm of brief sequences of
visual stimuli with long or short elements [11],
the right frontal operculum was also triggered.
The same region shows activations for motor
mental imagery, perception, and imitation tasks
involving the hands [49–52]. Correspondingly,
126
Fig. 10.2 Coronal
section of the human
parietal operculum
(green), temporal
operculum (blue), and
insular cortex (brown).
The red inset shows the
position of the brain
slice. (Adapted from
John A Beal,
Department of Cellular
Biology & Anatomy,
Louisiana State
University, 2005, with
permission.)
an area anterior to the right frontal operculum
was activated in ballet dancers viewing ballet
movements and in capoeira dancers while observ-
ing capoeira movements [53]. This report sup-
ports a role for this region in both elementary
motor sequencing and in dance, during both per-
ception and production.
10.4 Dance and Spatial Cognition
Brown et al. [21] found that the medial superior
parietal lobule is involved in the kinesthetic con-
trol of leg movement during navigation in dance,
interacting with the somatosensory, timing,
sequencing, and obviously motor areas of the
cortex. In older fMRI studies [27], activation in
the medial superior parietal lobule was also noted
for right-foot exion/extension timed to metric
auditory cues as well as in a similar PET study
[39]. More recent studies have conformed these
effects [54, 55].
The posterior parietal cortex is associated with
involvement in numerous cognitive-spatial func-
tions [56–58] including those related to body
schema [57, 59–61]. The inferior and superior
parietal lobules receive both somatosensory and
G. Leisman and V. Aviv
visual inputs. The posterior regions of both lob-
ules process visual information, the anterior
superior parietal lobule somatosensory, and the
anterior inferior parietal lobule integrates the
somatosensory and visual information [62–64].
Dancing with the eyes closed was reported by
Brown and associates [3] by some of their par-
ticipants to be accompanied by mental imagery
of their body. They assumed that the parietal acti-
vation was probably involved in spatial cognitive
functions based on proprioceptive processing of
leg position and joint angle and on somatosen-
sory contact of the feet with the surface [62, 65].
While not much is known about leg represen-
tations in posterior parietal cortex of either
humans, somesthetic guidance of navigation is
crucial to dance, where vision provides a support
role indicating whether there is ample area to
carry out particular movements. The fact that
superior parietal lobule is activated in some of the
studies of elementary ankle and wrist rotation
suggests that, unlike isometric muscle contrac-
tion, these simple movements still have a basic
element of spatial patterning. This suggests that
activity in superior parietal lobule increases as
the spatial and navigational demands of the
movement increase.
10 A Neuroscience of Dance: Potential for Therapeusis in Neurology
The numerous brain areas activated for dance
are the same as those recruited in nondance sen-
sorimotor activities. It is likely that learning or
re nement of natural complex tasks would entail
changes in functional and effective connectivity,
and in the reorganization and redistribution of
processes basic to the process of rehabilitation [6,
66, 67].
Dancers, for example, must learn complex
movement sequences by ef ciently reproducing
movements they observe that incorporates the
translation of visual and verbal information into
motor action. Dancers modify movements with
respect to direction in space, speed, rhythm, and
amplitude, and express them precisely as
observed from the choreographer’s instructions,
adding the dancer’s re nement of the movements
for aesthetic purposes.
When dancing individuals must remain atten-
tive to their partner so as to be in synchrony.
Dance, therefore, requires observing, generating,
executing, and coordinating complex movement
patterns through cognitive–movement
interaction.
10.5 Dance and Equilibrium,
Posture and Motor Control
Dancers show enhanced abilities in posture con-
trol and equilibrium maintenance as a vital part
of their expertise [68]. A number of studies have
investigated the cognitive control mechanisms
fundamental for dancers’ exceptional motor
skills, concentrating on the acquisitions mecha-
nisms and their maintenance and how the acqui-
sition mechanisms may affect other sensorimotor
processes.
Dance training heightens sensorimotor control
functions underlying static as well as dynamic
equilibrium. For example, classically trained
dancers exhibit better postural control [69], can
maintain given postures for longer durations
[70], and show more vertical alignment during
stepping than nondancers [71]. Numerous studies
have demonstrated that dancers possess better
balance skills than do nondancers [72–74], in
adult dancers compared to younger and less
127
experienced dancers [75], and in female com-
pared to male dancers in equilibrium reactions
[73]. Even short episodes of breakdance training
have been found to increase balance skills in
young amateurs [76].
We know that with greater skill acquisition in
dance, there is a complimentary increase in
somatosensory functional ability with physical
training. For example, enhanced proprioceptive
skills associated with dancers’ heightened pos-
ture control have been suggested to interfere with
other sensory processes such as vision [74, 77].
Dance training has been claimed to increase the
relative effect of somatosensory function with a
shift of sensorimotor dominance to propriocep-
tion from vision [78, 79]. Therefore, skilled
dancers demonstrate a greater position sense
based on proprioceptive information, and should
rely more on proprioception than on vision com-
pared to nondancers. Evidence for this hypothe-
sis has been found for dynamic equilibrium tasks
among professional ballet dancers [79], and for
position-matching tasks involving matching the
hand location in space [77, 80]. Dancers even
appeared to be more reliant on proprioception
even when vision was available, leading to a ten-
dency toward higher error rates in the vision-only
condition, in which controls are generally more
accurate.
On the other hand, static equilibrium in danc-
ers demonstrates that their balance strategies for
motion rely more on visual rather than to somato-
sensory information [78, 81–83]. Nonetheless,
dancers’ dynamic patterns of postural sway are
regulated by visual input in different ways com-
pared to nondancers. While dancers often dem-
onstrate lesser pitch sway oscillations than do
nondancers, roll sway and pitch were increased
in dancers standing on one leg with the left hemi-
eld occluded, whereas only pitch sway was
increased in untrained controls [84].
These ndings suggest that sensory control
strategies are likely task-speci c, and that dance
training enhances the relative in uence of
somatosensation, speci cally proprioception, on
multimodal assimilation for position-matching
and for dynamic equilibrium tasks, but not for
static tasks.
128
One can, therefore, conclude that the essential
functions fundamental to the dance, which
include the control of equilibrium, posture, and
sway, are sensitive to training effects, and that,
therefore dance training has the potential to stabi-
lize and align dancers’ performance via these
functions. The roles of individual sensory modal-
ities in multimodal integration, especially rela-
tive in uences of vision and somatosensation
deserve further study. The intimation here is that
there is a potential therapeutic bene t for those
with developmental delays, developmental coor-
dination disorders, individuals post-stroke, and
those suffering from a plethora of neurodegener-
ative conditions.
10.6 Dance and the Control
of Complex Movements
The seemingly effortless performance of challeng-
ing moves is a characteristic of skilled dance.
Dancers realize this by optimizing motor syner-
gies reducing energy costs of force and muscle
tension as a consequence [5]. Overall, classical
dancers have the ability to ef ciently combine
movements of related joints into single motor syn-
ergies, thus reducing the number of degrees of
freedom required for neuronal control, resulting in
a highly accurate reproduction of the orientation
and shape of the required trajectories [85, 86].
On the basis of our current understanding of
the effects of dance training, on neurocognitive
control functions and its capability of modifying
physical abilities, such as facilitating the optimi-
zation of muscle activation and coordination of
novel movements, we learn that dance training
has the potential to in uence basic functions
underlying motor control, including multimodal
integration as well as posture and equilibrium
control, facilitating the performance of complex
movements in body alignment and balance tasks.
On this basis the employment of dance as a thera-
peutic intervention tool in neuromuscular and
developmental disorders allows the individual to
develop strategies such as the optimization of
motor synergies when executing complicated
movement combinations.
G. Leisman and V. Aviv
As dancers develop and apply strategies in
ways that require attentional processes and higher
cognitive processes, such as the use of imagery
and adaptable to external acoustic or visual cues,
therefore, even though dancers’ movement exper-
tise can be examined and described via biome-
chanical measures [87], physical skills in dance
cannot be separated from the cognitive functions
and strategies that enable dancers to make use of
them in a way that makes dance an art form.
10.7 Dance and Motor Learning:
Imitation, High-Level
Cognition,
and Improvisation
Motor learning is the modi cation of the behav-
ior following experience (Leonard 1988). In this
section, we concentrate on the motor learning
phase of the dance, summarizing brie y the
experimental ndings on the brain regions
involved in motor learning in dance. It also
assesses some possible implementation of differ-
ent motor learning methods for movement
therapy.
When discussing the various motor learning
procedures of dance, we focus on acquiring and
improving dance skills using three main meth-
ods: learning dance by imitation, learning dance
via a high cognitive component instructions, and
learning through improvisation. We will show
that each of these different ways of learning
dance utilizes somewhat different neural path-
ways and, therefore, is eligible for different pur-
poses of dance and therapy practices.
10.8 Learning Dance Moves by
Imitation
Learning movements by imitation is a common
and useful method for learning dance. It is a fas-
cinating phenomenon whereby while observing
another person moving one can instruct one’s
own motor system to produce the same moment
with his/her own body simultaneously [89].
There is considerable evidence regarding the role
10 A Neuroscience of Dance: Potential for Therapeusis in Neurology
of mirror neurons system in motor learning and
movement imitation, in animals as well as in
humans. For the observer, the mirror neuron sys-
tems mediates the transition between visual
response to movement and motor responses that
mimic the performance by the dancer [90]. The
human action observation network (i.e., the mir-
ror neuron system) is thought to involve premotor
and parietal cortices, possibly involved in action
simulation, as well as the SMA, superior tempo-
ral sulcus, and primary motor cortex [4, 91, 92].
Another brain area engaged during imitation is
the superior parietal lobule, activated in the case
of speci c instruction to imitate a movement
[93]. Studying imitation of movement by musi-
cians, Buccino and associates [94] showed that
the basic circuit underlying imitation learning
consists of the inferior parietal lobule, the poste-
rior part of the inferior frontal gyrus, and the
adjacent premotor cortex (mirror neuron circuit).
This circuit was shown to be involved in action
understanding. Experimental results also indicate
that the basic circuit underlying imitation coin-
cides with those which are active during action
observation and that the posterior part of IFG is
involved in direct mapping of the observed action
and its motor representation [90].
The correlation of brain activity with imitation
in dance has been studied mostly indirectly, as
part of measuring brain activity while watching
dance. During this research, two basic conditions
were employed: observation of dance with no
physical movement and observation of dance
with some physical execution of dance. The stud-
ies under the rst condition are summarized by
Karpati et  al. [91] as follows: “neuroimaging
studies of action observation in dance have shown
that (1) dancers show activation of the action
observation and simulation networks, particu-
larly the premotor cortex, when observing dance,
likely because they have an enhanced motor rep-
resentation of an observed movement; (2) func-
tional differences in the action observation
system of dancers are related to the degree of
dance training; (3) short-term dance training is
correlated with brain functional plasticity in non-
dancers; and (4) observation of recorded versus
live dance performance results in differential
129
brain activity. However, the studies reviewed in
this section are limited by the fact that they only
address observation of dance” [91].
Brain activity during observation of dance
together with physical execution of the dance is
very hard to achieve. Thus, only a few studies
pursued this direction so far. These works indi-
cated the involvement of some brain regions in
various aspects of execution of dance, such as the
superior temporal gyrus, superior parietal lobule,
frontopolar cortex, and middle temporal gyrus
[21, 91, 95].
Taken together, imitation in dance is com-
posed of several processes including the intention
to imitate, observation of someone else moving,
and the execution of the movements in real time.
The phenomenon of imitation involves the action
observation network, which also considered par-
ticipating in understanding of social behavior and
empathy. This form of dance learning is so natu-
ral that practically everyone, from early child-
hood, uses it onwards.
10.9 Learning Dance by the Use
of Higher Cognitive
Functions
At times, motor learning of dance is based on a
highly cognitive comprehension of the task. Such
types of tasks can include, for example, learning
a dance score from movement notation, which is
a challenging cognitive task in terms of the trans-
formation from one language (dance notation) to
physical execution (dance) and in terms of the
cognitive demand of understanding and analyz-
ing the notated movements (cf. [96]). Additionally,
working with dance notation may induce a heavy
load on the memory systems (both the explicit
and the implicit systems) and may challenge the
coordination system (cf. [97]). Another example
of high cognitive components of learning dance
is simply the performance of complex dance
demands, in terms of learning the physical
sequence of the movements, timings, directions,
dimensions, simultaneous movements of differ-
ent body parts, and learning the subtle qualities
of the dance movements (such as “ ow”).
130
This form of highly cognitive learning is charac-
terized by comprehension of concepts, knowing
and memorizing facts and events, conscious and
verbal communication—all referred as declarative
learning. It is contrasted with the procedural learn-
ing, also referred as “learning by doing”, which can
be acquired without conscious awareness of the
rules being learned but rather by motor practice
[98–100]. It is common to think about procedural
memory as independent neurally of declarative
memory, and that these two systems operate inde-
pendently during learning [98, 101, 102]. Some
studies have shown that during sequence learning,
declarative and procedural systems operate in paral-
lel whereas these memory systems may interact fol-
lowing learning [101]. There has been some
evidence that manipulation of practice procedure
in uences cognitive processes during the encoding
phase. For example, the random-order practice of
motor sequence (compared to blocked-order prac-
tice) engages the learner in deeper cognitive pro-
cessing of information. This deeper cognitive
processing leads to a stronger motor memory repre-
sentation, which improves learning and retention
[103]. Even though there is some evidence in sev-
eral studies for overlap between various brain areas
activated in these two procedures (such as left pre-
frontal cortex, left inferior parietal cortex and right
putamen), some studies found also that SMA, cau-
date nucleus, and somatosensory cortex were acti-
vated during procedural learning. A clear difference
in the activity of several brain areas (such as left
prefrontal cortex, dorsal prefrontal cortex, and supe-
rior parietal cortex) has been found during declara-
tive motor learning in comparison with procedural
learning [98, 100].
All this indicates that manipulation of practice
structure using a high cognitive component motor
learning provides an opportunity to in uence brain
activity and physical behavior, via manipulation of
the memory systems (declarative and procedural).
10.10 Learning Dance Movement
by Improvisation
Improvising is an important form of learning and
performing dance, being used among profes-
sional dancers and novices. Improvisation is
G. Leisman and V. Aviv
studied and practiced in order to look for and
develop new movement materials for the dance.
Also, it is intended to convey emotional and con-
ceptual ideas through the body. Improvisation in
dance introduces a set of movements, which are
composed and performed in real time. There are
no stylistic rules for improvisation or xed move-
ments. Yet, there are some general rules for
improvisation. For example, the technique might
be generic in the sense that it can be applied to
different body parts and speci c in the sense that
it chooses a particular set of movements (or
avoids particular movements) [104]. According
to Hagendoorn, improvisation in dance is distin-
guished from pure motor learning of motor skills
by the need of understanding of the concept
behind a technique, so study and practice impro-
visation improves both—the motor performance
and the cognitive aspects of dance [104].
Improvisation is based on the generation of a
variety of alternatives motor patterns in order to
create a divergent production. Its relationship to
creative thinking has been demonstrated.
Particularly, the relation of contact improvisation
(sharing of a constantly moving point of contact
with a partner, so the movements arise from a
re exive relationship with the partner) enhances
the divergent of responses, thus stimulating
motor creativity [105]. The study by Fink et  al.
[106], one of the very few works on the connec-
tion of brain activity to dance improvisation, has
shown that a task of improvisation in dance
(namely imagery of free-associative dance task,
recorded by EEG) has elicited more alpha activ-
ity than a Waltz dance (by imagery of a known
structured sequence of movements). Enhanced
alpha brain wave activity was most pronounced
in frontal, fronto-central, and centrotemporal
regions of the brain. This phenomenon was found
in both professional dancers as well as in novices.
This research demonstrates that improvisation
task recruited brain regions which are active
during creative thinking in general and more so
than in learning a structured dance, such as Waltz.
We have learned that there are three main
methods for learning a dance: learning via imita-
tion, learning via higher cognitive processes, and
learning via improvisations. Imitation in dance
can be associated with procedural learning,
10 A Neuroscience of Dance: Potential for Therapeusis in Neurology
which can be acquired without conscious aware-
ness of the structure or the rules of the sequence
being learned. Highly cognitive dance learning,
which is, by nature, part of declarative learning,
involves conscious awareness of the facts and
events of the dance being learned. Improvisation
in dance involves creative thinking and compre-
hension of principles. These different methods
activate some overlapping brain regions and
some nonoverlapping brain regions. One impli-
cation of these ndings is that implementation of
all three teaching methods is important in order
to stimulate the brain and body of a dancing per-
son to various conditions of brain activity and
motor learning. It is more so with regards to peo-
ple who have impaired motor system, or people
who use dance therapy for various other reasons.
10.11 Therapeutic Applications
of Dance
Given the forgoing indicating how dance and
dance instruction can affect the brain and how
motor learning serves to effectively integrate
brain function, one can therefore wonder whether
there exists signi cant therapeutic bene t in
dance training for individuals in various states of
neurological compromise either developmentally
or as a result of neurodegenerative conditions
such as Parkinson’s disease, as well as post-
trauma or stroke?
In a 2003 study in the New England Journal of
Medicine by researchers at the Albert Einstein
College of Medicine, Verghese et  al. [107] dis-
covered that dance could decidedly improve
brain health. The study investigated the effect
that leisure activities had on the risk of dementia
in the elderly. The researchers looked at the
effects of 11 different types of physical activity,
including cycling, golf, swimming, and tennis,
but found that only one of the activities studied—
dance—lowered participants’ risk of dementia.
According to the researchers, dancing involves
both a mental effort and social interaction and
that this type of stimulation helped reduce the
risk of dementia. Numerous studies show that
dance helps reduce stress [108], increases levels
of serotonin [109], and helps develop new neural
131
connections [21], especially in regions involved
in executive function, long-term memory, and
spatial recognition.
The Parkinson’s Disease Foundation reports
that over a million people in the United States
live with Parkinson’s disease with 60,000 new
cases reported yearly in the United States [110].
Parkinson’s disease belongs to a group of condi-
tions called motor-system disorders, which
develop when the dopamine-producing cells in
the brain are lost [111]. Dopamine is an essential
component of the brain’s system for controlling
movement and coordination. As Parkinson’s dis-
ease progresses, cells of the basal ganglia increas-
ingly die, signi cantly reducing the amount of
dopamine available in the brain. The primary
motor symptoms of Parkinson’s disease include
bradykinesia (slowed movement), stiffness of
the limbs and trunk, tremors, and impaired bal-
ance and coordination. Dance may help allevi-
ate these symptoms, as the dance is a form of
rhythmic auditory stimulation (RAS). In this
technique, a series of xed rhythms are pre-
sented to patients, and the patients are asked to
move to the rhythms. Studies of the effects that
this technique has on patients with movement
disorders have found signi cant improvements
in gait and upper extremity function among par-
ticipants [112–114]. Although there have been
no scienti c comparisons of RAS with dance or
music therapy, individuals with Parkinson’s
“speak and walk better if they have a steady
rhythmic cue” [115].
At the Osher Center for Integrative Medicine
at Brigham and Women’s Hospital, Peter Wayne
et al. [116] have conducted clinical trials designed
to evaluate the safety and ef cacy of tai chi for
patients with Parkinson’s and other balance dis-
orders. Tai chi, now performed as exercise, is a
self-defense Chinese martial art. Wayne considers
tai chi to be a more ritualized, structured form of
dance. Tai chi is an exercise that bene ts for both
balance and mental function. Wayne and col-
leagues contend that the increased susceptibility
to falls occurring among the aged, who also suf-
fer from movement impairments including
Parkinson’s, can be mitigated by tai chi as it
improves exibility and strength as well as cog-
nitive performance [116].
132
A study appearing in the New England Journal
of Medicine in 2012 [117] found that tai chi
helped improve balance and prevent falls among
people with mild to moderate Parkinson’s dis-
ease. Those who practiced tai chi twice weekly
had better balance and were physically stronger
compared with those who did either weight train-
ing or stretching after 6 months. Participants per-
forming tai chi achieved balance measures that
were twice as good compared with weightlifters
and four times better than those participants who
stretched. Those people who practiced tai chi
also fell less and had slower rates of decline in
overall motor control.
Animal research suggests that an amalgam of
sensory enrichment and physical activity has a sig-
ni cant and sustaining effect on adult neuroplasti-
city. Dancing has been suggested as a vehicle for
intervention in neurological compromise, as the
dance poses demands on physical, motor, and cog-
nitive functions. Rehfeld et  al. [118] reported the
results of the effects of a challenging dance program
in which elderly participants were required to learn
novel and increasingly dif cult choreographies.
This 6-month-long program was compared to con-
ventional tness training matched for intensity. The
pre/post-assessment measured general cognition,
attention, memory, postural and cardio-respiratory
performance, and neurotrophic factors along with
an examination of changes in MRIs. These investi-
gators found differences in the effects on brain vol-
umes. When dancing interventions were compared
to conventional tness activity, larger volume
increases in more brain areas, including the cingu-
late cortex, insula, corpus callosum, and sensorimo-
tor cortex (represented in Fig. 10.3a, b) were noted
for the dancing intervention. Only dancing was
associated with an increase in plasma BDNF levels
(brain-derived neurotrophic factors highly associ-
ated with fomenting neuroplasticity). Both groups
improved in attention and spatial memory manifest-
ing no signi cant group differences.
Kim and associates [119] performed a study
of the effects of dance on the cognitive function
in elderly individuals with metabolic syndrome.
Metabolic syndrome is highly associated with an
increased risk of cognitive impairment [120–
122]. The purpose of their investigation was to
G. Leisman and V. Aviv
examine the effects of dance exercise on cogni-
tive function in elderly patients with metabolic
syndrome. Their participants included 38 elderly
metabolic syndrome patients with normal cogni-
tive function. Their dance-exercise group per-
formed dance exercise twice a week for 6 months.
Cognitive function was assessed in all partici-
pants. Compared with the control group, the
exercise group signi cantly improved in verbal
uency, word list delayed recall, and word list
recognition. Their results indicated that 6 months
of dance exercise improved cognitive function in
older adults with metabolic syndrome.
Hackney and Earhart [123] had examined the
effects of dance on gait and balance in Parkinson’s
disease. They found that tango dancing with part-
ner has a signi cant effect on gait and balance.
Partnered tango dance can improve balance and
gait in individuals with PD.  They compared the
effects of partnered to nonpartnered dance on bal-
ance and mobility in individuals with mild-
moderate PD.  Balance and gait were compared
after 20 lessons within 10 weeks. Both groups the
partnered and nonpartnered groups reportedly
demonstrated improvement as rated by the Berg
Balance scale, with no signi cant differences noted
between the partnered and nonpartnered groups.
In yet another recent study by de Natale et al.
[124], these investigators explored the outcomes
of Dance Therapy (DT) and Traditional
Rehabilitation (TR) on both motor and cognitive
domains in Parkinson’s disease patients with pos-
tural instability. Sixteen PD patients with recent
history of falls were divided into DT and TR
groups. Motor (Berg Balance Scale, Gait
Dynamic Index, Timed Up and Go Test, 4 Square-
Step Test, and 6-Minute Walking Test) and
cognitive measures (Frontal Assessment Battery,
Trail Making Test A and B, and Stroop Tests)
were tested at baseline, after the treatment com-
pletion and after eight-week follow-up. Motor
and cognitive outcomes signi cantly improved
after treatment and were retained after follow-up
in the DT but not in the TR group. Their ndings
support the notion that DT is an intervention for
PD patients, which effectively impacts on motor
(endurance and risk of falls) and on executive
functioning.
10 A Neuroscience of Dance: Potential for Therapeusis in Neurology 133

