The crumpled old gentleman nestled in the armchair of his hospital room, bundled in blankets from the warmer down the hall, cards from his family propped up like a miniature Stonehenge on the table beside him. I listened closely to his heart and lungs, eyed the half-full urinal hooked onto his bed frame, and drew my fingers along his shins. It was early in the morning, and he didn’t say much — just watched me with thoughtful eyes as I completed my physical exam. When I slipped out of the room to attend rounds, he saluted me with one of the tight, frozen hands he kept in his lap, folded into each other like nested spoons.
My patient had been steadily losing the use of his hands for years. The rheumatoid arthritis settled in for a long war against his immune system, making marred battlefields of his tissues. As the bones became more pliable and his disease progressed, his ligaments grew tighter and tighter. Without the opposing tension the devastated bone once provided, his fingers angled inward, stiffening away from the straight and narrow. Of course, he could have avoided some of the disease burden if he received treatment at an earlier age, but limited access to health care had conspired to keep these medications secreted away from him. In his old age, his condition had progressed too far for antirheumatic drugs to thwart the damage. My heart ached every time I opened his hospital-grade Jell-O cup for him.
During my clinical years, I spent hours behind the wheel driving to my third-year rotations while John Steinbeck’s “East of Eden” audiobook narrated my commute. My waking moments were bookended by Adam Trask’s haunting childhood and his American dream coming to fruition. As he fell in love with one of the most despicable villains in literature and his sons inched towards their scriptural fate, I escaped the reality of my day-to-day and reveled in the complexity of plot and ideas spun by the great American novelist. The book permeated my life — as books tend to do if you spend enough time with them — and finally, there was a frank bleeding over.
As the multigenerational epoch unfolds, villainous Kate Trask continues her descent further into wickedness. She manipulates the other criminals she surrounds herself with and condemns to death anyone who dares to cross her. She destroys lives and revels in it, and as her youth and beauty slip away arthritis lays waste to her body. Steinbeck in “East of Eden” portrays the demise of Kate’s health as a mark of her immorality, and Kate herself seems to accept her disfigurement as a given, insinuating she knew of her imminent punishment:
The pain was creeping in her hands again, and there was a new place. Her right hip ached angrily when she moved. She thought: So the pain will move in towards the center, and sooner or later all the pains will meet … and join, like rats in a clot.
From rudimentary parables to film classics to metaphors constructed in novels, conflation of physical appearance and one’s moral compass is pervasive in literature and pop culture. An evil, jealous witch in Disney’s “Snow White” reaches towards a horrified princess with wizened fingers. An entire community rejects Tim Burton’s shy protagonist Edward Scissorhands, forcing him into reclusion over his razor-sharp appendages. Oscar Wilde writes of Dorian Gray’s portrait decomposing as his soul descends into hell. In “East of Eden”, Kate Trask wore gloves everywhere, attempting to conceal the destruction that mortifies her, unveiling a prevailing theme — “If a twisted gene or a malformed egg can produce physical monsters, may not the same process produce a malformed soul?”
I could not reconcile Kate Trask’s decay and depravity with the kind patient I took care of every day. Both Kate and my patient required help turning door knobs and writing notes, but the similarities ended there. I was shocked by the way literature had utterly failed to represent reality. My patient thanked every provider who entered his room, even when they came to deliver frustrating news, whereas Kate Trask plotted the death of unsuspecting innocents who fell under her spell. Perhaps John Steinbeck should have given her a different ailment, or maybe she should not have been ill in the first place. Though Steinbeck has been lauded for his astute insight into the workings of mankind, who was he to suggest that illness is directly correlated with a state of sin? Ultimately, no matter what disease afflicted Kate’s character, the delivering of the aforementioned theme persisted. What does it say about our cultural perceptions of illness when we so readily assign physical ailments to villains?
For decades, medical education has utilized literature as a tool to convey the richness of context and the nuances of everyday clinical, personal and professional encounters. Medical students are encouraged to digest patient narratives and pathographies with the end goal of better understanding our patients’ experiences. “East of Eden” reminded me that there is another role for literature in medical education. Without a doubt, art, language and literature help us understand our patients, but they can also challenge perceptions that we readily accept. This dissonance between literature and reality reminded me to question the messages coded in the art we consume. We should seek to diversify our exposure to other worldviews and narratives but should remain diligent in questioning whether our assumptions about morality are applicable to the illnesses among which we and our patients spend our lives.
“A sad soul can kill you quicker than a germ.” –John Steinbeck