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Pure alexia, unaccompanied by any difficulty in writing (“alexia sine agraphia�) is not that uncommon, although it usually comes on suddenly, following a stroke or other brain injury. Less often, alexia develops gradually, as a consequence of a degenerative disease such as Alzheimer’s. But Lilian was the first person I had encountered whose alexia manifested first with musical notation, a musical alexia.
People with PCA preserve elementary aspects of visual perception, such as acuity or the ability to detect movement or color. But they tend to experience complex visual disturbances—difficulties reading or recognizing faces and objects, occasionally even hallucinations. Their visual disorientation may become profound: some patients get lost in their own neighborhoods or even in their own homes; Benson called this “environmental agnosia.� Other difficulties commonly follow: left-right confusion, difficulty in writing and calculation, even an agnosia for one’s own fingers, a tetrad of problems
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Wittgenstein, the philosopher, distinguished two methods of communication and representation: “saying� and “showing.� Saying, in the sense of propositionizing, is assertive and requires a tight coupling of logical and syntactic structure with what it asserts. Showing is not assertive; it presents information directly, in a nonsymbolic way, but, as Wittgenstein was forced to concede, it has no underlying grammar or syntactic structure.
Music therapy is invaluable for some patients with expressive aphasia; finding that they can sing the words to a song, they are reassured that language is not wholly lost, that they still have access to words somewhere inside them. The question is then whether the language capacities embedded in song can be removed from their musical context and used for communication. This is sometimes possible to a limited extent, by reembedding words in a sort of improvised singsong.
Psychologists have sometimes spoken of “interlingua� or “mentalese,� which they conceive to be the brain’s own language, and Lev Vygotsky, the great Russian psychologist, used to speak of “thinking in pure meanings.�
