Mice and Humans: Lennie Small's Differential Diagnosis - Hektoen International (2023)

mice and humans: Differential Diagnosis by Lennie Small

March 26, 2021 r

Howard Fischer
Uppsala, Sweden

Mice and Humans: Lennie Small's Differential Diagnosis - Hektoen International (1)
Colin Waters plays Lennie in the 2018 Charleston Stage productionmice and humans.Photo courtesy of Marybeth Clark.Those.

In John Steinbeck's 1937 novelmice and humans,1The two main characters work as migrant workers on farms and ranches in California during the Great Depression. Their only ties are to each other. George is "small and quick" with "sharp, strong features," while his companion, Lennie, is "a huge man with a shapeless face. . . with broad, sloping shoulders, striding heavily and shuffling a little. . . His arms didn't dangle at his sides, but hung loosely at his side.

After the death of Lennie's orphaned Aunt Clara, George decided to be a protector of sorts for him. Lennie is mentally challenged, has a poor memory, and is impulsive. His impulsiveness leads him to do "bad things" and get into trouble.

These three key characteristics of Lennie—his height, intellectual deficits, and behavioral problems—can serve as clues to possible diagnoses of his condition. Lennie is described as "enormous", which is clinically defined as greater than the 97th percentile for age and gender.2and is diagnostically divided into proportional and disproportionate tall stature.3,4Disproportionately tall people have an arm span (arms stretched out like airplane wings) greater than their height, and the bottom half of their body is longer than the top half. Simply put, being disproportionately tall means having very long arms and legs. There is no indication in the novel that Lennie is disproportionate in size, so certain medical conditions involving this physical trait include: Marfan syndrome; 47, XXY syndrome (Klinefelter); Beckwith-Wiedemann syndrome; and XYY syndrome are excluded.5

Conditions of proportionally large stature include cerebral gigantism (Sotos syndrome) and Weaver syndrome.6Adult males with Sotos syndrome average 183 cm tall, although there have been at least two reports of males with the condition being over 213 cm tall.7People with Sotos syndrome also have prominent foreheads, jaws, and ears, large hands and feet, below-average intelligence (97%), and language problems. They are described as clumsy and have an awkward gait, and about half of those affected have seizures.8Sotos syndrome is linked to a deletion in the NSD1 gene.9

Weaver syndrome, another disorder characterized by height proportionality, involves typical facial features, hand deformities, and intellectual deficits in 80% of individuals.10

Intellectual disability (formerly known as intellectual disability) includes below-average intelligence and deficits in two or more age-appropriate adaptive behaviors: self-care, housekeeping, communication, self-determination, and security. Disability is mild in about 85% of the intellectually disabled population, which corresponds to about 9-11 years of intellectual adulthood. A moderate intellectual disability corresponds to an adult with a mental age of 6-8 years or an IQ below 50 or 55, where 100 is the average for the general population.11

In autism or autism spectrum disorders, language and reciprocal social behavior are more affected than nonverbal reasoning skills. These individuals may have narrow repertoires of interests and behaviors, repetitive activities, and echolalia.12They may have a sensory attraction to soft things like fur or velvet, and respond to sensory overload (like noise) with "breakdown" behavior—a complete and involuntary loss of behavioral control.13

It is estimated that around 70% of people with autism spectrum disorders also have some degree of intellectual disability.14

Diagnosing a fictional character like Lennie Small is difficult. We have no medical history regarding his family, birth, childhood or early adulthood. Body and behavioral descriptions are included in the book, but there are no clinical observations or standardized tests.

Based on what Steinbeck wrote, I believe Lennie most likely had Sotos Syndrome. We have no reason to believe that his height is disproportionate, and although Lennie was taller than the average person affected by Sotos syndrome, there are reports in the medical literature of adult males with the condition being over six feet tall . Sotos syndrome includes intellectual deficits that are mild in about 30%, moderate in 45%, and severe in 20%.15Lennie loves to pet soft things, and in the novel he accidentally kills a mouse and a puppy by petting their soft fur too hard. He eventually kills the woman who invited him to stroke her hair. If the stroking becomes too rough, the woman will panic and start screaming. Lennie collapses, won't let go of her, and ends up choking her from the screams. It's the worst "bad thing" he's ever done.