Lingual MCC/ MCC/

gyrus SMA SMA

v1

ACC

Middle frontal Cerebellum

gyrus
Culmen

Temporal Pole Cerebellum

Superior
temporal
gyrus

a Precentral Postcentral Insula

gyrus gyrus
Corpus Corpus
callosum AWS
callosum

AWS

OWS

TWS OWS
Inferior Inferior
parietal parietal
AWS
lobe lobe

b
Inferior fronal gyrus Corpus callosum

Fig. 10.3 Compared to typical tness programs, Rehfeld
et  al.’s [118], 6-month dancing program increased vol-
umes in regions which relate to higher cognitive processes
such as working memory and attention that are speci -
cally affected by age-related deterioration. Dancing stim-
ulates simultaneous processes of spatial orientation,
movement coordination, balance, endurance, interaction,
and communication all associated with age-related
declines and structured partnered dancing can provide a
potentially therapeutic effect. Here presented are (a) gray
matter volume increases for the contrast dance > sport
(red-colored) and for the contrast sport > dance (blue-
colored). ACC anterior cingulate cortex, MCC medial cin-
gulate cortex, SMA supplementary motor area, V1 primary
visual cortex (from https://doi.org/10.1371/journal.
pone.0196636.g002). (b) Comparison of white matter
volume increases for the contrast dance > sport (red-
colored) and for the contrast sport > dance (blue-colored).
AWS anterior white matter, OWS occipital white matter,
TWS temporal white matter. (From https://doi.
org/10.1371/journal.pone.0196636.g003)
134
Individuals having suffered a stroke may have
done so for numerous reasons. Whether dysfunc-
tion of the autonomic nervous system is a cause
or an effect, post-stroke it is certainly an issue to
be examined and treated, prophylactically or oth-
erwise. We know that physical inactivity and low
resting heart rate variability (HRV) are associated
with an increased cardiovascular deconditioning,
risk of secondary stroke and mortality. Dance
offers the possibility of multidimensional physi-
cal activity and recent research supports its appli-
cation as a valid alternative cardiovascular
training [125, 126].
Sampaio et  al. [126] evaluated cardiac auto-
nomic modulation in individuals with chronic
stroke post-training using a virtual reality-based
aerobic dance training paradigm of 6 weeks dura-
tion. HRV analysis pre- and post-intervention
consisted of HRV for 10 min in the supine and
quiet standing positions. High-frequency (HF)
power measures as indicators of cardiac para-
sympathetic activity, low-frequency (LF) power
of parasympathetic-sympathetic balance, and LF/
HF of sympathovagal balance were calculated.
YMCA submaximal cycle Ergometer test was
used to acquire VO2 max pre- and post-
intervention. After training, participants demon-
strated a signi cant improvement in autonomic
modulation. Post-training the participants had
signi cantly higher VO 2max, thereby justifying
dance as an adjunct therapy in stroke
rehabilitation.
Patterson et  al. [127] produced a systematic
review of papers studying or purporting to have
studied the value of dance as a rehabilitation tool
in numerous conditions. Their systematic review
supported the use of dance in adults with a vari-
ety of neurological conditions, not only those
suffering from PD.  Their results suggested that
dance is a useful interventional tool for adults
with neurological conditions that can affect gait
and balance such as stroke, multiple sclerosis,
and Huntington’s chorea with no adverse events
reported. While the types of dance varied across
studies as did the frequency and duration of
classes. These ndings contrasted with a system-
atic review of dance in PD, which included stud-
ies focused primarily on tango [128].
G. Leisman and V. Aviv
Patterson et al.’ [127] review found that gains
in gait, balance, and functional mobility could be
made with diverse forms of dance with numerous
neurological conditions. The current review
revealed that intensity of the program was rarely
reported when describing the dance intervention.
It should be noted, however, that the majority of
studies analyzed in Patterson et al.’s [127] analy-
sis were randomized controlled trials and the
quality of ve of the nine studies reviewed were
rated poor or fair and therefore de nitive conclu-
sions about the effects of dance cannot be made
at this time.
However, all six studies that measured func-
tional mobility reported improvement with
dance and three of those were rated good qual-
ity. The ndings for the effects of dance on spa-
tiotemporal parameters of gait differed between
studies; for example, velocity declined in some
studies and did not change in others, whereas
double support time was improved in another
study.
The effects of dance on gait as measured by a
clinical scale were more consistent; both studies
that used the Dynamic Gait Index were rated as
good quality and both reported improvement.
Finally, some of the changes reported on gait
velocity and Berg Balance Scale scores for indi-
viduals with stroke exceeded published MID cut-
offs suggesting that some changes made with
dance are likely to have an impact on partici-
pants’ function. Given the indication of positive
changes with dance in some studies with better
quality ratings, further investigation of the effects
of dance on balance, gait, and functional mobility
of people with neurological conditions other than
PD is warranted.
In conclusion, the use of dance for neurologi-
cal conditions other than PD has received very
little attention. Like PD, many adult neurological
conditions involve damage to central nervous
system structures and feature motor impairments
resulting in gait, balance, and mobility dysfunc-
tion (admittedly due to different underlying
pathologies) that could be improved with a dance
program. It can be concluded that dance holds
promise as an intervention to improve gait, bal-
ance, and mobility in a variety of disorders. The
10 A Neuroscience of Dance: Potential for Therapeusis in Neurology
neurophysiological justi cation for such inter-
ventions re ected in the current literature is
self-evident.
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 Literature and Neurosciences:
The temps perdu, Between
Hermann von Helmholtz
and Marcel Proust
Marco Piccolino
11.1 Proust Versus Helmholtz
It might be dif cult to imagine two personalities
as different as Helmholtz and Proust.
Although not insensible to literature and art,
Helmholtz appears to be a typical (although
very great) expression of the nineteenth century
German scientist, with his unlimited con dence
in science and scienti c rationality. An experi-
mentalist with a prodigious productivity in a
huge variety of elds, he was also a great theo-
retician and played a very signi cant role in the
emergence of the modern scienti c attitude out of
a vision of the world dominated by the enchant-
ments of the romanticism with its tendencies to
irrationality and metaphysics. Like most nine-
teenth century exponents of the intellectual elite
of his country, he had a profound knowledge of
philosophy. However, he had a negative attitude
toward the philosophy of his age, and in particu-
lar, toward Hegel and his followers. Kant was his
intellectual reference, mainly because the enlight-
ened rationalism of the Königsberg philosopher,
with his con dence in the causality principle,
provided solid grounds for scienti c knowledge.
In the matter of art and literature, Helmholtz’s
tastes were, on the whole, rather traditional and
academic. He was a great expert on music and
devoted much attention to musical theory and
M. Piccolino (*)
Centre of Neurosciences, University of Ferrara,
Ferrara, Italy
© Springer Nature Switzerland AG 2020
B. Colombo (ed.), Brain and Art, https://doi.org/10.1007/978-3-030-23580-2_11
11
to the history of music, culminating in his Die
Lehre von den Tonemp ndungen, a masterpiece
encompassing both the science and the aesthetics
of hearing and music. However, even in the eld
of music, he seemed to be incapable of accept-
ing the challenge of modernity, and apparently of
appreciating German (and European) music after
Mozart and Beethoven, a music that did not con-
form to the classical notions of harmony (see [1])
(Fig. 11.1).
On the other side Marcel Proust, with his
apparently exasperating and almost morbid
sensibility, a symbol of the new century, more
modern but more fragile, whose reference is not
science and rationality, but aesthetics, art, and
history; the creator of a new and unique way
of writing, where words, sentences, and peri-
ods ow sometimes for whole pages apparently
without structure, but with the charm and fasci-
nation of musical phrases with mysterious and
captivating rhythms. Proust, author of a novel
without an evident story, where the subtle thread
of memory keeps together events disparate in
both place and time, with rapid movements
similar to sudden alterations of the heartbeat
(intermittences du cœur), and where the charac-
ters perform in an seemingly freeway, liberated
as they are from the rigid rules of any de nite
literary plot. Proust’s life became dominated by
his art so that he spent long years of his exis-
tence con ned in a sound-proof room, closed
to external world, sleeping during the day and
working at night, as if the absence of external
139
140
Fig. 11.1 The two
protagonists of our story,
Hermann von Helmholtz
(1821–1894) and Marcel
Proust (1871–1922)
interference made his interior senses more acute
and allowed him to recall the past moments of
his life, and to live them again, according to
more deep dimensions of literature and art. In
so doing, he could rediscover and recover the
past and “lost time” of his apparently dissipated
life, of which his literary work was a search (La
recherche du temps perdu). Proust appears to be
modern in both his musicals tastes (the “small
phrase of Vinteuil” which recurs in La recherche
is a “virtual” composition echoing the music of
contemporaneous artists), and in his philosophi-
cal interest (among his references there was
Henri Bergson, a philosopher who anticipated
some of the intellectual tendencies of the twen-
tieth centuries, certainly far beyond the limits of
Kant’s rationalism).
Is there any possibility of nding a link, an
intersection between such disparate personages
as Helmholtz and Proust?
The link could be the phrase “temps perdu” of
the title of Proust’s masterpiece, which seems an
echo of Helmholtz’s “latent time” in the muscle
response to electrical stimulation, a time that is
denoted as temps perdu in a communication of
the German scientist to the Paris Académie des
sciences read in the séance of 1st September
1851 [2]. Although the identity of the expressions
might be just a coincidence, there are indications,
albeit tenuous, to suggest that temps perdu (in
Helmholtz’s acceptance) might have recurred
M. Piccolino
in Proust’s work through the mediation of the
French medicophysiological culture.
In this chapter, I will try to retrace these
fragile connections that could possible between
Helmholtz and Proust, by following the lead-
ing thread of the temps perdu. It will be a long
research, as you will see, which would bring us
in disparate places and times. As—for instance—
from the Greenwich astronomic observatory of
the late eighteenth century, to the physiological
laboratory in Königsberg (the city of the famous
Kant’s promenades) at the mid of the next cen-
tury; or from Paris to Marseille, at an inde nite
time, following a letter travelling on the train
imagined by an eminent French scientist to
account for a famous Helmholtz’s experiment;
and to other real or ctitious places or times.
Before embarking for our scienti c and
literary journey, we need to be aware of the
fact that, far from being a pure literate totally
avulse from the science of his time—as it might
seem—Marcel Proust cultivated important sci-
enti c interests, particularly in the elds of
neurology, neurophysiology, and psychology,
and these interests transpire in his masterpiece.
Medicine dominated his scienti c culture for
various reasons. Among them is the constant
action exerted on his life by different patholog-
ical conditions, of both physical and psycho-
logical character (asthma in particular). Often
he consulted doctors, and, for a long time, he
11 Literature and Neurosciences: The temps perdu, Between Hermann von Helmholtz and Marcel Proust
nourished the plan of spending a long period
in a hospital or some other form of therapeutic
institutions, in France or abroad. Eventually,
between December 1905 and January 1906, he
spent 6  weeks in the clinic of Paul Sollier, an
important psychiatrist of the epoch. This epi-
sode, greatly expanded in its temporal limits,
will surface in the Recherche.
Marcel’s father, Achille Adrien Proust, was
an eminent physician, professor at the Paris
Medical Faculty (since 1855) and member of the
Académie de Médecine (since 1889), particularly
expert in infectious diseases, but also interested
in pathological conditions of neurological rel-
evance, such as aphasia and neurasthenia. Many
doctors frequented Proust house when Marcel’s
father was alive, and some of them resurface in
the personages of the Recherche. Medical books
were undoubtedly present in Marcel’s world,
both at his young age and in his more mature
years, when he attempted to understand the
nature of his diseases, and was particularly atten-
tive to the complex relations existing between
psyche and body, which were emerging in the
medicine and philosophy of the late nineteenth
century.
The list of doctors (and other scholars inter-
ested from various viewpoints to the study of
physical or psychical diseases) that Proust men-
tions in his published works, in his manuscripts,
and in his correspondence—because he had
read their books or for other reasons—is very
long. Besides the already mentioned Sollier, it
includes personages of very different scienti c or
historical relevance, as for instance, Jean Martin
Charcot, Charles Bouchard, Théodule Armand
Ribot, Jules Dejerine, Edouard Brissaud,
Paul Charles Dubois, Paul Richer, Wilhelm
Brügelmann, Fernand Widal, Joseph François
Babinski, Henri Vaquez, Jean Camus, Gustave
Roussy, Philippe Pagniez, and others. Proust’s
acquaintance with medicine and diseases is
attested also by the precision, in the Recherche
(and in correspondence) of the descriptions
of the symptoms of some diseases, and, more-
over, by the fundamental correctness, within the
framework of the contemporary medicine, of his
diagnosis and therapies (see [3]).
141
11.2 A Visuoacoustic Method
of Astronomic Observation
and the Errors at Greenwich
in 1796
Our journey in the search of an elusive link
between Helmholtz and Proust will start from the
Royal astronomical Observatory of Greenwich, a
few years before the end of the eighteenth cen-
tury, and will deal with the dif culties and intri-
cacies of the method used at the time to locate the
stars in the sky.
As we know, the observation of the transit of a
star with a powerful telescope requires an exact and
prompt determination of the position of the celes-
tial body moving rapidly across the sky, combined
with an accurate measurement of the passage time
with a subsecond precision. However, the chro-
nometers available in the period considered (and
also for some decades afterwards) were capable
of measuring time only to the nearest second.
To overcome these dif culties, James Bradley
(1693–1762) the third “Astronomer Royal” at
Greenwich developed an interpolation method
based on an “eye and ear” coordination. The tele-
scopic eld being divided by a mesh of parallel
wires, the observer had to track the rapidly mov-
ing star with respect to a wire of the mesh, and to
take into account the time, by counting the beats
heard from the clock. In order to make the mea-
sure with a greater precision than that allowed by
clock, he should note the star at the instant of the
clock beat just before it crossed the wire, and at
the beat time immediately after the passage, and
he should mentally interpolate the time fraction
corresponding exactly to the wire crossing.
Despite the complex sensory and mental tasks
involved, Bradley’s method was used up to the
mid-nineteenth century. It allowed an expert
astronomer to achieve a time precision of about
one tenth of a second. Sometimes, however, the
observations of the same star passage made by
two astronomers might differ by a considerable
amount. This turned to be the case at Greenwich
with David Kinnebrook (1772–1802), who, in
the period 1795–1796, repeatedly estimated a
stellar transit with a systematic difference of
about 800  ms with respect to his chief, Nevil
142
Maskelyne (1732–1811). After having been sum-
moned to use a more correct observation method,
Kinnebrook was eventually dismissed by his
chief at the end of 1796 [4, 5].
In 1818 the episode came to the attention of
Friedrich Wilhelm Bessel (1784–1846), direc-
tor of the Königsberg observatory. Besides
being one of the principal astronomers of his
age, Bessel was also a great mathematician, par-
ticularly interested in the theory of instrumen-
tal errors. By comparing his own observations
with those of other respected astronomers of the
epoch, he came to the conclusion that, in astro-
nomical observations, the case with Kinnebrook
and Maskelyne might be the rule rather than an
exception. The problem thus came to center stage
of astronomers’ attention, and it became evident
that an irreducible and systematic difference per-
sisted in spite of the greatest care in the observa-
tion process. Astronomers were then requested to
calculate their own difference with respect to a
standard observation (with a true star or with a
“simulated” star) and to express it as a “personal
equation,” in such a way as to permit a compari-
son between different observers.
The problem was eventually overcome by the
introduction, around 1850, of precise chronographs
and by the use of automatic methods for recording
star transit. Interest in the matter continued, how-
ever, up to about 1870. Bessel and others assumed
that the problem might depend on some property
of the physiological mechanism involved in the
complex task based on the interplay of visual and
auditory sensations. This pointed to the possibil-
ity that nervous and mental processes may require
a sizeable time, a possibility that contrasted with
the view, still dominating the science of the epoch,
that processes belonging to the sphere of percep-
tion were not amenable to the physical territories
of measurement and experiment (see [6–8]).
11.3 Hermann von Helmholtz
and the Measurement
of Nerve Conduction Time
In 1849, due to a series of complex academic
arrangements involving Ernst Brücke, Karl
Ludwig, Emil du Bois-Reymond, and Hermann
M. Piccolino
Helmholtz, an impressive quartet of disciples of
Johannes Müller, Helmholtz was appointed pro-
fessor of physiology at Königsberg. Although
aged only 28, he had already made fundamen-
tal contributions to both physiology and phys-
ics, along with a scienti c attitude that would
dominate all his scienti c life. From the aca-
demic viewpoint, this attitude would culminate
in his becoming appointed (in 1870) professor
of physics at the University of Berlin, the same
where he had graduated in medicine in 1842. The
interplay between physiology and physics had
marked the beginning of Helmholtz’s scienti c
life. In 1847, he had written his classical mem-
oir on the “Conservation of the force” (stipu-
lating what would become the rst principle of
thermodynamics), mainly to provide theoretical
grounds for his experiments on muscle physiol-
ogy. In these experiments, he showed that pro-
longed muscle contraction was associated with
detectable chemical changes in muscle tissue,
suggesting that the development of mechanical
force depended on physicochemical transforma-
tions in muscle [9].
Before moving to Königsberg, he was study-
ing muscle physiology and, in particular, he
tried to graphically record muscle contraction
by adapting the smoked drum method originally
developed by Ludwig. The rst results obtained
by Helmholtz with this method seemed to argue
against the view, held in particular by Edward
Weber (1806–1871), that the contraction induced
by an electric stimulus had an instantaneous time
course, beginning without any time delay at stim-
ulus onset and terminating abruptly at the end of
stimulation (see [10]).
Once he arrived in Königsberg in 1849,
Helmholtz rapidly established a friendship with
the astronomer August Ludwig Busch (1804–
1855), director of the local Observatory and
a former assistant of Bessel whom he had suc-
ceed upon his death in 1846. Very likely, through
conversations with Busch, Helmholtz became
familiar with the problem of the personal equa-
tion that still had a strong impact on the astron-
omers of the epoch. In the autumn of the same
year, he set up an experimental apparatus for
recording muscle contraction and started his rst
experiments on frog nerve-muscle preparations.
11 Literature and Neurosciences: The temps perdu, Between Hermann von Helmholtz and Marcel Proust
In these experiments, a short-duration electrical
stimulus (produced with an especially designed
inductive coil) was applied to a motor nerve, and
muscle contraction was recorded graphically.
From the outset, it appeared that the contrac-
tion lasted much longer than the stimulus and,
moreover, the muscle started contracting with a
clear delay after the end of a short electric pulse.
Furthermore, Helmholtz noticed that the delay
between the stimulus and the onset of contraction
varied, depending on experimental conditions
and, in particular, became longer as the nerve-
stimulating electrode was situated at progres-
sively greater distances from muscle body. In the
elusive way that characterizes great discoveries,
experiments initially aimed at investigating the
time course of muscle contraction, changed their
purpose in a somewhat radical way: they became
instead an attempt to measure the time required
for nerve conduction (see [11, 12]).
For various reasons, Helmholtz was able
to realize the importance of his experimental
Fig. 11.2 Emil du Bois-Reymond’s molecular model for
nerves and muscles. He theorized that each excitable ber
is made up of parallel cylinders (on right), each containing
electric molecules that would be negative at the poles and
positive across, and which would be lined up longitudi-
143
