The Brain That Changes Itself
Excerpt from the book The Brain That Changes Itself by Norman Doidge, M.D.
The origin of Paul Bach-y-Rita's understanding of brain rehabilitation lies in the dramatic recovery of his own father, the Catalan poet and scholar Pedro Bach-y-Rita, after a disabling stroke. In 1959 Pedro, then a sixty-five-year-old widower, had a stroke that paralyzed his face and half of his body and left him unable to speak.
George, Paul's brother, now a psychiatrist in California, was told that his father had no hope of recovery and would have to go into an institution. Instead, George, then a medical student in Mexico, brought his paralyzed father from New York, where he lived, back to Mexico to live with him. At first he tried to arrange rehabilitation for his father at the American British Hospital, which offered only a typical four-week rehab, as nobody believed the brain could benefit from extended treatment. After four weeks his father was nowhere near better. He was still helpless and needed to be lifted onto and off the toilet and showered, which George did with the help of the gardener.
"Fortunately, he was a little man, a hundred and eighteen pounds, and we could manage him," says George.
George knew nothing about rehabilitation, and his ignorance turned out to be a godsend, because he succeeded by breaking all its current rules, unencumbered by pessimistic theories.
"I decided that instead of teaching my father to walk, I was going to teach him first to crawl. I said, "You started off crawling, your are going to have to crawl again for a while.' We got kneepads for him. At first we held him on all fours, but his arms and legs didn't hold him very well, so it was a struggle." As soon as Pedro could support himself somewhat, George then got him to crawl with his weak shoulder and arm supported by a wall. "That crawling beside the wall went on for months. After that I even had him practicing in the garden, which led to problems with the neighbors, who were saying it wasn't nice, it was unseemly, to be making the professor crawl like a dog. The only model I had was how babies learn. so we played games on the floor, with me rolling marbles, and him having to catch them. Or we'd throw coins on the floor, and he'd have to try and pick them up with his weak right hand. Everything we tried involved turning normal life experiences into exercises. We turned washing pots into an exercise. He'd hold the pot with his good hand and make his weak hand -- it had little control and made spastic jerking movements -- go round and round, fifteen minutes clockwise, fifteen minutes counterclockwise. The circumference of the pot kept his hand contained. There were steps, each one overlapping with the one before, and little by little he got better. After a while he helped to design the steps. He wanted to get to the point where he could sit down and eat with me and the other medical students." The regime took many hours every day, but gradually Pedro went from crawling, to moving on his knees, to standing, to walking.
Pedro struggled with his speech on his own, and after about three months there were signs it too was coming back. After a number of months he wanted to resume his writing. He would sit in front of the typewriter, his middle finger over the desired key, then drop his whole arm to strike it. When he had mastered that, he would drop just the wrist, and finally the fingers, one at a time. Eventually he learned to type normally again.
At the end of a year his recovery was complete enough for Pedro, now sixty-eight, to start full-time teaching again at City College in New York. He loved it and worked until he retired at seventy. Then he got another teaching job at San Francisco State, remarried, and kept working, hiking, and traveling. He was active for seven more years after his stroke. On a visit to friends in Bogota, Columbia, he went climbing high in the mountains. At nine thousand feet he had a heart attack and died shortly thereafter. He was seventy-two.
I asked George if he understood how unusual this recovery was so long after his father's stroke and whether he thought at the time that the recovery might have been the result of brain plasticity.
"I just saw it in terms of taking care of Papa. But Paul, in subsequent years, talked about it in terms of neuroplasticity. Not right away, though. it wasn't until after our father died."
Pedro's body was brought to san Francisco, where Paul was working. It was 1965, and in those days, before brain scans, autopsies were routine because they were one way doctors could learn about brain diseases, and about why a patient died. Paul asked Dr. Mary Jane Aguilar to perform the autopsy.
"A few days later Mary Jane called me and said, 'Paul, come down. I've got something to show you.' When I got to the old Stanford Hospital, there, spread out on the table, were slices of my father's brain on slides."
He was speechless.
"I was feeling revulsion, but I could also see Mary Jane's excitement, because what the slides showed was that my father had had a huge lesion from his stroke and that it had never healed, even though he recovered all those functions. I freaked out. I got numb. I was thinking, 'Look at all this damage he has.' And she said, 'How can you recover with all this damage?'"
When he looked closely, Paul saw that his father's seven-year-old lesion was mainly in the brain stem - the part of the brain closest to the spinal cord - and that other major brain centers in the cortex that control movement had been destroyed by the stroke as well. Ninety-seven percent of the nerves that run from the cerebral cortex to the spine were destroyed - catastrophic damage that had caused his paralysis.
"I knew that meant that somehow his brain had totally reorganized itself with the work he did with George. We didn't know how remarkable his recovery was until that moment, because we had no idea of the extent of his lesion, since there were no brain scans in those days. When people did recover, we tended to assume that there really hadn't been much damage in the first place. She wanted me to be a coauthor on the paper she wrote about his case. I couldn't."
His father's story was firsthand evidence that a "late" recovery could occur even with a massive lesion in an elderly person. But after examining that lesion and reviewing the literature, Paul found more evidence that the brain can reorganize itself to recover functions after devastating strokes, discovering that in 1915 an American psychologist, Shepherd Ivory Franz, had shown that patients who had been paralyzed for twenty years were capable of making late recoveries with brain-stimulating exercises.
His father's "late recovery" triggered a career change for Paul. At forty-four, he went back to practicing medicine and did residencies in neurology and rehabilitation medicine...
Traditional rehabilitation exercises typically ended after a few weeks, when a patient stopped improving, or "plateaued", and doctors lost the motivation to continue. But Paul Bach-y-Rita, based on his knowledge of nerve growth, began to argue that these learning plateaus were temporary -- part of a plasticity-based learnign cycle -- in which stages of learning are followed by periods of consolidation. Though there was no apparent progress in the consolidation stage, biological changes were happening internally, as new skills became more automatic and refined.