Some authors have suggested other diagnostic options. ledesma16writes that Lennie's breakdowns are actually panic attacks. However, panic attacks can occur suddenly and unexpectedly with no initiating event, and are accompanied by a range of somatic symptoms not described in the story. Watanabe17suggests that Lennie is "Lennie Small" because Steinbeck wants to tell the reader that Lennie is minorlittle evilepileptic seizures. Very few people with Sotos syndrome have themLack(little evil) Cramps,18and an autistic breakdown is a more likely possibility.

"Ockham's Razor" suggests that the simplest explanation with the fewest assumptions is usually the best explanation. Sotos' team would explain both Lennie's physical appearance and intellectual deficit. It's reasonable to assume that an autism spectrum disorder is also part of his condition.

Was Lennie modeled after someone Steinbeck knew, a combination of traits from several people, or an entirely imaginary display of strength, poor judgment, and poor impulse control? Steinbeck responded to this in an interview withNew York Timesin December 193719“Lennie was a real person. He's in an insane asylum in California now. I worked with him for many weeks. He didn't kill the girl. He killed the ranch foreman. It hurt because the foreman fired his buddy and stuck a pitchfork in his stomach. . . I saw him doing it. We couldn't stop him until it was too late.

More than eighty years have passed since thenmice and humansit was written. One can only hope that the fate of a man like Lennie would have been very different today. Changes in the social environment and adaptive education can help people like Lennie live better in society, although society itself has yet to learn to adapt better to people with physical and cognitive differences.


  1. John Steinbeck.Of Mice and Men / Cannery Series. New York: Penguin Books, 1949.
  2. Pinchas Cohen and Melanie Shim, 2007. "Tall Rise," vNelson Manual of Pediatrics, Hrsg. 18RM Kleegman i., 2304-2307. Philadelphia: Saunders.
  3. Christina Meazza, Chiara Gertosio, Roberto Gincchero, Sara Pagani and Mauro Bozolla, "High Altitude: Difficult Diagnosis?",Italy JPed, 43, Nr. 6, 2017.
  4. Justin Davies and Tom Cheetham, "Researching and Managing High Growth",Arch Dis Kind, 99, no. 8, 2014.
  5. Davies and Cheetham, "The Inquiry".
  6. Davies and Cheetham, "The Inquiry".
  7. Steinbeck, "About Mice".
  8. Steinbeck "About Mice".
  9. Davies and Cheetham, "The Inquiry".
  10. Meazza, "skyscraper",
  11. Bruce K. Shapiro and Mark L. Batshaw, 2007. “Mental Retardation (Intellectual Disability)”, inNelson Manual of Pediatrics, Hrsg. 18RM Kleegman i., 191-197. Philadelphia: Saunders.
  12. Eric M Butter i James A. Mulick, 2009. „Autyzm”, wHandbook of Pediatric Care from the American Academy of PediatricsTK McInerny et al., Hrsg. 1196-1201. Elk Grove Village, IL: American Academy of Pediatrics
  13. Clare Lawrence, is Lennie a monster? Reconsideration of Steinbeckmice and humansin inclusive teaching contexts of the 21st century”Palgrave Parish, 6, Nr. 17., 2020.
  14. Butter and Mulick, "Autism".
  15. Andrew Edmonson and Jennifer Kalish, "Overgrowth Syndrome",J Pediatr Genet, 4, Nr. 3, 2015.
  16. Jillian Ledesma, “Diagnosing Lennie Small,” transThe Muse Project - Intellectual Disability in Carlisle Floyd's Of Mice and Men.2016
  17. Nancy Ann Watanabe, "Medical Genetics and Steinbeckmice and humans“, https://www.researchgate.net/publications/341844984
  18. Francesco Nicita, Martino Ruggieri, Agata Polizzi, Laura Mauceri, Vincenzo Salpietro, Silvana Briuglia, Laura Papetti et al., "Seizures and epilepsy in Sotos syndrome: Analysis of 19 Caucasian patients with long-term follow-up"Epilepsy, 56, Nr. 6, 2012.
  19. Thomas Fensch, wyd.Conversations with John Steinbeck. Jackson: University Press of Mississippi, 1988.

HOWARD FISCHER, MD, is a retired professor of pediatrics at Wayne State University School of Medicine in Detroit, Michigan. He has spent most of his career diagnosing and treating child abuse and neglect. He has always been interested in the relationship between literature and medicine.

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