observation of the dependence of the contrac-
tion delay in the muscle on the distance from the
nerve segment stimulated. First he was familiar
with the problem of personal equation which had
led astronomers to suppose that a sizeable time
might be required for nervous function in gen-
eral and for conduction in particular. Moreover
he was acquainted with the work on nerve physi-
ology pursued in that period by his friend du
Bois-Reymond. According to du Bois-Reymond,
signal progression along nerve bers was an
electric event, but it differed from typical electric
conduction along metallic cables (a phenomenon
conceivably very fast), because it involved a spa-
tial rearrangement of the “electric molecules”
composing the core of excitable bers (see du
Bois-Reymond, 1848–1884). In Helmholtz’s
opinion, this movement would require a nite
time, and thus nerve conduction could not occur
at an immeasurably fast speed (as was generally
held by the supporters of the earlier physiological
doctrines) (Fig. 11.2).
nally (on left). The disruption of this orderly arrangement,
he argued, would result in the disappearance of the resting
current and result in the negative Schwankung, the propa-
gated excitation wave (from [13])
144
Of particular signi cance in this context was
Johannes Müller’s attitude, because it prob-
ably helped to stimulate Helmholtz to attempt to
measure what his great teacher had considered
immeasurable. Müller held the opinion that the
“nervous principle” was “an imponderable uid
or a mechanical undulation,” somewhat akin to
light, and should, therefore, propagate along nerve
bers at an extremely high speed. Consequently,
any attempt to measure the time necessary for
the propagation of a nervous signal along a nerve
trunk of limited length was, for Müller, doomed to
failure [14].
Having realized the importance of his achieve-
ment with nerve-muscle preparation, Helmholtz
tried to con rm his observations by using a more
precise method than that based on graphical
recording. The graphical method appeared unsat-
isfactory in terms of the quality of the tracings
(the vertical de ections monitoring muscle con-
traction were so small as to require a microscope
to be observed), as well as the repeatability and
reliability of results. Besides, conduction time
appeared to be a very small fraction of the total
time involved from stimulus onset to the comple-
tion of muscle contraction. It was therefore dif-
cult to measure the time difference between
the tracings corresponding to the muscle con-
tractions evoked by stimuli applied to different
places along the nerve.
Helmholtz thus made recourse to a more pre-
cise method developed by the French physicist
Claude Pouillet (1790–1868) and already used
in artillery for determining the speed of cannon
balls [15]. It was based on the observation that
the galvanometer excursion caused by short cur-
rent pulses was proportional to pulse duration.
By synchronizing the onset of the electrical stim-
ulus, it was thus possible to accurately measure
very short intervals. Another experimental design
derived from Pouillet consisted in arranging the
relationship between the animal preparation and
the stimulating device in such a way that frog
leg contraction automatically interrupted the
current passage (and thus terminated the time
measurement).
M. Piccolino
With the new method, Helmholtz obtained
suf ciently precise and reliable results in a series
of experiments begun at the end of 1849. With
the nerve stimulating electrode distance from
muscle varying from 50 to 60  mm, the time
from the stimulus onset to the start of contrac-
tion varied between 1.4 and 2 ms. At the begin-
ning of the next year, he had enough data to send
a short note to be presented at the meetings of
two scienti c societies of Berlin (the Akademie
der Wissenschaften, and the Physikalische
Gesellschaft; see [16, 17]).
The rapidity with which Helmholtz published
preliminary announcements concerning the pres-
ence of a “measurable time” for nerve conduction
betrays his conviction of the epochal importance
of his achievement. It was the rst unequivocal
measurement of the time required for the pro-
gression of nervous signal, the elusive message
that in ancient medicine was supposed to involve
mysterious entities indicated as “animal spirits,”
the agents mediating the relationship between
the immortal soul and the corporeal body in both
sensory and motor mechanisms (see [12]).
By showing that nerve conduction involves
quanti able physical phenomena, Helmholtz was
concluding a millenary endeavor of humankind
toward a scienti c comprehension of nerve func-
tion. At the same time, he paved the way for a
new scienti c approach to the experimental study
of nervous (and mental) functions. In a sense,
Helmholtz’s was just one contribution in this direc-
tion, which acted together with other important
achievements of the epoch such as, for instance,
Müller’s formulation of the law of the speci city
of nervous action, Carlo Matteucci’s (1811–1868)
and Emil du Bois-Reymond’s demonstration of
the role of electricity in the function of excitable
tissues and Gustav Theodor Fechner’s (1801–
1887) rst quantitative assessment of sensations.
Yet, as was accurately remarked, Helmholtz’s
measurement of nerve conduction speed was “so
dramatic that it did more than any other single bit
of research to advertise the fact that mind is not
ineffable but a proper subject for experimental
control and observation” ([18], p. 45).
11 Literature and Neurosciences: The temps perdu, Between Hermann von Helmholtz and Marcel Proust
11.4 A Disconcerting Discovery
We are now accustomed to the idea that mental
activity involves various physiological processes
taking place in speci c circuits of our brain and
leading to a variety of manifestations, as ner-
vous signals propagate toward the periphery of
our body. We also know that time is required
for nerve signal conduction and for more elabo-
rate nervous operations, particularly when these
involve a multitude of synapses with their com-
plex machinery. We may thus have dif culties
in appreciating what Helmholtz’s demonstration
of a nite (and relative long) nerve conduction
time could mean for the mentality of the period,
and how hard was to accept the idea of a time
lag between a mental act and its bodily expres-
sion. In 1850, Helmholtz’s father, in congratulat-
ing his son for his brilliant achievement, could
not refrain from expressing his perplexity on that
point of view:
As regards your work, the results at rst appeared
to me surprising, since I regard the idea and its
bodily expression not as successive, but as simulta-
neous, a single living act, that only become bodily
and mental upon re ection ([19], vol. II, p. 122).
In order to undermine his father’s astonish-
ment, Hermann observed that the existence of
a delay in nerve conduction did not imply any
speci c statement on the temporal character of
mental process. In the case of hearing, he noted,
it was just adding to the time required from stim-
ulus to sensation, an additional “nervous” delay
which added to the time already needed for the
transmission of sound waves along the middle
and inner ear. Elsewhere he remarked that nerve
conduction, although slow compared with other
communication processes, was fast enough for
physiological requirements. Only in the case of
very large animals might it involve consider-
able times: in a whale, for instance, it might take
about a second for a sensory signal originating in
the tail to reach the brain.
To support the idea that nerve processes
required time, in his letter, Helmholtz alluded
to the “personal equation” which, in his view,
pointed to the possible variations of time esti-
mation by different sense organs (eye and ear).
145
He also mentioned the dif culty encountered in
ascertaining the synchrony of two clock beats
perceived by the two different ears, which might
in part be accounted for by small conduction dif-
ferences in the two cochlear nerves.
In his further experiments on nerve conduc-
tion, Helmholtz decided to return to graphical
recordings of the time course of muscle contrac-
tion, inspired by the Kymographion invented by
his colleague Karl Ludwig [20]. Although this
method appeared to be less precise, it was more
expressive than Pouillet’s method as a visual
illustration of the results was obtained. By care-
fully improving his Myographion (the ancestor
of modern myographs), Helmholtz recorded reli-
able tracings which he presented in 1852 in his
extended paper [21].
11.5 The “Temps Perdu”
In order to ensure priority for his discovery at an
international level, Helmholtz also sent two com-
munications to the French Académie des Science
in Paris, one in 1850 [22] and another in 1851.
In the second communication (Deuxième note…
[2]) he rst presented the data obtained with
Pouillet’s method, and estimated the conduction
velocity obtained in this way to be about 26 m/s.
He also referred to the graphical method by not-
ing that it was “a more expedite method […]
requiring a smaller number of experiments.” After
describing this method in some detail, Helmholtz
concluded that the “measurements obtained with
the new method are in perfect accordance with
those provided by the method of Pouillet.”
For the theme of our chapter, the second com-
munication is of particular interest because it
contains the rst instance of the phrase “temps
perdu” that would recur about 60  years later
in the title of Marcel Proust’s masterpiece (see
Fig. 11.3). Interestingly in Helmholtz’s Deuxième
note, this phrase is rst used, not to describe the
physiological time lost in the nerve conduction
process, but only to say that, in the case of an
instantaneous electrical stimulus applied directly
to muscle, there is a latency between stimulus
and response.
146
Fig. 11.3 The passage of the original draft of the com-
munication sent by Helmholtz to the French Académie
des Sciences in 1851, where the phrase “temps perdu”
appears for the rst time to indicate the latency of muscle
response to direct electric stimulation. The writing is not
Very likely Helmholtz was tracing, in a faith-
ful way, the path that had led him to his discov-
ery. As already discussed, initially he started his
experiments in order to ascertain whether the
muscle contraction excited by an electrical stim-
ulus was an instantaneous process, closely corre-
sponding to the stimulus time course (see [10]).
It turned out not to be so, and, in particular, the
initial mechanical effect was detectable shortly
after the stimulus. Helmholtz wrote that a temps
perdu (italics are Helmholtz’s) is thus present
in the muscles of animal life (i.e., striated or
voluntary muscles, the kind of muscle involved
contraction of frog legs); however, in these
muscles this “lost time” was much shorter than
in the muscles of organic life (i.e., the smooth
muscles of viscera), a kind of muscle whose
slow time course was well known. Afterwards
he presented what is his main achievement, the
discovery of the nite time necessary for the
nerve conduction process, simply as an augmen-
tation of the temps perdu between the applica-
tion of electric stimulus and contraction onset,
an augmentation evident when the stimulus was
on a motor nerve further away from its insertion
into the muscle. In all, the phrase temps perdu
recurs three times in Helmholtz’s Deuxième
note (only at the rst occurrence it is in italics),
and this occurs in the same page (p. 263) of the
Académie Proceedings.
M. Piccolino
Helmholtz’s, but of du Bois Reymond, the closest friend
of Hermann von Helmholtz, who helped him in translat-
ing the text of the communication into French (From the
Archive of the Berlin Brandenburgische Akademie der
Wissenschaften, NL Helmholtz 526)
11.6 A “Travelling Letter”
from Helmholtz to Proust
via Marey?
In order to proceed forward to trace the path
which might lead from the temps perdu of
Helmholtz to that of Proust let us rst see how
Helmholtz’s phrase arrived in the French scien-
ti c literature.
The phrase is present in La machine ani-
male [23], a book published in 1873 (more
than 20  years after Helmholtz’s experiments)
by Etienne Jules Marey (1830–1904) an impor-
tant French physiologist, then Professor at the
Collège de France and member of the Académie
de Medicine (in 1878 he would also be elected at
the Académie des Sciences).
From his rst experimental studies (and up to
the end of his career), Marey had been interested
to the graphical recording of a variety of physi-
ological events (muscle contraction, heart and
respiratory movements, blood pressure and vascu-
lar pulsations, locomotion in humans and quadru-
peds, ight in insects, and birds). He had a special
talent in developing new instruments or improving
previous ones, and his initial essays were mainly
devoted to improving the graphic methods devel-
oped by German scientists, notably by Helmholtz.
Later on he developed photographic methods and,
in that regard, he is considered to be one of the
11 Literature and Neurosciences: The temps perdu, Between Hermann von Helmholtz and Marcel Proust
pioneers of cinematography (on this aspect of
Marey’s work see particularly Braun, [24]).
In order to study the mechanical pulsation of
blood vessels, and particularly of arteries, Marey
developed one of his many recording instru-
ments, the “sphygmograph” (a much improved
version of an instrument invented by Karl
Vierordt [25]. He could thus also investigate vari-
ous kinds of alterations of cardiac rhythm. Due
to his achievements, Marey became the leader of
French physiology in the second half of the nine-
teenth century. Figures portraying the recording
instruments he had invented and illustrating his
experiments (particularly in muscle and cardiac
physiology, with his myographic and sphygmo-
graphic tracings) were almost constantly present
in any French textbook of physiology up to the
rst decades of the twentieth century.
In La machine animale, Marey makes a
detailed reference to Helmholtz’s temps perdu
in nerve conduction, a reference that is interest-
ing and rich in suggestion mainly because of a
metaphorical argument used in order to clarify
the problems with Helmholtz’s experiment. For
Marey, Helmholtz’s case with nerve conduction
studies is formally similar to the measurement
of the (average) speed of a mail train, which
transports a letter, by knowing the exact time of
the train departure (from say to Paris), and the
time of letter delivery to the addressee (living for
example in Marseille), but ignoring the time of
train arrival to the nal station (Marseille). The
dif culty comes from the ignorance of the time
needed for the letter to arrive from the station
of Marseille to the very nal destination (i.e., in
the hands of the addressee), a time required for
a series of postal operations. Had this time been
known, it would be easy to ascertain the time
needed for the train to go from Paris to Marseille,
and thus to measure the average train speed.
Having introduced his metaphorical argu-
ment, Marey is on safe ground in illustrating
Helmholtz’s experiments on the muscle contrac-
tion evoked by electrical stimulation. He says that
Helmholtz had discovered that “not all the time
elapsed from the excitation to the contraction is
147
taken by the transportation of the nervous agent;
but that the muscle, once it has received the order
carried by the nerve, is for one instant at rest
before acting.” He continues by saying: “It is what
Helmholtz has called temps perdu,” and notes that
this time would correspond, in his metaphorical
example, to “the duration of the preparatory work
made between the arrival of the letters and their
delivery.”
The phrase is repeated twice more by Marey,
always in italics, and always taken to mean the
time taken by local processes in muscle after the
arrival of the excitation and before the develop-
ment of any visible contraction. Of course, Marey
reports how Helmholtz succeeded in measuring
the nerve conduction time by placing the stimu-
lating electrode on the nerve at various distances
from muscle. In a further chapter of the Machine
animale (Chap. 6), in dealing with the discharge
of electric sh, Marey comes again to the temps
perdu. He reports there the results of an experi-
ment (already published in a preliminary form in
1871, [26]) aimed at measuring the conduction
velocity in the nerves of the electric organs of the
torpedo.
A description of Helmholtz’s experiments,
very similar to that in the Machine animale (with
the recourse to the metaphorical argument of the
travelling letter) would appear in later Marey’s
publications, as, for instance, in his book La
Méthode graphique, rst published in 1878
[27]. In Marey’s work, however, the mention of
Helmholtz’s temps perdu precedes the Machine
animale. It appears, for instance, in a book pub-
lished in 1868, a collection of lectures given at
the Collège de France (Du Mouvement dans le
fonctions de la vie, [28]). There is, however, no
reference there to the metaphorical argument of
the travelling letter. As in many other occasions
in his books, in Du Mouvement, Marey also dis-
cusses the problem of conduction speed in sen-
sory nerves (by alluding to further experiments
made by Helmholtz and others) and, moreover,
he considers the delay in re ex motor responses.
Marey would deal again with Helmholtz’s
temps perdu in other publications. For instance,
148
in 1875, in a memoir published in the rst volume
of the Travaux, he noted the existence of a delay
in the heart muscle contraction evoked by electric
stimulation [29]. Marey commented by saying
that this delay corresponds, in heart physiology,
to the temps perdu discovered by Helmholtz in
striated muscles (although, as he noted, in the
heart the temps perdu is much longer than in stri-
ated muscles, 1/3 versus 1/100 of a second).
Due to his progressively increasing author-
ity in the scienti c world, and also at a more
public level (among others, he was invited to
give a demonstration of the sphygmograph by
Napoleon III), Helmholtz’s temps perdu spread
from Marey’s publications to the scienti c litera-
ture of the time.
A reference to it became almost inevitable in
French textbooks of physiology in the second
half of the nineteenth century and it appeared
with signi cant frequency also in the rst half
of the twentieth century (and it is still present in
some relatively recent textbooks, as, for instance,
in the third edition of the Precis de physiologie of
Herman and Cier published in 1974).
Very probably Marey’s use of the metaphori-
cal argument of the travelling letter, and likely
also subtle linguistic reasons (in French, perdu
referred to temps means, at the same time, elapsed,
lost, wasted) contributed to this diffusion, and to
the consolidation of Helmholtz’s temps perdu in
French scienti c literature. Compared to phrases
such as période latente, période de l’excitation
latente (which more faithfully re ect the German
phrase “Zeitraum der latenten Reizung” used by
Helmholtz), also employed to indicate the same
phenomenon, temps perdu more likely captured
reader’s attention and was more easily retained
for the richness of the suggestions implied.
In the scrutiny of physiological textbooks
and related publications that I have been able
to perform, temps perdu (in Helmholtz’s accep-
tance) appears with an impressive frequency.
Apart from in textbooks, it appears in periodicals
(as for instance, in the Comptes rendus of the
French Académie des Sciences), and is particu-
larly frequent in the Travaux of Marey’s labora-
tory (with the impressive score of 56 recurrences
in a long memoir published in 1880 by Maurice
M. Piccolino
Mendelsson, [30]). Among the textbooks exam-
ined, temps perdu may appear even 9–10 times
in the same page (as for instance, in some edi-
tions of Arthus’ Éléments de Physiologie and of
Beaunis’ Éléments de Physiologie humaine). In
Arthus’ book, the phrase is also indexed in the
“Table of contents.”
In the case of Beaunis’ volume, temps perdu
rebounds into the Italian edition of the textbook,
due to Vittorio Aducco (1860–1937), where it
appears ten times within a single page as tempo
perduto. In the Italian version, the phrase also
appears in Luciani’s physiology textbook, a mon-
umental work that had numerous editions and
was translated into various languages including
German, English, and Spanish.
11.7 “Intermittences Du Cœur,”
Sphygmographic Tracings
and Writing
In Marcel Proust’s epoch, temps perdu, used to
mean the time of nervous conduction and the
time lost by fundamental physiological processes
involved in any sensory, motor, and psychologi-
cal action, was present in the French scienti c lit-
erature, mainly through the mediation of Marey,
who had introduced Helmholtz’s experiments to
the French scienti c audience in an expressive
and easily understandable way. Proust might thus
know temps perdu in Helmholtz’s sense, and this
possibility is made more likely by the fact that
Proust’s father, Achille Adrien, was acquainted
with Marey (both were members of the Académie
de medicine) and on some occasions they had
even collaborated. Adrien Proust was one of
the main French experts of cholera, a subject to
which Marey had devoted a study in 1865. In
1885, Marey was the rapporteur of a Committee
of the Académie de Medicine charged to prepare
a report on the cholera epidemic of 1884 and
Adrien Proust was one of the Committee mem-
bers (see [31]).
I have not been able to trace any positive evi-
dence in Proust’s correspondence (and in the
other papers consulted), that Proust referred to
Helmholtz’s temps perdu when, in the period
11 Literature and Neurosciences: The temps perdu, Between Hermann von Helmholtz and Marcel Proust
1911–1912, he nally chose the general title for
the book he was writing and beginning to publish.
However, there are some suggestions of a pos-
sible “resonance” of Helmholtz’s phrase (through
Marey’s mediation) in the title of La recherche du
temps perdu.
Before arriving to the nal decision, Proust
had already in mind “temps perdu” for the title of
his work. It was when he was contriving to con-
centrate the material that he was accumulating in
the long nights of creative self-reclusion in his
sound-proof room in only two volumes. Initially,
Temps perdu would be the title of the rst vol-
ume and Temps retrouvé the title of the second.
Interestingly, at this stage, the general title would
be Les intermittences du cœur, a title that, in the
published edition, would remain to designate
only one episode of Sodome et Gomorrhe. Here
it is used to indicate—as already mentioned—the
psychological (and literary) process whereby
the past and forgotten time may suddenly come
again to the conscience, thus revealing the deeper
aspects of reality that were not initially apparent.
As Proust explicitly recognizes, intermittences
du cœur, is of medical derivation.
In the physiological and clinical terminology
of the epoch, intermittences du cœur was used
to designate a variety of troubles of the cardiac
rhythm, notably those characterized by a sud-
den cessation of the beat and by a subsequent
reappearance of the pulsations, generally of a
particularly strong intensity (i.e., the extrasys-
tolic conditions according to modern terminol-
ogy). Together with other alterations of cardiac
rhythm, the intermittences had been intensively
studied from the second half of the nineteenth
centuries, thanks mainly to the recording appa-
ratus invented by Marey. In particular, sphygmo-
graphic tracings had become popular as a way for
characterizing and documenting heart diseases
(see, for instance, [32]) (Fig. 11.4).
In this context, it is interesting to note that,
in 1905, a reference to sphygmographic trac-
ings appears in a work of Proust, which marks
a fundamental phase of the path that would
eventually lead him toward La Recherche. This
occurs in a long footnote added by Proust to
his French translation of a conference of John
149
Ruskin (1819–1900) on the importance of read-
ing (Sesame and lilies). The footnote appears in
relation with a passage in which Ruskin com-
ments on the importance of choosing accurately
the words in translating a text.
Proust writes:
Ruskin, who has so well and so often shown that
the artist, in what he writes or in what he paints,
infallibly reveals his failings, his affectations, his
defaults (and as for the hidden rhythm of our
soul—much more vital than that we perceive it
ourselves—is not indeed the work of art similar to
those sphygmographic tracings where the pulsa-
tions of our blood inscribe themselves in an auto-
matic way?), Ruskin should have seen that if the
writer obeys in its choices to a concern for erudi-
tion […] it would happen that it is this concern for
erudition  – interesting as it could be, but never
more than interesting—which would be re ected,
which would inscribe itself in his book. ([34],
pp. 93–94).
Afterwards Proust brie y discussed the atten-
tion devoted by different authors to the choice of
words, with results which may be very diverse.
In some of them, the recourse to a term particu-
larly re ned or of an ancient taste may simply be
the expression of “second order” talent. In oth-
ers, as, for instance, Victor Hugo, the attention
to the wording would result in literary effects of
great moment. However, Proust says, echoing
Schelling’s romantic theory of artistic creation
(see [35, 36]), before starting his work, the good
writer knows his dictionary and the texts of the
great writers from whom he draws his linguistic
inspiration well.
In the act of writing he does not think of them any-
more, but he cares of what he wishes to express,
and chooses the words that express that at the best,
with the greatest force, color, and harmony. He
chooses them from an excellent dictionary, because
it is the dictionary which, in his memory, is avail-
able for him, since his studies have established the
propriety of each word. But he does think of them
[i.e., the great writers] when he writes ([34], p. 95).
There might be other arguments to suggest
that, besides a simple verbal correspondence,
there is some more deep analogy between
Helmholtz’s and Proust’s temp perdu. The pro-
tagonist of Proust’s Recherche is able to give a
real meaning to the events of his life, not in the
150
Fig. 11.4 Marey’s portable sphygmograph (a), and (b) a recording obtained with this instrument of an intermittence
du coeur (or extra-systolic beat, according the modern terminology (from Marey 1881, [33])
actuality of their presence, but only when he is
able to recall them and live them again through
the lter of his memory. Thus he can confer a
deep reality to these events only when they have
gone away, and are thus lost in the ordinary sense
of the irreversible ow of time.
Helmholtz’s discovery that an elusive time is
taken by fundamental physiological processes,
and particularly by nervous conduction, and that,
by consequence, things come to consciousness
after a de nite (although short) time, points to
the existence, even in the physico-physiological
aspects of our nervous and mental activity, of a
reality nonperceptible at the very moment of its
presence. It opens a rst window to the existence,
even in the physicality of our body, of hidden
processes, a window through which men would
eventually penetrate the existence of a variety of
processes happening below the conscious level
which are, nonetheless, capable of shaping their
life, their way of thinking and behaving, both at a
private and at a social and historical level.
M. Piccolino
One could propose this, and other resonances,
between the temps perdu of Helmholtz and of
Proust, a writer interested in medicine and psy-
chology, and particularly in the mechanism of
memory, and puzzled by the existence of memo-
ries which we can never be able to recollect in a
conscious way.
However, in the absence of compelling and
documented evidence of a link between Proust
and Helmholtz-Marey, we prefer just to say that
it is likely, in putting temps perdu in the nal title
of his Recherche, Proust was thinking neither of
Helmholtz nor of Marey, but he was choosing a
phrase from his dictionary, a rich dictionary to
which surely his medical culture had contributed,
because, as already noted, when a writer chooses
his words:
He chooses them from an excellent dictionary,
because it is the dictionary which, in his memory,
is available for him, having his studies established
the propriety of each word… but he does think of
the excellent writers who might have contributed to
his dictionary.
11 Literature and Neurosciences: The temps perdu, Between Hermann von Helmholtz and Marcel Proust
Acknowledgements This is largely based on two my pre-
vious texts on the same themes, an article in English,
appeared in 2003 on Audiological Medicine [37], and a
more ample writing, published as a chapter of my book in
Italian printed in 2005 and entitled Lo Zufolo e la Cicala,
Divagazioni galileiane tra la scienza e la sua storia [3].
Many thanks to Alessandro Martini, editor of Audiological
Medicine for viewing in a favorable way this new version
of my former English essay. My texts on Helmholtz and
Proust were inspired by a stimulating essay of Thomas
Schestag [31]. In order to make this chapter more read-
able, I have not indicated in the present chapter most of
the bibliography on Proust that I have consulted. Besides
the correspondence (mainly in the edition of Kolb, [38]),
classic biographies (as, for instance, that of Painter [39],
and of Tadié [40]), and speci c essays, I have pro ted
mainly of the works of Mariolina Bongiovanni Bertini,
Anna Maria Contini, Anne Henry and Giovanni Macchia
(some of which are listed among the references: see [41–
47]). In order not to make the reference list excessively
long, I have also decided not to include the textbooks of
physiology that I have searched for the occurrence of
temps perdu. I wish to thank the many colleagues and
friends that have read previous versions of this manuscript
and have encouraged this work, somewhat outside my
speci c eld of interest. Among them Livia Iannucci,
Giacomo Magrini, Alessandro Martini, Dafydd Stephens,
Paolo Mazzarello, Germana Pareti, and particularly, Dora
and Hersch Gerschenfeld.
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séances de l’Académie des Sciences de Paris, vol. 32.
Paris: Académie des sciences; 1851. p. 262–5.
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Boringhieri; 2005.
4. Mollon JD, Perkins AJ.  Errors of judgement at
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Nerven. Zweite Reihe. Arch Anat Phys Wiss Med.
1852;19:199–216.
22. Helmholtz H.  Note sur la vitesse de propagation de
l’agent nerveux dans les nerfs rachidiens. Comptes
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Paris, vol. 30. Paris: Académie des sciences; 1850.
p. 204–6.
23. Marey E-J. La machine animale: locomotion terrestre
et aérienne. Paris: G. Baillière; 1873.
24. Braun M.  Picturing time: the work of Etienne-Jules
Marey (1830–1904). Chicago, IL: The University of
Chicago Press; 1992.
25. Vierordt C.  Die Lehre vom Arterienpuls in gesun-
den und kranken Zuständen, gegründet auf eine neue
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26. Marey E-J. Du temps qui s’écoule entre l’excitation
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27. Marey E-J. La méthode graphique dans les sciences
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la Vie, leçons faites au Collège de France. Paris:
G. Baillière; 1868.
29. Marey E-J. Mémoire sur la pulsation du cœur. Travaux
du Laboratoire de M. Marey. 1875;1:19–85.
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sain et à l’état pathologique. Travaux du Laboratoire
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Traduction, préface et notes de M.  Proust. Paris:
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la Pléiade; 1987–1989.
 Wax Anatomical Models
and Neuroscience: From Artistic
Italian Creation to Therapeutic
Approach
Alessandro Porro and Lorenzo Lorusso
12.1 Introduction
Wax, because of its chemical and physical char-
acteristics, is malleable, resistant to atmospheric
factors and absorbent. It has been used for a vari-
ety of purposes (religious, artistic and scienti c)
since ancient times and is obtained from many
sources such as animals, vegetables and minerals.
Wax was rst used in modelling gures, espe-
cially votive and ex voto statues [1, 2]. In
Florence, from the Renaissance to the Modern
era and in particular from the thirteenth to seven-
teenth centuries, an industry was established in
the production of coloured wax for its common
use in religious practice. Due to the dif culty in
obtaining cadavers in the seventeenth century,
anatomical studies became more scienti cally
based for investigative and teaching purposes.
Beforehand, many artists used wax to nd a suit-
able material to create a two-dimensional repre-
sentation of drawings. The wax anatomical model
was also precise, capable of illustrating many
dissections or of reproducing very complex struc-
tures, such as the plexus of lymphatic vessels,
dif cult to represent in a single drawing. Some
artists applied wax models on reduced scale, i.e.
A. Porro
Dipartimento di Scienze Cliniche e di Comunità,
Università degli Studi di Milano, Milano, Italy
L. Lorusso (*)
Neurology Unit, Neuroscience Department,
ASST-Lecco, Merate, Italy
© Springer Nature Switzerland AG 2020
B. Colombo (ed.), Brain and Art, https://doi.org/10.1007/978-3-030-23580-2_12
12
Andrea del Verrocchio (1434/1437–1488),
Donatello (1386–1466), Michelangelo
Buonarroti (1475–1564), Sandro Botticelli
(1445–1510), Benvenuto Cellini (1500–1571)
and Ludovico Cardi (named ‘Cigoli’, 1556–
1613) who created a small statue that is consid-
ered to be the rst known anatomical
representation modelled in wax. Artists were
doing vastly more dissections and they were
familiar with the structure of the body than were
anatomists, whose chief concern was with the
viscera, blood vessels, and nerves [3–5]. The rst
neuroanatomical model was a product of wax
injection into the ventricular system of the brain,
created by Leonardo da Vinci (1452–1519) who
recorded his method in his notebook now at the
British Royal Collection. Leonardo was inter-
ested in the seat of the soul and he was in uenced
by the Platonic dogma that the cognitive process
was contained within the ventricular system [6].
The same procedure of injection was carried out
in teaching anatomy early in the fourteenth cen-
tury by a young female prosector for Mondino
de’Liuzzi of Bologna (1270–1326), Alessandra
Giliani of Persiceto (d. 1326), who was appar-
ently the pioneer of the wax injection technique,
a technique later furthered by Frederick Ruysch
(1638–1731), a student of Jan Swammerdam
(1632–1680), and still later by Joseph Hyrtl [7].
Italian physician Marcello Malpighi (1628–1694)
and the Dutch naturalist Jan Swammerdam used
colourless and coloured preserving uids
composed of alcohol, mercury, different metals
153
154
and wax. This method was reasonable, although
the preparations were not long-lasting and subse-
quently deteriorated. Another method of provid-
ing an accurate reproduction of the various organs
of the human body was required. At the end of
the seventeenth century, a collaboration between
Gaetano Giulio Zumbo (1656–1701) and the
French surgeon Guillaume Desnoues (1650–
1735), who in 1680 became professor of anatomy
and surgery at the University of Genoa and later
at the Academy of Bologna, resulted in the cre-
ation of the rst realistic anatomical models
made from coloured wax, representing a valid
alternative to dissected human specimens. Wax
gradually took its place as a material capable of
allowing the creation of extremely realistic and
long-lasting artefacts [8].
12.2 General Concepts
When trying to deal with the problem of wax as a
material, one often thinks of an intrinsically
weak, delicate material, easily prone to decay. A
common feeling is that it has dif culty in associ-
ating itself with the artistic world, and even more
so to the scienti c. Even when we want to locate
the use of wax over the long course of history it
seems to emerge only periodically and incon-
stantly. Surrounding the use of wax in retaining
and conveying concepts and thoughts, much can
also be said of its characteristic adaptability and
its possible reuse. The same concepts of ideation,
thought, images and memory can be referred
back to wax and wax moulages in ancient times.
It would seem that after Roman wax tablets
its use seems to disappear, however, we could
cite authoritative literary texts that show us this
was not really the case: from the librillos de
memoria used by Cardenio in Don Quixote by
Cervantes (1547–1616) to the writing tables,
mentioned in the works of William Shakespeare
(1564–1616). Wax was not only used to make
candles and was much more present and impor-
tant in the past than we can imagine today.
Interest in the role played by ceroplasty in the
development of the sciences has now been well
established, particularly in relation to medicine
A. Porro and L. Lorusso
and surgery [9, 10]. Moreover, the primacy of
the Italian ceroplasty tradition has been recog-
nized and agreed on, especially relating to the
seventeenth and eighteenth centuries [8, 11].
This chapter will focus mainly on this tradition.
Even on a strictly historiographical level, wax
modelling has represented, and still represents,
an interesting intersection between the sciences
and the arts: we can still recall today, an interna-
tional conference dedicated to ceroplasty in sci-
ence and art, in Florence in 1975, whose themes
remain an unavoidable reference point for
scholars [12]. A revival of scienti c interest,
precisely in the wake of the Florentine experi-
ence, was certainly represented by the recent
International Congresses of Wax Modelling
held in London in September 2017 and in Padua
in June 2019, organized by Roberta Ballestriero
(see abstracts of presentations on: https://www.
waxmodellinglondon2017.com/) and https://
www.waxmodelling.com.
12.3 The Origins of Wax
Anatomical Models: Gaetano
Giulio Zumbo
Anatomic modelling as a didactic instrument had
its dawn thanks to a Sicilian abbot, Gaetano
Giulio Zumbo [13]. Zumbo studied anatomy to
perfect his depictions of the human form. In
1691 in Florence, the Sicilian artist came to the
attention of Cosimo III de’ Medici (1642–1723),
the Grand Duke of Tuscany, who was impressed
by his ability as a craftsman. Thanks to his wax
artistry and interest in death and disease (a taste
for the macabre in uenced by the culture of
Mannerism and the early Baroque) Gaetano
Zumbo created the rst wax anatomical composi-
tions: ‘The Plague’, probably inspired by paint-
ings of the Neapolitan plague of 1656 by Mattia
Preti (1613–1699), Luca Giordano (1634–1705)
and others. He created also ‘The Triumph of
Time’, ‘The Vanity of Human Glory’ and ‘The
Syphilis’ or ‘The French Plague’. In these works,
Zumbo produced tableaux and anatomical heads
[8, 13–15]. Later in 1695, after a short stay in
Bologna in 1694 at the School of Anatomy,
12 Wax Anatomical Models and Neuroscience: From Artistic Italian Creation to Therapeutic Approach
Zumbo moved to Genoa where he met the French
anatomist and surgeon Guillaume Desnoues.
This collaboration could be considered to be the
origin of anatomic wax modelling. Only two
specimens that are representative of Zumbo’s
anatomic work survive. The most well known is
the caput cereum solicita cura ctum, described
by Albrecht von Haller (1708–1777), depicting a
dissection of a man’s head. The model was given
to the Duke of Tuscany and now resides in the La
Specola Museum in Florence. Another wax head
was brought to Paris and is now found in the
Museum of Natural History. After 5  years, the
collaboration between Desnoues and Zumbo
ended prematurely as a result of a disagreement
over who should be credited for the anatomic
wax models. In 1700, Zumbo moved to
Marseilles, where he modelled religious compo-
sitions and the anatomic heads that were exhib-
ited at the Academie Royale des Sciences in
Paris. He obtained the exclusive right to model
anatomic wax preparations from King Louis XIV
(1638–1715). His fame was short lived due to his
sudden death on 4th December 1701 [8, 13, 15].
12.4 Italian Schools
in Ceroplastics
The most renown anatomical wax models, dis-
playing both normal and pathological features of
neurological, obstetric and surgical conditions,
can be seen in collections in Bologna, Cagliari,
Florence, Milan, Modena, Naples, Padua, Parma,
Pavia, Rome and Turin. These testify to the meth-
odologies, which have characterized training in
many of the medical and surgical disciplines
since the seventeenth century, but do not fully
exhaust the use of wax techniques. The use of
three-dimensional, non-perishable wax models
that are suf ciently true to life gives the material
not only the quality of becoming concrete but
also effective. This can elevate it as a method-
ological tool: the arti cial, precisely because it is
three-dimensional, can stand alongside the natu-
ral and perpetuate some characteristics, other-
wise destined to disappear. Compared to other
materials, such as terracotta, wax is more func-
155
tional and suitable for the above purpose.
Therefore, it becomes not only useful but even
indispensable for a complete training to bene t
from arti cial models: today we call them man-
nequins, simulators, and well know and recog-
nize their important role. Returning, however, to
the past, the gures of Gaetano Giulio Zumbo,
Giovanni Manzolini (1700–1755), Ercole Lelli
(1702–1766), Anna Morandi Manzolini (1714–
1774), Felice Fontana (1730–1805), Clemente
Susini (1754–1805), Luigi Rolando (1773–
1831), Giovan Battista Amici (1786–1863), Luigi
Calamai (1800–1851), Remigio Lei (1828–
1905), Edoardo Bassini (1844–1924), Angelo
Fermo Bellini (1872–1949) represent the corner-
stones of scienti c ceroplasty and the expres-
sions of the individual schools.
12.5 The Beginnings
of the Schools: Bologna
and Florence
The development of ceroplasty [16] cannot be
separated from the evolution of anatomical tech-
niques. The injecting techniques of the times did
not solve the problem of fragility and easy disin-
tegration, so that the wax gure could be exported
with ef cacy and utility from the artistic to the
anatomical eld. In de ning a chronological
framework, we can begin in the second half of the
seventeenth century, and refer to the emblematic
gures by the aforementioned Zumbo. His cero-
plastics, preserved in Florence, can be considered
the point of passage and connection between the
artistic and anatomical areas (of normal anatomy,
if we consider his head ceroplasty, but also of
pathological anatomy if we analyse his individ-
ual gures representing the plague). The
Bolognese School of Wax Modelling [17] con-
tains exemplary stories deserving attention, albeit
very brie y. First, we must identify the timing in
relation to the three makers we will look at:
Ercole Lelli, Giovanni Manzolini and Anna
Morandi Manzolini. Covering the last part of the
seventeenth century and during the greater part of
the eighteenth century, we encounter the gure of
Cardinal Legate of Bologna (1731–1740)
156
Prospero Lambertini (1675–1758), the future
pontiff Benedict XIV (1740–1758). Immediately
after his ascent to the papal throne, the latter
commissioned Lelli to create a complete cero-
plastic collection. The work was nished in
6  years and is characterized by large life-size
statues. Lelli was curator of the school’s anatomy
museum, a position that later was occupied by
Luigi Galvani (1737–1798). An admirer of Lelli’s
wax models was Harvey Cushing (1869–1939),
who commented on his anatomic statuettes in
1938 [18]. Among Lelli’s collaborators was
Manzolini but sometimes this collaboration
broke down, however, Manzolini found impor-
tant help in his wife, Anna Morandi [19]. Thus, a
pair of exceptional ceroplasts was formed.
Manzolini’s fame, skill and work were carried on
after his death by his wife Anna (the wax works
were considered superior to those of Lelli). These
pieces of the Bolognese school could be built on
a skeletal substratum of human bones. Bolognese
modelers made their models by moulding wax
directly over natural bones, a technique that
placed the verisimilitude of the models, literally,
in the hands of the arti cers [20]. The waxes from
Bologna created by Lelli, with reference to oste-
ology and myology, together with those of the
sensory organs, bowels and obstetric parts pro-
duced by Manzolini and his wife Morandi, prob-
ably constitute the oldest known collection of
wax anatomical models [8]. Morandi and
Manzolini are part of the collection of the Musei
di Palazzo Poggi, in Bologna, with their replicas
in wax. Presenting the two anatomists dissecting
a brain and heart, respectively the portraits cor-
roborated the modelers’ own self-presentation as
anatomists (Fig. 12.1) [19–22].
The Bologna collection was also enriched
with obstetrics gures, demonstrated by the work
of Giovanni Antonio Galli (1708–1782); how-
ever, these are partly in terracotta and in wax.
This is still worthwhile mentioning as we also
come across Lambertini, who was patron of the
Bolognese model collections. Even the Florentine
collections [23, 24] depend, in some way, on the
Bolognese experience. The complexity and
importance of the Florentine school, like that of
Bologna, meant that for about a hundred years,
A. Porro and L. Lorusso
Fig. 12.1 Anna Morandi Manzolini’ self-portrait (1714–
1774) who was able to combine neuroscience and art with
creation of wax neuro-anatomical models. The picture
shows Anna Morandi dissecting a brain. Copyright by
Museo di Palazzo Poggi, SMA-Sistema Museale di
Ateneo, Alma Mater Studiorum Università di Bologna,
Italy
between the eighteenth and nineteenth centuries,
it could be seen as the main point of reference for
technique and training in the wax eld.
Under the supervision of anatomists and nat-
uralists, ceroplasts made works also intended for
export such as the rst works of Felice Fontana
and Amici, while among those coming later were
those by Giuseppe Ferrini (eighteenth century),
Susini, Calamai and Egisto Tortori (1829–1893),
by whom the activity was shut down. The consis-
tency of the collections, amounting to over 1400
pieces, demonstrates the variety and quality of
ceroplastic work and represents the scienti c
elds in which ceroplasty could be applied [25]
and here we can identify the precursors to nor-
mal and pathological anatomy. Unlike the
Bolognese waxes, which usually contained the
skeleton, the Florentine models were entirely
made of wax, using various kinds and mixtures
[11]. The fact that by the late eighteenth century
anatomy had become the most advance science
is supported and con rmed by nely detailed
examples of anatomical models at La Specola
12 Wax Anatomical Models and Neuroscience: From Artistic Italian Creation to Therapeutic Approach
Fig. 12.2 Wax
anatomical models at the
Museum of Zoology and
Natural History, best
known as ‘La Specola’,
Florence, Italy
museum, one of which detailed the head, neck
and brain along with the cranial nerve and
branches. This is not a surprise because Fontana
already published the rst accurate description
of the peripheral nerves [15, 26]. At the end of
1771, Fontana created a complete collection of
anatomical wax models at the Natural History
Museum of ‘La Specola’ [27–29]; this was a
department of wax models annexed to the
Florentine museum, bringing together artists
such as Clemente Susini and Francesco
Calenzuoli (1796–1829), and anatomists such as
Paolo Mascagni (1753–1815). Concerning neu-
roscience, in that period, the internal knowledge
of the nervous system was a eld of increasingly
active research that allowed Clemente Susini to
create a study of the major inner structures of the
brain, including the corpus callosum, hippocam-
pus, anterior commissure, basal ganglia and thal-
ami. It is interesting that although these structures
are clearly demonstrated, their function was
unknown at the time the models were created.
The lack of knowledge relating to neuroanatomi-
cal structures was largely a result of the inability
to preserve the brain for dissection and this
aspect was overcome by the creation of anatomi-
cal wax models [15]. Between 1771 and 1893,
entire collections were created for La Specola
157
Museum and for both Italian and foreign univer-
sities: the scienti c and didactic value of these
works is indisputable; the creation of which was
intended to facilitate the education of students of
medicine [8, 30]. A notable collection of
Florentine ceroplastics is at the University of
Cagliari, which has some re ned examples from
Susini’s workshop, also found in other Italian
institutions such as Pavia, Pisa, Genoa, Perugia,
and Turin. Other institutions, including the
museum at Montpellier, France, and the
Wellcome Museum for History of Medicine in
London stored smaller collections of wax mod-
els from Florence. Other cities included
Budapest, Leyden, Paris, Uppsala, Stockholm,
New Orleans (whose models disappeared soon
after 1900, [28]) and possibly Charleston, Cairo
and Lausanne [11, 31]. La Specola created
approximately 3000 anatomical models of which
2000 survive today (Fig. 12.2) [28, 29].
12.6 Other Italian Wax Model
Collections
The Cagliari collections, showing both male and
female bodies, have been studied and valued by
anatomists from the Caralitan University such as
158
Luigi Cattaneo (1925–1993) [32] and Alessandro
Riva [33]. The 23 models, all signed and dated by
Susini, were produced in the laboratory of the
Florentine Specola between 1803 and 1805, but
their link with Sardinia stems from the journey
made by Francesco Antonio Boi (1767–1855)
starting from 1801, which also took him to
Florence [11]. The Cagliari museum is very small
in terms of numbers of the pieces: 23 showcases
for a total of 64 preparations. The wax models
were ordered by Carlo Felice of Savoy (1765–
1831), Viceroy of Sardinia, through the Sardinian
anatomist Francesco Antonio Boi who spent a
period of leave at the Department of Surgical
Anatomy of the Santa Maria Novella Hospital in
Florence [11, 31]. Boi also went to Pavia to
improve his knowledge of anatomy under the
anatomist Antonio Scarpa (1752–1832) [11]. A
distinctive feature of the collection in Cagliari is
the importance given to both visceral and somatic
nerves, which are shown in more than one-third
of the models. The representation of nerves in
especially those of the cardiac, celiac and pelvic
plexus compete, in precision, with the most cel-
ebrated textbooks of the rst half of the nine-
teenth century [11]. Another characteristic that
distinguishes the waxes at the present location in
Cagliari Citadel of Museums [33] from those of
Bologna, Vienna and Florence is the absence of
lymphatics in the brain. Lymphatics are present
in brain preparations of these collections by mis-
take as Paolo Mascagni had erroneously depicted
them in his textbooks [11, 34]. Another important
Italian museum is in Naples and derives from two
locations: one was established at the Ospedale di
San Giacomo Apostolo in the seventeenth cen-
tury by the anatomist and surgeon Marco Aurelio
Severino (1580–1656) and a second by Domenico
Cutugno (1736–1822) a follower of Giovanni
Battista Morgagni (1682–1771) and a supporter
of anatomical dissections, relevance at the
Ospedale degli Incurabili. At the end of the
eighteenth century, the future Anatomy Museum
of Naples’s history was linked with that of two
more Neapolitan institutions, the Mineralogy
Cabinet and the Zoology Cabinet. Francesco
Folinea (1778–1833) and Antonio Nanula (1780–
1846) established the Human and Pathologic
A. Porro and L. Lorusso
Anatomy Cabinet of the University. Nanula
devoted himself to the development of the
University’s Anatomy Cabinet, to which he
donated his rich personal collection, including
human anatomy and comparative anatomy prepa-
rations. During the decade 1830–1840, the col-
lections increased in specimens, including new
wax models created by the sculptor Francesco
Saverio Citarelli (1790–1870), a pupil of the
ceroplastic artist Clemente Susini. In 1845, the
museum increased its room to receive new mate-
rials. In 1871, Giovanni Antonelli (1870–1914)
ordered the move of the Anatomy Cabinet from
the Collegio del Salvatore to the former
Monastero di Santa Patrizia [35]. We come across
Domenico Cotugno and Domenico Cirillo
(1739–1799) [36] by way of their preparations
for the inner ear. Here the use of wax, on the one
hand, clashes with the particularity of the ana-
tomical structure to be investigated and the cre-
ativity and ability of researchers dealing with a
scienti c and technical problem, on the other
hand, however, it is the only way to grasp, observe
and describe the anatomical reality of the time.
Regarding the studies of these two illustrious
exponents of Neapolitan culture and, in a more
general sense, the problems that can arise in rela-
tionships between medical specializations, the
core of their work was to create an objective
approach to this type of representation as icono-
graphic material. It can be substantiated and cor-
related more to the physiological data in terms of
normal anatomy. That is to say the pathological
connection with it or with surgical activity, or
even to some disciplinary branches such as
dermatology.
The Parma works are two life-size anatomical
gures representing what remains of a complete
wax model endowment from the rst quarter of
the nineteenth century [37]. These were in u-
enced by the Susini school, where Andrea Corsi
also worked. The scarcity of any documentation
here is a hindrance to con rming wax model
activity with much certainty since the beginning
of the seventeenth century, although the existence
of an Anatomical and Pathological Cabinet in
wax seems to bear some witness. A particular
collection is housed in Parma, with specimens
12 Wax Anatomical Models and Neuroscience: From Artistic Italian Creation to Therapeutic Approach
associated to criminal anthropology created by
Lombroso’s pupil Lorenzo Tenchini who was
professor in anatomy at the University of Parma
[38–40]. These specimens were considered wax
models, but are actually anatomical preparations
of face where the use of wax was integrative and
protective. In Modena, close to Parma, produc-
tion in the mid-nineteenth century of facial repro-
ductions for ethnographic–anthropological use
was a prime activity. Already at the end of the
eighteenth century, under the in uence of
Antonio Scarpa [41], obstetric wax models were
being produced by the Bolognese Giovan Battista
Manfredini. The same applies to the Paduan
obstetric wax collection: contemporary to those
of Modena, they were also commissioned to
Manfredini by Luigi Calza (1737–1784), the
founder of the Paduan obstetric of ce [42], oph-
thalmological models [43] are also an important
feature here. In Ferrara, the wax model collection
was organized by Giovanni Tumiati (1761–1804),
then anatomist at the local university [44], while
in Rome we nd obstetrics waxes by Manfredini
[45]. We can nd life-size Susinian preparations
in Pavia Anatomical Museum [46] and in the
Cabinet of Anatomy and Surgical Pathology in
the same city, promoted by the Clinical Surgeon
of the University of Pavia, Luigi Porta (1800–
1875) [47]. In addition, other models were pre-
pared by his pupil Edoardo Bassini (1846–1924),
who was known for the creation of a radical sur-
gical treatment of inguinal hernia, based on the
physiological reconstruction of the inguinal
canal. Bassini’s wax models represent the inner
ear created by injecting wax in the moulages [9].
We have already seen how these preparations
were dif cult to produce, and a century after sim-
ilar Neapolitan preparations, they were still indis-
pensable for anatomical teaching. We remark that
in 1804, the surgeon Antonio Scarpa listed a col-
lection of 350 natural preparations in the cata-
logue of his Anatomical Museum at the University
of Pavia. There was a section of arti cial prepara-
tions composed of six wax models of Florentine
origin. These models are still retained at the
University of Pavia, which can boast a small but
valuable collection consisting of two wax statues,
one female and one male, showing the lymphatic
159
vessels in the Angiology section, three pieces
related to the hearing organ in the Aesthesiology
section, and nally a head representing the nerves
in the Neurology section.
The most antique waxes, crafted by Clemente
Susini, came to Pavia from Florence between
1794 and 1795, after being purchased by Scarpa.
In recent times, several pathological waxes have
been rediscovered and brought to the museum to
be inspected. The museum holds three moulages
connected to the Trattato di vaccinazione
(Vaccination Treaty), written by Luigi Sacco
(1769–1836) in 1809, and to the rst smallpox
vaccination campaigns [48, 49]. The Turin cero-
plastic collections, promoted by the neuroanato-
mist Luigi Rolando (1773–1831), also derives
mainly from Florentine experiences. The pieces
produced in Turin favoured the Florentine tech-
nique, which also reproduced the skeletal ele-
ments of the body and its development was
mainly due to the activity of Luigi and Giuseppe
Cantù, at the end of the Napoleonic period. This
collection also houses an interesting gure called
Anatomy of Head (c. 1780) by an anonymous art-
ist [50].
12.7 The Milanese Case
The Milanese ceroplastics are of even greater
importance, and are concentrated on the dermato-
logical eld [51] They were prepared for the der-
matology department of Ospedale Maggiore [52]
in the early twentieth century by the physician
Angelo Fermo Bellini (1872–1949). The waxes
were modelled from the plaster casts of patients,
and coloured with a technique he invented, allow-
ing for a very faithful reproduction of the derma-
tosis [53]. He also took inspiration from the wax
collection prepared by Jules Baretta (1824–1923)
at the Hôpital Saint-Louis in Paris. The Milanese
ceroplastics were also sent to the Buenos Aires
International Exposition of 1910 (where the
Ospedale Maggiore won a Grand Prix) and may
therefore have played a role in the development
of modern wax models in Latin America [54]. We
can also nd ceroplastics in the Museum of the
Gynecological Obstetric Institute. In addition to
160
those relating to vaccination, similar to Pavia and
which were partially received by us, only one
obstetrical wax model survives. A particular type
of ceroplastic, widespread in almost identical
specimens in many of the places already men-
tioned, is that of the representation of the tables
attached to the Vaccination Treaty (1809) by
Luigi Sacco [55]. These show the cow’s udder
with the cowpox pustules; the snout of a sheep
showing pustules; the representation of an equine
hoof struck by the so-called giavardo; the repre-
sentation of the evolution of true vaccine and
sperm vaccine. They commissioned by the
authorities of the Cisalpine Republic, then Italian
and subsequently of the Italian Kingdom, to pro-
mote the spread of vaccination [56].
The study of documents in the Medical
Department of the Milanese Ospedale Maggiore,
under way by Daniela Bellettati and Paolo Maria
Galimberti, has also allowed us to identify a prac-
tice from 1802, concerning the preparation of a
model of the inner ear by the ceroplast Giuseppe
Chiappi [57]. The surgeon Giovanni Battista
Palletta (1748–1832) was taken by the quality of
the wax preparation and he forwarded a purchase
request to the authorities of the then Italian
Republic.
12.8 Ceroplastics in Europe
and Around the World
Numerous collections of wax anatomical models
were created throughout the world starting from
the Italian experience with the foundation of
prestigious schools in England, France, Spain
and Austria [58]. This diffusion was a conse-
quence of the scienti c value of the wax models
rather than the artistic aspect. The rst of the ana-
tomical waxes is thanks to Desnoues who, after
his collaboration with Zumbo and leaving Genoa,
had a collaboration with Lacroix, an ivory-carver
from Burgandy. In 1711, they opened a museum
of wax anatomical works in Paris to exhibit wax
anatomical models reproducing dissections to the
paying public, which moved to London in 1719
[30]. He maintained that wax preparations could
allow people to learn anatomy while avoiding the
A. Porro and L. Lorusso
horror of dissection. Following Desnoues’ exam-
ple, several museums exhibiting human wax
models to the public were then opened in central
Europe, France and Britain, mostly for pro t [16,
59–61]. In France, the rst collection of the cero-
plastic was at Le Palais-Royal at the end of the
Ancien Régime under Louis XIV, Philippe
d’Orléans [62]. This collection at the Revolution
was requisitioned and transferred to the com-
pletely new National Museum of Natural History
in Paris. At the end of the eighteenth century, wax
anatomical models were regarded as one of the
essential bases of instruction and teaching. A
contemporary of Anna Morandi was the French
anatomist Mlle Marie Catherine Bihéron (1719–
1786), who created a collection of anatomical
wax gures in Paris, which, near the end of her
life, was purchased by the Russian ambassador
for the Empire Catherine II (1729–1796) [4]. The
Revolution turned these collections into a form
didactic courses, essential for teaching the ‘heal-
ing art’. The wax collections became indispens-
able tools of knowledge, agents essential for
spreading knowledge and medical training. A
particular growth of these anatomic collections
became a token for the medical teaching and
research. This was the beginning of didactic col-
lections of the ceroplastic anatomic collections of
the nineteenth century. It gave rise to different
schools and museums such as Dupuytren, related
to pathologies such as tumours, cancers and
aneurisms or at the Hôpital Saint-Louis, the work
of the modeler Jules Baretta (1834–1923), who
constructed a series on venereal dermatology and
there was also a short-lived school of wax sculp-
ture in Rouen. During the nineteenth century,
France replaced Italy as the main producer of
wax anatomical models. Specialized establish-
ments under Jacques Talrich (1789–1851 and his
son Jules (1862–1904), then Gustave Tramond
(1846–1905) and Louis Thomas Jérôme Auzoux
(1797–1880), aimed at commercializing models
in wax, then in papier mâché or plaster, at a more
modest cost. Jules Talrich also tried to establish
an anatomic museum intended for the education
of the general public, the last echo of which was
to be the great travelling fair-ground museum of
‘Doctor’ Spitznet (1833–1896) [30, 62]. Another
12 Wax Anatomical Models and Neuroscience: From Artistic Italian Creation to Therapeutic Approach
important European museum for wax anatomical
models is in Vienna. In 1785, Joseph II (1741–
1790), Emperor of Austria, inspired by a visit to
Anna Manzolini, established an academy to train
his army surgeons, which became known as the
Josephinum. One of the important teachers of his
Academy was the Italian surgeon Giovanni
Alessandro Brambilla (1728–1800) (Giovanni
Alessandro Brambilla [63]) from the University
of Pavia. Brambilla was well aware of the teach-
ing potential of the wax models and suggested
that some should be acquired. The Emperor
approached his cousin, Peter Leopold (1747–
1792), Grand Duke of Lorraine, in Florence and
he commissioned approximately 1200 specimens
from Felice Fontana. In 1786, the specimens
were transported to Vienna were installed in the
Josephinum and contributed to the anatomical
knowledge of hundreds of army surgeons. Today,
there are 867 models on display in the museum
into ve body systems: ligaments and muscles
(271 models); brain, spinal cord and sensory
organs (224 organs); heart, blood and lymph ves-
sels (163 models); visceral organs (107 models)
and obstetrics (102 models) [34, 64, 65]. In
Spain, different museums were established such
as in Valladolid in 1861 with wax anatomical
models present at the Anatomy Museum of the
Faculty of Medicine. This museum has reproduc-
tions of dissections carried out by French anato-
mists and almost all come from the house of
Tramond; it has 122 pieces such as vessels and
nerves coloured with natural pigments dissolved
in animal oils creating liform structures [66]. In
Madrid, the Olavide Museum houses over 600
dermatological specimens [67]. In the same city,
at the Universidad Complutense, there are two
large collections of both human and animal cero-
plastics, elaborated during the eighteenth and
nineteenth centuries. The rst in the cabinet of
the Real Colegio de Medicina de San Carlos
founded in 1787 (in the Museo de Anatomía
‘Javier Puerta’ of the Faculty of Medicine) with a
collection of cranial nerves by the embryologist
Francisco Orts Llorca (1905–1993) and the sec-
ond in the Real Escuela de Veterinaria (Museo
Veterinario Complutense), institutions estab-
lished in 1793 [68, 69].
161
In England, the rst serious attempt at intro-
ducing the art of modelling anatomical works
from coloured wax was made by the sculptor
Joseph Towne (1808–1879). Here cadavers were
more readily available and were thus habitually
used in anatomical studies; it was only following
the regulation of the use of cadavers that an
attempt was made to create anatomical models
capable of replacing the former for teaching pur-
poses. Joseph Towne worked at Guy’s Hospital in
London from 1826 to the time of his death at 53.
He is said to have created approximately 1000
anatomical and pathological models from
coloured wax, some of which were sent to India
and Russia, among other countries. Town’s mod-
els are on display at the Gordon Museum of
Pathology in London and are still used for teach-
ing, some 200 of these models are based on the
dissection of John Hilton (1804–1878). There are
three other collections of his work at The Royal
College of Surgeons, the Anatomy School,
Cambridge and at the University of Pennsylvania
[59, 70]. Most of Town’s ceroplastics are derma-
tological models but there are neurologic speci-
mens and one of them is an astounding dissection
of the fth cranial nerve [70]. In Germany, in
1842, a young sculptor Gustav Zieller (1826–
1904) started to work on wax anatomical models
in Munich, the Bavarian centre of arts and sci-
ence, in collaboration with the physiologist Carl
Bogislaus Reicher. Zieller was well known by
other scientists of his time such as Johannes Peter
Müller (1801–1858), Friedrich Theodor von
Frerichs (1819–1885) and Emil Du Bois-
Reymond (1818–1896). Zieller’s brother, Paul,
was also a wax modeler who collaborated with
anatomists. Zieller formed a collection of extreme
quality with models of: locomotor apparatus,
sense organs, brain and embryology at The
Antropological Museum [71–73]. Two other aca-
demic wax collections are located in the North of
Germany (Kiel) and the South (Erlangen). The
Keil collection had 1000 objects (from 1906 to
1937) and only 455 remain today, mainly derma-
tologic moulages. The Erlangen collection has
today only 147 objects, most of them by Munich
artist Hugo Emanuel Becher (1871–1942) [74].
Another important and large collection in
162
Germany is in Bonn, founded in 1910 by Erich
Hoffmann (1868–1959) who discovered
Spirochaeta pallida together with Fritz Schaudinn
(1871–1906) [75]. There are many other derma-
tological moulage museums in Germany and in
other Northern European countries, for a com-
plete list see references of Tataru and Worm [76,
77]. An interesting and unusual collection is at
the German Historical Museum in Berlin, it
houses a larger-than-life-size wax model of a so-
called Phrenological Head and is the only one of
its kind known so far. Dating back to the begin-
ning of the twentieth century it was made by an
unknown modeler residing in Zurich [78]. In
Switzerland, the William Bonard private collec-
tion was founded by a local painter Leonce
Schiffman in the early twentieth century. Besides
its educational purpose in medicine, the collec-
tion was extremely important in education of
people in several German cities, with interesting
wax heads showing the effects of syphilis and
their treatments. This collection was unfortu-
nately lost [72]. In Zurich, in 1918, the local
Medical Faculty of the Dermatological wax mod-
els with over 2000 specimens was opened [79].
Elsewhere around the world, we can mention
the ceroplastic museums in South America: in
nineteenth century, at the Faculty of Medicine at
the University of Guatemala with wax models on
osteology, myology and splanchnology by José
Flores (1751–1824), unfortunately destroyed in
1921 [4, 80], the Faculty of Medicine in São
Paulo (Brazil) with forensic wax models pro-
duced by Augusto Esteves (1891–1966) between
1923 and 1955 [81]. In Colombia, Bogotá, the
Museo de Historia de la Medicina Andrès Soriano
Lleras conserves 325 pieces produced during the
1930s, these specimens are important for the his-
tory of Colombian medicine and of medical edu-
cation [82]. In Argentina, the Pedro Ara anatomic
museum founded in December 1920 in Cordoba
contains 1211 pieces in different materials,
including wax models, with 120 nervous system
specimens and 92 head neck artefacts [83]. In
Japan, dermatologic moulages were produced by
founder of the Japanese Dermatology Association
Keizo Dohi (1866–1931), who went to Vienna to
learn the technique of moulage-making [84]. In
A. Porro and L. Lorusso
North America, we can mention a collection of
medical wax models at the Mayo Clinic, created
by in-house artists from 1925 to 1983, they were
used by Mayo physicians to demonstrate presen-
tations at medical meetings around the United
States and Canada. They depict normal, patho-
logical and traumatic conditions; dermatological
diseases, physical anomalies, organs, anatomical
structures and parts of the body, pathological
specimens and, quite memorably, farm accident
cases. Several sets of models demonstrate the
progressive steps in surgical procedures such as
an appendectomy or tonsillectomy. Because a
number of the models were created from real
patients treated at the Mayo Clinic, medical
records exist to document their cases [85].
According to Ballestriero, the difference between
Italian wax models and the other international
ceroplastic specimens is that the Italian models
are imbued with a real sense of beauty. Anatomical
collections differ in style. They are usually very
accurate from a scienti c point of view but their
nal artistic result is speci c to the country of
provenance. Italian waxes are usually re ned and
pleasant. Specimens from northern European
countries are usually more realistic, almost bru-
tal, preferring anatomical accuracy rather than
artistic air [8].
12.9 Therapeutic Applications
An Italian phrase, which indicates a state of good
(or bad) health, is to have a good (or bad) wax.
The etymology of the word wax, while referring
to the head and to the complexion of the face,
illustrates the concept of complexion or colour.
This was original in identifying the chromatic
aspect of the face as a characteristic in de ning
the state of health. In fact, we know that some
pathologies are expressed also with a marked
colouring, or a sensitive modi cation or absence,
of the skin. Think of the phenomenon of jaun-
dice, from cutaneous hardening in the advanced
stages of pellagra to the pallor that was believed
in the past connected to some anaemic forms or
the so-called chlorosis, characterized by the
greenish tint of the skin.
12 Wax Anatomical Models and Neuroscience: From Artistic Italian Creation to Therapeutic Approach
However, if we want to look for the oldest
roots we can go back to the Romans and their
problem in using wax as amalgamating pigments
or protection for picture surfaces, we would not
nd ourselves in very different conditions from
those mentioned with regard to the ceroplastics
prepared for scienti c purposes. Therefore, we
not only re ect on the association of the good (or
bad) wax with three-dimensional and coloured
representations of the face, but also come into
contact with the therapeutic use of beeswax.
Today, the term plaster de nes a protective tis-
sue for small wounds covered by an adhesive
substance: the model being that of the Band-Aid
produced and marketed by the American com-
pany, Johnson & Johnson, since 1920. In the past,
the term plaster, identi ed wax as part of a poul-
tice, enriched with various medicinal substances
and held in place with a covering bandage.
In the neurosurgical eld, the use of wax as a
haemostatic for bone tissue has been documented
since the mid-nineteenth century [86, 87]. The
evolution of plasters has progressively dispensed
with the use of wax [88], but this material, with
its particular characteristics, still maintains its
own essential therapeutic value, precisely
because of its direct descent from the scienti c
ceroplastics. We must also mention the period
between the nineteenth and twentieth centuries,
remembering that some professional gures used
wax in their daily activities: think, for example,
of dental technicians.
In this regard, we can recall some gures of
dental technical ceroplasty: the Viennese Adolfo
Koll (1877–1964), who worked in Bologna and
Gorizia, and the French Léon Gatineau (active in
Cairo) who published a manual on the subject in
the rst quarter of the twentieth century. The for-
mer’s preparations, kept in the Odontological
Clinic of the University of Bologna, ranged from
normal morphology to pathology, while taking
ethnological aspects of populations into account
[89]. The latter, Gatineau, represents a point of
reference for early twentieth century dental
chemistry [89, 90]. His text, a complete manual
of ceroplasty, appears to be addressed to both
dental surgeons and dermatologists; however,
the section dedicated to this last discipline
163
appears to be decidedly minor in comparison.
There are also two variants of Gatineau’s work
in the form of two completely identical volumes,
except for the publisher’s description: the rst is
by Ash & Sons [91] who produced odontostoma-
tological instruments throughout the world for
over a century (a century 1921); the second is by
a Parisian publisher specialized in scienti c
texts [92]. Gatineau’s book seems to be from the
end of the 1920s, but there are some accounts of
it already having been in circulation around
1914 [89]. The variants of the two editions of
Gatineau’s volume remind us how the industry,
at the time, had a positive in uence on European
odontostomatological culture. Thanks also to the
printing and dissemination of texts in different
languages and published in different cities.
Gatineau’s ceroplast activity appears to be of
great importance, not least because he practiced
dental technology but also dental surgery. In
fact, the impression of the dental arches is thanks
to the use of workable material (such as wax)
and was as fundamental as the practice of draw-
ing the negative from the moulage where three-
dimensional positive was essential. The period
we have been dealing with was greatly in u-
enced by the First World War: this introduces us
to the most important application of wax in the
therapeutic eld. Facial mutilations required an
aesthetic and functional restoration; they needed
specialized care facilities and new surgical tech-
niques, which exceeded those handed down for
centuries. Among the exponents of this period
(and for all the post-war period) were Fernand
Lemaitre (1880–1958), Eastman Sheehan
(1885–1951), Ferris Smith (1884–1957),
Gustavo Sanvenero Rosselli (1897–1974) [93]
who founded new plastic surgery. Regarding the
institutional structures, we cannot forget the
Hôpital Saint Louis or the military hospital of
Val de Grâce in Paris. Even in recent times, the
severity of the mutilations, the impossibility of a
complete reconstruction, the dif culties of social
reintegration have all been the subject of literary
and lm interpretation [94, 95]. At the time, the
only prostheses that could be used to aestheti-
cally remedy facial mutilations had to use cero-
plasty, or masks consisting of thin metal sheets,
164
or even the use of grease for lling purposes,
where possible [96]. Today, prosthetic applica-
tion in the maxillofacial area is widespread and
represents a bridge between odontostomatology,
surgery and general medicine and is often related
to the need for complete oncological treatment.
Also, in the otolaryngology eld, the use of wax
for the placement of intranasal splints has been
documented in the recent past: this is a further
derivation of the use of odontostomatological
wax [97, 98]. Another important therapeutic
application of the wax is in neurosurgery used
for over 100  years in craniofacial surgeries by
the pioneers Jean Louis Belloq, Khristian
Khristianovich Salomon (1796–1851) and
François Magendie (1783–1855). They used the
wax candles or modelling wax for haemostasis.
The rst successful application in neurosurgery
was demonstrated by Henri Ferdinand Dolbeaus
(1840–1877) with an extirpation of a frontal
osteoma, in 1864 ([99, 100]). Dolbeau was
therefore not only the rst to operate on an oste-
oma of the frontal sinus, but also the rst to use
wax for bone haemostasis [101]. This technique
was popularized by the founder of British
Neurosurgery Sir Victor Alexander Haden
Horsley (1857–1916) as a haemostatic agent
after experimenting on cranial bones of dogs in
1885 [102–104]. Wax bone originally derived
from beeswax, a commercial preparation that
contains paraf n wax isopropyl palmitate,
whose main function is as a mechanical tampon-
ade, is used today [102]. Bone wax has found
several uses in neurosurgery to prevent cerebro-
spinal uid leakage for skull base repair during
craniotomy and temporal bone nibbling. Bone
wax can be applied as a rapid haemostasis when
the middle meningeal artery becomes torn and
the stump retracts into foramen spinosum pro-
ducing heavy bleeding during drilling of skull.
This acts as a protective covering against the
blades of the drill and as a template for intraop-
erative evaluation of craniofacial defects if a
cavernous carotid aneurysm exhibits repeated or
massive epistaxis. In spine surgery, bone wax is
used to attain haemostasis after removal of dis-
traction pins during anterior cervical spine sur-
gery; in the cervical intervertebral disc herniation
A. Porro and L. Lorusso
bone wax could indeed facilitate the operation
by guiding the drilling process and instantly
controlling the bleeding without obvious inter-
ference with bone healing, following vertebral
artery injury after a placement of cervical spine
screws and for spatial orientation in intraopera-
tive magnetic resonance imaging [102, 105].
Although bone wax is widely used in neurosur-
gery there are some complication descriptions
such as allergy granuloma, in ammation and
infection, interference with bone healing, cord
compression leading to neurological de cits,
osteohypertrophy, venous sinus thrombosis, pto-
sis and diplopia [102]. Other alternatives are
being developed, but at the moment none are yet
a full replacement for wax.
We can therefore say that the long journey that
started from eighteenth-century ceroplastics has
been uninterrupted, and indeed is very much still
relevant in meeting the needs of twenty- rst-cen-
tury patients.
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 The Signi cance of Art Therapy
Emanuela Galbiati
13.1 Art as the Primordial
Necessity of Man
The human being needs to experience, under-
stand, elaborate, and translate into symbolic
meaning the reality that surrounds him, giving it a
form whose essential function is to unveil hidden
meanings as well as to represent the emotional
involvements that the experience of reality causes.
Since ancient times, art, in all its forms, has been
an effective mean for this process of knowledge–
elaboration–expression to take place. A recent
research has placed the rst graphic traces of man
at the time of the Neanderthals, which is
20,000 years before Homo Sapiens [1]. In ancient
times, animal gures, geometric signs, and hand-
prints were already used by men to understand the
external reality sublimating desires and needs
related to the survival in the world of those times.
However it is not only the graphic-pictorial art
that effectively carries out this transformative task
of the knowledge, in fact all the art forms that
belong to the human creativity are a powerful
mean to accomplish the transition between the
inner and outer worlds. Greek Tragedy ( fth cen-
tury B.C.) allowed human beings to stage the full
range of emotions by which they were over-
E. Galbiati (*)
ATI-APIArt, Milan, Italy
FAC, Milan, Italy
UCSC, Milan, Italy
© Springer Nature Switzerland AG 2020
B. Colombo (ed.), Brain and Art, https://doi.org/10.1007/978-3-030-23580-2_13
13
whelmed, thus constituting a precursor of the psy-
chodrama born in 1920  in Vienna from the
psychiatrist Jacob Levi Moreno. The myth of
Orpheus (sixth century B.C.) attributed to making
music the ability to in uence animals and nature
and lays the very rst foundations for the appear-
ance of music therapy, which was not considered
as a scienti c discipline before the eighteenth
century, when the rst treatise on matter was writ-
ten by the musician Richard Brocklesby. Making
human art involves not only the mind but also the
body, psychology itself teaches us how the body
ego is the rst to be formed and how the experi-
ence of the body is fundamental to human beings.
Hence the dance, fully recognized as one the
expressive arts, through the dance of Tarantella
already in 1300 was a precursor of the Dance-
movement Therapy that will be established later
in the twentieth century. The Tarantella was con-
sidered an effective remedy to the effects of the
bite of the Lycosa Tarantula, such as physical pain
and moral suffering that, which through this
dance, could be freed from the body through the
expulsion of sweat and moods caused by the con-
tinuous movement in time to music. Contemporary
studies of psychology of the evolutionary age
show us how children of all cultures from
18  months of age are able to produce graphic
signs that, gradually, lose the meaning of simple
motor discharge to acquire intentionality. The
child has an innate need to leave a trace, Piaget
observes how he needs to “af rm his own active
experience” and “provoke the pleasure of being a
169
170
cause,” and this constitutes the primary motivation
of Art as an active and founding experience of the
Self. In summary, the same human psychological
structure perfectly corresponds to the expressive
potential that the Arts are able to offer, human
beings are born to express and communicate,
think and dream through images, as well as
express the deepest and most hidden selves
through what the body can give in terms of pres-
ence and movement in space and vibrations and
sounds that it can produce. Art is therefore able to
satisfy man’s innate need to give space to the
expression of the self and of the reality that sur-
rounds him.
By creating I could heal, by creating
I could nd my health again. (Kierkegaard)
Investigating man’s profound need to symbol-
ically transform his emotions, Pio Ricci Bitti,
physician and professor Emeritus of Psychology,
Alma Mater Studiorum (Bologna), emphasizes
how art can be an effective mean that regulates
emotional activity for the purpose of acquiring
individual psychophysical well-being [2]. The
professor states that human beings need art to
fully understand external reality because there is
a deep connection between art, expression, con-
trol of emotions, and daily life. The cathartic and
therapeutic function of art is therefore well
known and ascertained, it explores the origins of
mankind and investigates its essence through
modern knowledge, studies, and research in the
eld of the human psyche.
13.2 How Art Therapy Was Born.
Historical Notes
The investigation of the fascinating link between
art and the psyche has always been one of the
interests of human studies and research, which
aimed at understanding the concealed meanings
that can be hidden behind artistic manifestations.
The rst theories—the understanding of the psy-
chic state through artistic production—arose in
1700. Still, it was with Hans Prinzhorn, a German
psychiatrist and art historian who lived between
1866 and 1933, with “The plastic activity of the
E. Galbiati
mentally ill,” [3] a translation of the original
“Bildnerei der Geistenkranken” (1922), who laid
the foundations for the understanding of the path-
ological manifestation of the mind through the
analysis of artistic creation. Prinzhorn wrote the
book following his experience at the German psy-
chiatric clinic in Heidelberg where he dealt with
the drawings of hospitalized patients. The author
tries to give a meaning to the artistic production of
the mentally ill patients by comparing it to the
pieces of art made by expressionist painters of his
time, identifying as a common point of origin
between the two forms of art: the rejection of real-
ity and the return to the Ego. Basically, Prinzhorn
identi ed in the psychic need to translate plasti-
cally the internal content of the trait d’union
between the two artistic expressions, elevating the
art of the fools, previously underestimated,
because generated by the same creative drives of
the major recognized artists. Analyzing the scrib-
bles of his patients, the German psychiatrist
underlined the absolute lack of intentional repre-
sentation, explaining the production as a result of
the playful impulse, that is, an impulse not yet
oriented toward a purpose. The playful impulse is
present in every artistic production and consti-
tutes the primary stimulus that leads the artist to
the translation of his imagination into meanings.
What differentiates the artist from the madman, is
the absence of the attribution of meaning, since in
his artistic production, the mentally ill patient still
maintains the urge to play. The theme of play as
the founding space of the creative act will be
taken up, deepened, and con rmed by Donald
Winnicott, who we will discuss later. Returning to
the origins of Art Therapy, the rst passage from
art as a tool for observation and diagnosis to art as
a tool for treatment dates back to the period of the
Great Wars in the healing of the so-called second-
ary victims of con ict, that is, veterans and civil-
ians who witnessed horror. In Europe, Edith
Kramer (1916–2014) analyzed the drawings of
children deported to Terezin camp. She was fol-
lowed by her teacher, Friedl Dicker Brandeis
(1898–1944), who through the drawing managed
to give voice to the damage that the war had
brought to the imagination of those children. In
America, it was Margareth Naumburg (1890–
13 The Signi cance of Art Therapy
1983), a psychodynamic psychologist, who
emphasized artistic production as a form of
expression of the unconscious and grasped its
undisputed therapeutic value. The two approaches
differ in the position assigned to art within the
creative therapeutic process, namely “art as ther-
apy” for Kramer and “psychotherapy through art”
for Naumburg. Edith Kramer considers creativity
as a real therapeutic resource and states that the
healing potential of art therapy lies in the psycho-
logical processes activated by creative work.
Margaterth Naumburg, on the other hand, consid-
ers spontaneous artistic expression in therapy as a
form of symbolic communication between patient
and therapist, giving to images a greater potential
to express thoughts and emotions than words. The
debate between the two positions then deals with
the role of art, questioning whether it is necessary
and suf cient for therapeutic activation or whether
they are instead the relationship patient/therapist/
work, and the interpretation of the image, the cor-
nerstones on which the creative therapeutic pro-
cess is based on. It will then be Arthur Robbins,
an American art therapist, psychoanalyst, and
sculptor still alive, who will integrate the two ori-
entations by observing the parallelism between
the creative process and the therapeutic process,
both bridges between the internal world and the
external reality, processes so powerful as to be
able to transform the Self of the artist and the
patient [4].
13.3 Art and Psychology: Two
Worlds from Which Art
as Therapy Is Born
and A rmed
The origins of art therapy should also be investi-
gated bearing in mind the great changes and evo-
lutions in the eld of art and in that of
psychoanalysis, because it is from these two
worlds that it was born, developed, and took
space as a method today established and recog-
nized. The discovery of photography at the end of
the 1800s contributed to giving an important
turning point to the meaning of artistic creation,
effectively freeing it from the function of faith-
171
fully reproducing reality. Gradually, the artist’s
emotions nd their privileged place within the
work of art and it will then be modern art that will
fully restore the symbolic emotional expression
in the works. The surrealism of Max Ernst (1891–
1976) and the Action Painting of Jackson Pollock
(1912–1956) can be considered precursors of art
therapy, Ernst for having translated into pictorial
form the unconscious and the dream, in uenced
by the reading of Freud’s Interpretation of
Dreams of 1899, and Pollock for having com-
bined body and creative expression through his
very special technique where, in the large space
of the canvas lying on the ground, the body move-
ment leaves powerful traces that re ect the art-
ist’s emotions and dialogue with those who
observe them. In the world of psychology, the
contribution of Sigmund Freud (1856–1939),
founder of psychoanalysis, will be decisive in
contributing to the codi cation of the therapeutic
approach of art therapy, and in starting to con-
sider works of art as projections of the artist’s
unconscious. For Freud, art is the second way to
the unconscious after dreams, being able to col-
lect and sublimate the instincts of men, creating
an intermediate space, in equilibrium and suspen-
sion between reality/soundness/matter/spirit.
That same space that Winnicott (1896–1971)
de nes as a transitional area, a psychic place, and
a founding phase of human development, but also
as a potential space between the individual and
the environment within which creative mental
processes can take place. Like children’s play, art
offers an intermediate area of experience that
alleviates the tension of the relationship between
one’s own internal and external reality. It is in
that area, therefore, that one is able to experience
the self in relation to the world, in a protected,
symbolic, and creative way. “Games and art are
free manifestations of the vital impulse” [5] says
Winnicott, assigning to art the natural continua-
tion of the child’s play area, active in all the sub-
sequent phases of existence, from childhood to
adulthood and senescence. Winnicott thus
directly relates game and creative act, as funda-
mental experiences of the human being that allow
the subject to express the full potential of his per-
sonality thanks to the suspension of the judgment
172
of truth about the world, a truce from the tiring
and painful process of distinction between him-
self, his desires, and reality, his frustrations. It is
through a playful approach to the experience of
living, in an intermediate area between subjective
and objective, that the creative drive can appear
and allow the child, as well as the adult, to re-
enter into deep contact with the core of the Self.
Winnicott recognizes the same creativity drive in
the “retarded child who is happy to breathe” as
“in the architect who suddenly knows what it is
he wants to build” and af rms that creativity can
never be completely nulli ed, even in the most
extreme cases of pathology and discomfort. Carl
Gustav Jung (1875–1961) continues the path
traced out by Freud, enriching it with the theory
of the archetypes from which, according to his
thought, art draws to express the core of the pro-
cess of individuation. The Jungian technique of
active imagination itself shows how, by mobiliz-
ing creativity, it is possible to bridge the gap
between consciousness and the unconscious, thus
de ning a parallel between active imagination
and art, both of which are capable of bringing to
light and giving shape to man’s unconscious pro-
cesses. Subsequent authors, including Melanie
Klein (1822–1960) and Marion Milner (1900–
1998), continue their investigation into the ways
in which the bridge between consciousness and
the unconscious can be accomplished and con-
sider gurative language as a privileged mean of
expression and a line of direct communication
between patient and therapist.
13.4 The Artistic Product
as a Transitional Object
Winnicott de nes the characteristics of the transi-
tional object as that bridge, represented by an
object, with tactile-sensory qualities, which the
child identi es and uses in the process of separa-
tion from the mother, a process de ned by
Margaret Mahler (1897–1985) as of identi ca-
tion and separation. The object is perceived by
the child as the rst “non-me,” which represents
the union with the mother and therefore allows its
detachment. In the same way, the creative work
E. Galbiati
constitutes a protected area of experience
between oneself and another, made concrete by
the presence of an artistic product, where the sen-
sory stimulations provoked by the different artis-
tic materials contribute to the psychological
development or to the restoration of a state of bal-
ance and well-being. In this delicate and signi -
cant process, the therapist takes on the role of a
“suf ciently good mother” (Winnicott), allowing
the patient to experience subjective omnipotence
just as the mother allows the child, giving him the
illusion that it is him, with his desires, who cre-
ates everything. This experience allows the cre-
ative act within a setting that corresponds to what
Winnicott de nes as “holding,” that is, the mater-
nal capacity of containment necessary and indis-
pensable for the healthy development of the
individual. Within the holding environment of the
room of art therapy, therefore, through creativity
as subjective omnipotence, the fundamental
grounds of human experience are recovered.
13.5 Art Therapy Today
The previous brief excursus illustrates how art,
from the primordial necessity of man, has been
shaped and developed over time, taking on thera-
peutic values, in step with developments in the
artistic and medical-psychological eld, taking
on the connotation of Art Therapy or a discipline
that uses creative expression to bring about
changes and transformations in the psychic eld.
In Anglo-Saxon countries, it is a practice recog-
nized and dispensed by the National Health
Service and regulated from a technical, ethical,
and deontological point of view. In Italy, a recent
law (No. 4 of 2013) established the requirements
of the profession and training schools and, subse-
quently, a UNI standard (No. 11592) de ned the
quality standards that professional art therapists
must meet. Art Therapy is therefore today a rec-
ognized method in all respects de ned by the
Professional Association of Italian Art Therapists
(APIArT) in these terms: Art Therapy is a set of
methods framed in different conceptual areas
(psychoanalytic, cognitivist, relational), aimed at
promoting human rehabilitation, psychopeda-
13 The Signi cance of Art Therapy
gogical, psychotherapeutic, and preventive
purposes of any form of psychosocial distress,
involving the systematic use of artistic practices
graphic-plastic-pictorial. In the United States,
specializations in the discipline in relation to the
speci c context of application have been estab-
lished, such as Medical Art Therapy (Art Therapy
in a hospital context applied to speci c diseases)
and Family Art Therapy (Art Therapy with a sys-
temic approach applied to families as a support,
or treatment of choice, in family therapy).
13.6 Fields of Application of Art
Therapy: Neurodegenerative
Diseases
Although Art Therapy can be applied “in any
form of psycho-social discomfort,” in this article
I will deal with applications in the eld of neuro-
degenerative pathologies, deepening the treat-
ment of Parkinson’s and Alzheimer’s diseases.
Chronic progressive pathologies, for which a
healing is not contemplable, can nd great bene-
t thanks to methods that put the Person, and his
Quality of Life, at the center of the intervention,
where it is not the care aimed at resolution to be
pursued but, rather, the care of the patient in his
body-mind unit.
When I draw, I forget about Parkinson’s and
Parkinson’s forgets about me
13.7 Art Therapy and Parkinson’s:
Rehabilitation
and Emotional Support
Degeneration of the nerve cells that produce
dopamine causes de cits in the activation of the
circuits responsible for movement and results in
symptoms characteristic of Parkinson’s disease
that include excessive involuntary movements,
sudden motor blocks, tremor and stiffness, speech
dif culties, depression, and hallucinations. The
disease is chronic and progressive and the current
therapeutic remedies are able to correct it, con-
taining the symptoms, but not to heal it de ni-
173
tively. Best choice of treatment is pharmacological
and it has the objective of recovering the motor
function to what is possible, reaching a good
compensation of symptoms, with the lowest pos-
sible doses of medication. In addition to the phar-
macological approach, other strategies for taking
care of the person with Parkinson’s disease are
necessary, and aim at supporting and amplifying
the effect of drugs and at addressing the inevita-
ble emotional and social problems related to
them. Art Therapy can be effective in this respect
because it can work both in motor rehabilitation
and as a tool of emotional and social support for
the patient. In addition, for the person with
Parkinson’s disease, an artistically mediated
intervention may be particularly appropriate, as
demonstrated by a research presented at the
EPDA (European Parkinson’s Disease
Association) general assembly held in Glasgow
in 1994 by the German neurologist Johannes
Lakke. The study entitled “Art and Parkinson’s
Disease” [6] evaluated the level of creativity in
artists affected by the disease, before and after
diagnosis. The results of the research con rmed
that, in the artists who had developed the disease,
there had been no impoverishment of the original
creativity, despite the considerable limitations at
the motor level, caused by the disease. In most
cases, in fact, cognitive and creative abilities
remained intact. The observed patients showed
greater dif culties in expressing themselves
through language and writing (complex modali-
ties that require an analytical process and the
involvement of more actions), but less dif culties
in using their creativity to communicate. Lakke
also observed that the examined artists produced
better results, using their imagination, rather than
copying a piece of art from life. Straight access to
one’s own emotions by bringing them back on
the sheet, in fact, allows a direct eye/artistic work
relationship capable of avoiding distractions,
increased dif culty, and consequent frustration.
This is why Art Therapy can offer Parkinson’s
patients an effective way of expression, giving
them the opportunity to create and externalize
their inner images with the help of artistic materi-
als. Creative expression can therefore have the
potential to help the patient to live with the
174
disease, increasing the capacity for processing
and resilience. In support of this thesis, the
English art therapist Diane Waller [7] draws
attention to how much Parkinson’s patient is
“consumed” by the artistic process, meaning that
the intensity of the creative investment in these
patients is enormous. Waller observes how, in the
on cycles, this intensity increases further, almost
as if to compensate and recover the “lost time”
during the off cycles.
13.8 Depression in Parkinson’s
Patient and Art Therapy
Depression is very common in Parkinson’s dis-
ease: approximately 60% of patients experience
at least one episode of depression regardless of
age, duration, and severity of the disease or cog-
nitive de cits. Apathy, anhedonia, feelings of
guilt and impotence, remorse and sadness, loss of
self-esteem and initiative, mental dif culties,
concentration, and judgment are unfortunately
frequent in these patients, along with the symp-
toms that often accompany depression or anxiety,
panic attacks, agitation, restlessness, and irrita-
bility. Two etiological hypotheses form the basis
of depression in the Parkinsonian patient namely:
one “reactive” to the diagnosis of the disease and
the consequent disability and the other de ned as
“endogenous biochemical” based on the changes
that affect the dopaminergic and serotonergic
system. As far as the reactive hypothesis is con-
cerned, two peaks of incidence are described, one
early at the communication of the diagnosis and
the other at stage IV of the Hoen & Yar Scale,
which corresponds to the transition from the
independence of the subject to the need for help.
It has also been observed that depression is more
frequent in the bradykinetic-rigid forms of the
disease than in tremorigenic forms and is often
related to clinical variations of the disease (off-
phase). To con rm the severity and importance of
depression in Parkinsonian, a new diagnostic cat-
egory under the heading “mood disorder due to a
general medical condition” had already been
included in the DSM-IV.  It is essential that
depression in Parkinson’s patients is recognized
E. Galbiati
and treated both because it has recently been con-
sidered a risk factor for a more rapid progression
of the disease and because its treatment can also
affect an improvement in motor symptoms.
Through Art Therapy it is possible to activate the
ability to elaborate one’s own experience and to
transmit it creatively to others; in fact, the artistic
process allows the recovery of one’s own creativ-
ity, as a vital force, and can favor the expression
of feelings that sometimes cannot be expressed in
words. It can relieve anxiety and tension,
strengthen self-esteem, and a sense of personal
identity, it can make the emotions conveyed by
more conscious sensory experiences and can
improve the relationship with oneself and others.
Through an extremely respectful tool of personal
defenses and by facilitating and allowing the acti-
vation of sensitive pleasure, it makes participants
feel a signi cant relief to their psychological sit-
uation. The manipulation of different materials,
and the targeted use of speci c artistic tech-
niques, promotes the re-education of the ne
motility of the hand by working on one of the
symptoms with more negative repercussions on
the personal identity of the Parkinsonian patient,
agraphia, which makes writing, and even the sim-
ple signing, complex and a source of frustration.
The group situation of the sessions is an opportu-
nity for sharing, it allows re ection and compari-
son and is a further strength of the path of support
to artistic mediation. The group is in fact a funda-
mental element in the therapy of depression, as
described by the American psychiatrist Irving
Yalom [8], who has identi ed 11 therapeutic fac-
tors, typical of group therapy. Among these, the
following four factors particularly meet the
demands related to the treatment of mood disor-
ders related to a chronic degenerative disease
such as Parkinson’s:
1. The infusion of hope: the structure of the
group itself bene ts from a speci c source of
hope that springs from sharing and mirroring
with its members.
2. Universality: the denial of the sad conviction
of being alone in misfortune, favored by group
experience, is a source of immediate relief for
each of the members.
13 The Signi cance of Art Therapy
3. Information: providing notions and explain-
ing the process of the pathology is important
because the explanation of a phenomenon rep-
resents the rst step toward the control of the
phenomenon itself.
4. Interpersonal learning: learning functional
and constructive ways of approaching the
problem from other members of the group is a
further therapeutic factor arising from the
group situation. In the support group, more-
over, the members receive something by the
very fact of giving; discovering that one’s own
experience may have been important for other
people is a restorative sensation that can
strongly bene t self-esteem.
13.9 A Clinical Experience
In 2006, in the Day Hospital department of the
Redaelli Geriatric Institute in Milan, a re-education
service was activated, through Expressive
Therapies, speci cally for users suffering from
Parkinson’s disease. The rst group of patients
treated was subject to clinical monitoring through
special Scales of Evaluation (UPDRS III—
HADS—IQ 39) in order to assess the effectiveness
of Art Therapy in the treatment of mood disorders
related to Parkinson’s disease. Eight patients with
Parkinson’s disease associated with depression
were observed, for a period of about 6  months,
placed in a weekly AT group. In general, there has
been a signi cant improvement in the mood of
patients (through the analysis of the results of tests
administered to T0 and T6) related to the possibil-
ity offered to the group to express and share
doubts, anxieties, and fears. Patients gradually
acquired the ability to express their feelings, even
the most disturbing and negative, through the free
and guided use of the artistic materials. The group
effectively compensated for the withdrawal from
social activities caused by the pathology, through
the interaction between the members; participants
learned to know each other and wait for the fol-
lowing session to nd each other again and the
relational aspect received a bene cial impulse.
The combined use of a wide range of materials
(tempera, clay, watercolors, pastels, pencils, etc.)
175
also allowed to exercise the ne motility of the
hand, often compromised by the disease.
13.10 Art Therapy and Alzheimer’s:
A Person-Centered Approach
Advances in modern medicine have made it nec-
essary to change the viewpoint regarding the con-
cept of treatment. Diseases that were once lethal
now, even if they are still unhealable, can be con-
sidered chronic and at the same time life expec-
tancy has increased considerably. From a
treatment aimed at healing it has been necessary
to move on to a concept of care understood as
“taking care” that, in a psychodynamic sense,
refers to the “holding” of Winnicot understood as
support, containment, and care. Taking care of
oneself is more closely related to the person and
introduces the theme of Quality of Life. Skautze
[9] observes that Quality of Life, understood as
the degree of satisfaction and pleasure that the
subject feels in the most important aspects of his
life, is related to subjective experiences such as
self-esteem, self-realization, inner harmony, free-
dom, pleasure, and love. In the Person suffering
from Alzheimer’s disease (AD: Alzheimer dis-
ease) the objective of rehabilitation as de ned by
the WHO (World Health Organization) is “to
restore in the individual affected by a disabling
illness the ability to occupy, with their own means,
a position, as normal as possible, in society,” it
requires a change of perspective because, since
most of them are elderly patients, the objective
cannot be centered on maximum ef ciency, as in
the young patient, but on maximum autonomy,
functional, and emotional. The concept has to
switch from rehabilitation centered on recovery
and performance, to a concept centered on the
person and his way of life in a given context. Kane
[10] identi es two primary objectives for the non-
pharmacological treatment of patients with
dementia: (1) to achieve overall functional
improvements; (2) to promote the well-being of
patients and their relatives. The meaning of the
intervention is therefore not to be sought in action
but in the patient’s possible “happiness,” that is,
from performance to Quality of Life. With these
176
premises, we begin to outline the reasons why the
approach through Art Therapy can be particularly
useful in Alzheimer’s disease, Vigorelli [11]
argues that “every patient, at a given time, still has
some autonomy, but is able to manifest it only if
he feels free to live in his possible world.” In
patients with Alzheimer’s disease, autonomy
should be understood as an instrument rather than
an end. In a progressive degenerative pathology,
in fact, the objective of autonomy is a source of
frustration, while if we consider it as a mean we
accompany the patient into his possible world,
considering his level of autonomy—even if dete-
riorated—an instrument that he possesses and
through which he is active, curious, and vital.
These considerations introduce two key aspects of
the Art Therapy intervention, the nonjudgmental
setting and the possibility of gaining experience.
A supportive and unjudgmental setting allows the
patient to use his residual skills avoiding the
freezing of the latter caused by the fear of failure.
The elderly hospitalized also risks, due to the nec-
essary excess of care, cognitively deteriorating
and losing the motivation to act faster than what
would happen because of the disease. Art Therapy
is an intervention that, rst of all, promotes the
experience of the patient and activates his desire
to experience reality, internal and external,
through the use of artistic materials as a privileged
bridge—transitional area—between himself and
others by himself. The direct use of different artis-
tic materials by the patient is also able to reacti-
vate body memories related to the primary
relationship, which trigger affections lost due to
cognitive impairment. Paraphrasing Vigorelli’s
thought on capacitation, Art Therapy can be
understood as a capacitating intervention, through
which the Alzheimer’s patient “can be happy, as
far as possible, can do what he does, as he does, in
the context in which he nds himself, regardless
of the correctness of the action to be performed.”
13.11 Alzheimer’s, Unconscious
and Creative Process
Another aspect that makes the creative process
particularly appropriate in this pathology is
related to changes in the personality structure of
E. Galbiati
the person with Alzheimer’s disease, who
changes due to the weakening of the Ego and
Superego and the predominance of Es. The rea-
son is overwhelmed by instinctual behavior and,
while the part of the brain responsible for the
transformation of thought into abstract concepts
decays, the part closest to the unconscious is acti-
vated. The Self is a product of the brain function-
ing, a damage to the brain tissue can therefore
cause signi cant alterations to the sense of iden-
tity. These alterations profoundly affect the
patient’s personality because they deteriorate the
ability to interpret the meaning of the stimuli and
to correlate them to the relevant feelings [12].
This generates a substantial inability to control
emotional responses, both because of the dif -
culty of giving proper meaning to what is hap-
pening and because of a de cit of cortical
inhibition of the structures of the limbic brain.
The continuity of the Self depends to a large
extent on the ability to remember and, when even
remote memories disappear as the disease pro-
gresses, the patient’s identity also begins to dis-
appear. The disorientation in time, already typical
of the early stages of the disease, leads to the
impossibility of building on experience and this
refers to the break in continuity of the experience
described by Thomas Odgen in the schizo-
paranoid mode. Like this mode of experience, the
Alzheimer’s patient is in a position to experience
an eternal present where the formation of a his-
torical consciousness is made impossible by the
organic pathological condition. Object relations
are unstable and fragile both because of the lack
of a stable and shared historical experience and
because mnesic de cits, abstraction, and deduc-
tion determine the inability to structure valid and
consoling internal objects and to resort to those
internalized in a state of health. Gabbard stresses
how memory loss can be associated with the loss
of a reassuring introject and with the return of
primary existential anxieties, since memory
involves the Self as much as the other by itself.
Odgen effectively describes the anguished condi-
tion of the schizo-paranoid mode as “an almost
constant background of anguish resulting from
the fact that the individual unconsciously always
feels as if he is living in an unknown country, at
the mercy of unpredictable extraneous experi-
13 The Signi cance of Art Therapy
ences” [13]. This description seems particularly
adequate to describe the extent and quality of the
anguish that invades the Alzheimer’s patient. The
same mode of symbolization described by Odgen
in the schizo-paranoid mode, the symbolic equa-
tion, seems equally adequate to describe the
inability of Alzheimer’s patient to understand
metaphorical language and symbolic images
(…), thoughts and feelings are not experienced as
personal creations but as facts, what-in-itself, that
just exist. Perception and interpretation are expe-
rienced as one thing. “The patient is entangled in
manifest reality since what is super cial and
what is deep are indistinguishable” [13]. Gabbard
observes that from a psychodynamic point of
view the loss of mental faculties due to progres-
sive dementia corresponds to a regressive process
within the Ego, because of which the more
mature defense mechanisms give way to more
primitive defense modes “aspects of the person-
ality that had been partly removed from a bio-
logically intact cortex gradually emerge with the
erosion of the defensive layers” [12]. Projection
and denial are the most common primary defenses
used by the AD patient, as the higher level
defenses are replaced by absorption on the self.
Patients therefore blame others for their own mis-
takes, as well as disregard traumatic sensory data
from outside in an attempt to defend themselves
against a highly disturbing external reality. The
impossibility of recognizing the existence of
internal objects probably favors the use of denial
as a defensive mode as an alternative to removal.
Aggressive accesses are explained by Goldstein
[14] by analyzing and comparing the psychologi-
cal reactions of patients with brain damage, for
whom an anxious state called catastrophic reac-
tion is described. This reaction stems from the
deep anger caused by the awareness of the loss of
cognitive functioning, responsible for failures in
the performance of habitual tasks before the dis-
ease. Goldstein has observed in patients with
brain injury the association of such failures to a
real danger for their very existence, from which
the catastrophic reaction that leads patients to
limit their lives, thus defending themselves from
catastrophic anxiety by avoiding the awareness
of their de cits. Vigorelli [11] identi es in the
self-limitation of the life of the AD patient an
177
additional damage de ned as excess disability,
because of which the patient fearing the error
(failure) chooses not to use a residual compe-
tence causing additional damage, for example,
the total loss of this competence and the conse-
quent reduction of autonomy. The concept of
catastrophic anxiety introduces the theme of the
disease consciousness of the AD patient, a theme
neglected until a few decades ago when the
unawareness of one’s own state was considered a
characteristic of AD patients. Alzheimer’s
patients, on the other hand, are aware of their dis-
orders and, unable to explain them, often have a
depressive reaction. Gabbard observes that in
many AD patients, while mental faculties deteri-
orate, self-knowledge can remain intact. Since
the recent memory is lost before the remote one,
it happens that these patients keep a living mem-
ory of “how they were,” making their pathology
even more emotionally disturbing. Vigorelli
observes that as the disease progresses, there is
an adaptation whereby the awareness is no longer
so evident but, he would like to stress, the level of
this awareness is dif cult to quantify from the
outside “what is certain is that for several years
the patient is aware of what is happening, the
patient knows that he is losing control of his
memory, words and thought, and is afraid of it”
[11]. The unconscious speaks through art and
creativity much more than through reasoning and
words, thus providing the tools of Art Therapy to
a person with dementia means offering him the
opportunity to use a more appropriate and effec-
tive language to nd the relationship with himself
and the environment. It is also known that the
artistic process promotes the recovery of implicit
and explicit memories, another reason why an
intervention to artistic mediation can be particu-
larly suitable for the Alzheimer’s patient. The dif-
ferent clinical experiences teach how Art Therapy
can help to slow down the degeneration of cogni-
tive faculties and, at the same time, offer moments
of psychological well-being by working on the
residual potential. During the creative process,
the patient is stimulated by the pleasure of reach-
ing an aesthetic form, expressed in the artistic
product, which is such as to support the ego and
self-esteem as an expression of the patient’s
residual ability. The artistic process allows the
178
acquisition of a form that re ects the level of
functioning of the here and now. By giving form,
it responds to the men’s need for an innate form,
thus promoting a rediscovered balance and inte-
gration of the Ego, even in the deterioration of
the disease. The artistic product, that is the work
of the patient, replaces words and leaves a trace
that can be processed, in full respect of its
defenses. There can be no fantasies of healing for
these patients, but it is still essential to be able to
offer them an activity that can support the resid-
ual potential and emotions, with the aim of
redrawing the boundaries of a confused and frag-
ile ego. In short, the primary objectives of an
intervention of Art Therapy in the Alzheimer’s
patient can therefore be summarized as follows:
to offer psychological well-being, stimulate the
memories of the past, promote the liberation of
emotions and feelings, even the most painful and
typically repressed, and encourage a sense of
identity and self-esteem.
13.12 A Possible Goal:
The Recovery of Emotional
Competence
Emotional competence is the ability to get in
touch with one’s own feelings and those of oth-
ers, to recognize and communicate them. The fra-
gility of the psychic structure of Alzheimer’s
patients, and their cognitive de cits, makes it dif-
cult to manage emotions. Moreover, from a
clinical point of view, the AD patient often suf-
fers from circulatory problems, so the degenera-
tive phenomena are added to pseudobulbar
syndromes, for example, microinfarctions that
cause brain access to sudden laughing and cry-
ing. As already mentioned, in past years, it was
believed that the Alzheimer’s patient was devoid
of emotions and feelings, because observing the
patients in advanced stage and hospitalized,
amimia and anhedonia can be noticed.
Institutionalization is the main cause of this
apparent absence of emotions, since it is now
known that prolonged hospitalization tends to
obscure the emotional reactions. The detachment
from one’s natural environment, the lack of stim-
E. Galbiati
uli, the sensory deprivation, and the estrangement
from relationships contribute to provoke an emo-
tional eclipse [11]. In reality, the emotional world
of the sick person, at least for the rst years of
illness, is extremely lively and covers the whole
range of disturbing and negative emotions linked
to fear and anxiety. Vigorelli observes that
Alzheimer’s patients live “in other possible
worlds, often in another time and in another
place.” Art Therapy can be the privileged bridge
to reach the sick person and reconnect with him,
offering him the opportunity to experience him-
self and the world again, because being in a rela-
tionship belongs to man and is necessary for the
sense of integrity and personal well-being “…
entering into a relationship and experiencing are
fundamental processes of human development
and are combined in Art Therapy as interacting
processes between the therapist, the patient and
the created object” (M. Della Cagnoletta) [15].
13.13 Therapy by Art and Art
as Therapy
That Visual Art can be able to strike deeply and
awaken resources and dormant affection is a
hypothesis that is becoming more and more con-
crete. The well-known neurologist and writer
Oliver Sacks has stated that the personal confron-
tation with a work of art is not only a visual expe-
rience, but is also strongly emotional: “In
different situations I have seen completely
demented people recognize and react with vivac-
ity in front of painted canvases and draw great
pleasure from painting. And this at a stage of dis-
ease already advanced, when they no longer
responded to the words, which, in fact, confused
them. That is why I am convinced that visual art
can go very deep.” The reason for this would
seem to be that Art is capable of soliciting parts
of the brain that remain intact after the onset of
dementia. An experimental study, in collabora-
tion with the Museum of Modern Art in
New  York, on the effects of art on Alzheimer’s
patients has recently been carried out. Through
guided tours of the Museum of Patient Groups,
monitored by specialized clinicians, the rst
13 The Signi cance of Art Therapy
results seem to demonstrate how Art can effec-
tively stimulate, even in a demented person, a
vital reaction and an intellectual stimulus so
strong as to make the positive effects felt even in
the short/medium term. In a disease like
Alzheimer’s, so speci c in reducing the mental
capacity of those affected, it is clinically interest-
ing to note how Art can awaken unsuspected
means of expression and interpretation.
13.14 Art Therapy, Visual Art,
and Alzheimer’s: The Project
“Two Steps in the Museums
of Milan”
The project “Two steps in the museums of Milan”
was born from the collaboration between Intesa
Sanpaolo and Manuli Foundation, which in 2013
entrusted me with the design of an art therapy
course for Alzheimer’s patients and their families,
assisted by the Foundation, present on the
Milanese territory for over 20 years. On the basis
of the review of the existing literature, a visual
and practical museum path has been developed,
according to the principles of psychodynamic Art
Therapy and Family Art Therapy, with regard to
the systemic approach. The forerunner of the
experience of sharing Art/Alzheimer’s was
MOMA in New  York in 2006, the rst museum
structure to experiment with the use of art for AD
patients. The project “Meet Me at the Moma” has
been studied by the New  York University
(Psychological Research and Support Program—
Centre of Excellence for Brain Aging and
Dementia) and the results have shown a signi -
cant increase in self-esteem and a positive change
in mood for patients and greater socialization
combined with a lower feeling of loneliness for
care givers. Following this rst path, several
museums in the United States have opened their
doors to experience, including the Columbus
Museum in Georgia with the project “Arts 4
Alzheimer’s” and in the rest of the world, just to
name a few, the Royal Academy in London, the
Prado in Madrid, the National Gallery of Australia
in Canberra and the Louvre in Paris. In Italy,
among the projects that link visual arts and
179
Alzheimer’s disease we can mention “The mem-
ory of beauty” of the National Gallery of Modern
Art in Rome and “ADarte” of the Royal Palace in
Naples, as well as the projects “A più voci” of the
Fondazione Palazzo Strozzi in Florence and
“MUSAL” of the Pinacoteca Provinciale
Giaquinto in Bari. Each of these interventions
involves the vision of selected works followed by
a creative moment, verbal or expressive, by psy-
chologists, geriatric operators, and experts in cul-
tural heritage. The experience of Rome has been
studied by the Department of Gerontological,
Geriatric and Physiatric Sciences of the Policlinico
Gemelli, which has shown a 20% decrease in psy-
cho-behavioral disorders of patients and a 25%
reduction in the level of stress of care givers. The
Neapolitan project was also observed by the staff
of the Alzheimer’s Evaluation Unit of the
Cardarelli Hospital and this research also con-
rmed the positive results of the experience. The
project “Two steps in the museums of Milan” has
as its objectives the improvement of the Quality of
Life of the patient, both of the patient and his fam-
ily through the support of his expressive and emo-
tional competence, through a systemic approach
aimed at rebalancing relationships and roles
within the family. The strong point of the project
is to have placed the person with Alzheimer’s at
the center of the experience, offering him a pos-
sibility not only visual, but also concrete and
practical, through the laboratory of Art Therapy
that follows each of the meetings of enjoyment of
works of art in the museum. The meetings take
place during the opening days of the museum in
order to allow the full social and relational experi-
ence of AD patients, in a context that belongs to a
common memory of life. Together with this,
ample space is dedicated to practical experience,
through artistic materials and according to the
theoretical foundations of Art Therapy with psy-
chodynamic orientation, with the aim of enabling
patients to elaborate their experience and expand
their expressive and creative possibilities.
Considering the social impact of this pathology,
which involves not only the patient, but also
his family, the project provides a systemic
approach, according to the principles of Family
Art Therapy (H.Y.  Kwiatkowska, L.C.  Wynne,
180
H.B. Landgarten, D. Linesch), a method of cially
recognized by the American Art Therapy
Association (AATA) in 1989. After a pilot project
of 3 months in 2013 at the Gallerie d’Italia Piazza
Scala, the route was made at the Poldi Pezzoli
Museum and the Pinacoteca di Brera, also in
Milan. This second tranche was the subject of
research by the Catholic University and currently
the project has assumed a stable character and is
still offered at Gallerie d’Italia Piazza Scala and
Pinatoceca di Brera, which open their doors to
this special public, and their families, every year
from October to June. The research was carried
out in 2013/2014 by the Catholic University of
Milan, Psychology and Art Research Unit,
directed by Professor Gabriella Gilli. The aim of
the study was to highlight the positive effects in
terms of improving cognitive and psychobehav-
ioral symptoms, increasing self-esteem, and the
perception of personal effectiveness, highlighting
the improvement in mood derived from the activa-
tion of creativity as a healthy and vital part of the
personality and, nally, to observe the improve-
ment in communication within the family group.
The research design had a qualitative and quanti-
tative nature and provided for various speci c
tools to test the effectiveness of the intervention
according to different items and observation
sheets. For a period of 3 months, in each museum,
four groups were observed, composed of a total of
16 women and 11 men, aged between 66 and
97  years, with an average level of education,
medium-low socioeconomic status, mainly mar-
ried. The inclusion criteria involved a diagnosis of
dementia according to the criteria of DSM V with
severity of moderate to medium cognitive impair-
ment (MMSE Mini Mental State Evaluation >8),
a standard drug therapy for the treatment of
dementia approved by the specialist physician and
the signing of informed consent. The exclusion
criteria include institutionalized patients, patients
participating in other clinical trials and patients
with sensory de cits. The study, although not
claiming statistical validity, especially for the low
number of subjects involved, con rmed what
emerged in the literature about the positive effects
of an intervention of Art Therapy applied to
Alzheimer’s disease, mainly in terms of slowing
E. Galbiati
down the loss of residual skills and the develop-
ment of positive emotions. The analysis of quanti-
tative data (Smile Test, POMS, SAT-P) does not
reveal a statistically signi cant change between
the beginning and the end of the treatment, but
rather an increase in the average scores, which
shows how the experience of Art Therapy can
maintain and improve some cognitive perfor-
mance, and the individual perception of effective-
ness, thanks to the activation of creativity through
which the patient has the opportunity to redis-
cover himself in a new guise rediscovering dor-
mant abilities. The participatory observation with
qualitative method, aimed at measuring the degree
of involvement, collaboration, visible mood tone,
perceived well-being and emotional sharing
between patients, workers, and care givers, it
showed a high level of involvement both individ-
ual and shared with the group, an extremely posi-
tive mood tone and a general well-being evident
in facial expressions, comments, and the desire to
extend the time of the meeting. Rich and signi -
cant graphic productions have also been observed,
highlighting the high level of involvement and
investment in the artistic process and, as far as the
care givers are concerned, they were overall
pleasantly surprised by the residual resources of
their loved ones, with an improvement in the
internal dynamics of the family group. In con-
clusion, although considering the limits of the
research related to the number and reliability of
data attributable to the type of clinical popula-
tion affected by dementia and the limits inherent
in the choice of nonspeci c tests for the popula-
tion under investigation, the study showed how
the path of Art Therapy in a museum context has
generally provided AD subjects with a variety of
stimuli that have supported performances
related to cognitive capacity and a positive emo-
tional state. Moreover, the substantial stability
of the data and the increase of some variables
related to well-being can be interpreted as fur-
ther positive signals related to the bene cial
effects of the intervention of Art Therapy on
people with AD, because in line with what
emerged from the research of the Policlinico
Gemelli and the Catholic University of Rome,
mentioned above.
13 The Signi cance of Art Therapy
13.15 A Further Possibility: Art
Therapy as a Diagnostic Tool.
The Role of Art Therapist
in Teamwork
In 1999, James Wald, an English Art Healer,
developed a scheme of diagnosis through art for
patients suffering from chronic degenerative dis-
eases. Some of Wald’s evaluations are taken, for
example, from the following exercises:
– copy geometrical shapes to evaluate spatial
conception and ability to concentrate.
– drawing a clock, to evaluate the ability to con-
ceptualize and the ability to perform or reject
a speci c task.
– draw your own portrait, to evaluate the con-
ceptualization of your body image and the
psychological state.
– choose colors, to evaluate feelings and mood
tone.
– create a painting at will, to assess the ability to
abstract, symbolize and express ideas and
feelings.
Starting from Wald’s considerations, we
observe how Art Therapy can be useful to deter-
mine residual capacities, cognitive, physical-
manipulative and sensory de cits, psychological
state, and interpersonal capacities. Art Therapist
can use his sessions to draw information about
visual perception and the ability to process sen-
sory inputs and translate them, organizing the
thought in a graphical mode. The degree of de -
cit and the stage of dementia can be assessed by
observing the ability to follow instructions, the
ability to orient, the omissions, and the ability to
notice errors. Perceptive abilities, residual intel-
lectual and processing skills, can be assessed by
asking the patient to give a title to his work, sign
it, and tell what it represents. The onset of psy-
chotic traits can be detected, as well as depressive
states and suicidal symptoms. Abilities, residual
intellectual and processing skills, can be assessed
by asking the patient to give a title to his work,
sign it, and tell what it represents. The onset of
psychotic traits can be detected, as well as depres-
sive states and suicidal symptoms. The work of
181
the Art Therapist can therefore provide valuable
guidance to the clinician (neurologist, psychia-
trist, etc.) responsible for the treatment of patients
with chronic degenerative disease.
13.16 You Are Never Too Old When
You Have Something to Say,
to Do, to Design, to Invent
Making art belongs to men, as does the need to
express oneself creatively, and Art Therapy can
intervene positively in all phases of life to con-
tribute to the well-being and psychic balance of
the person. The applications on Alzheimer’s and
Parkinson’s, typical pathologies of advanced age
mostly, introduce us to a re ection on the impor-
tance of creativity in senescence. Creativity is
present in each human being and develops and
enriches through experience. At the basis of the
creative process is imagination, understood as
the ability to imagine a situation never experi-
enced before and depict something never seen
before. The ability to be creative does not end
with time, on the contrary, right in the last phase
of life, forcibly marked by physical and psychic
losses, it can represent for the individual a new
space of experience functional to self-assertion
and vital self-expression. This introduces a
vision of old age not as a phase of decline, but as
another phase of existence, in which it is still
possible to discover and experience, in a moment
made particularly favorable by the attenuation of
sociocultural constraints and conditioning. In
conclusion, the creative potential of human
beings remains intact even in old age and Art
Therapy can be the right tool to regain posses-
sion of it.
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