Quiz: Diagnosing Timy Tim


As health care practitioners, you are all naturally curious about diseases of all kinds, especially those that have remained undiagnosed mysteries.

Since the holiday season is upon us, I decided to do a little research into Tiny Tim, the lovable son of Scrooge’s employee, Bob Cratchit, in Dickens’ A Christmas Carol. The little boy’s disability is never explained in the famous tale, with the author leaving it to readers—and practitioners—to take an educated guess as to what his ailment was.

Take the poll at the end to see how your diagnosis stacks up.

Not surprisingly, a number of physicians have reflected upon the topic, and here’s what they’ve had to say.

According to the late Russell Chesney, MD, of Le Bonheur Children’s Hospital in Memphis, Tiny Tim suffered from rickets and tuberculosis. Chesney came to this conclusion based on the symptoms described in the story, suggesting that Tim’s disease would have been curable if his father had possessed more money. Rickets is caused by a lack of vitamin D, calcium, or phosphate. Not having these crucial nutrients often causes bones to become soft and malleable, and leg braces would have been the answer in the 1840s, when the story was written. Since infant formula and milk fortified with vitamin D were introduced decades ago in the US, the disorder is rarely seen in this country.1

Another practitioner, the late pediatrician Donald W. Lewis, of Norfolk, Virginia, spent several years studying Tiny Tim’s condition. His diagnosis, published in 1992 in the American Journal of Diseases of Children: a potentially deadly kidney ailment now known as distal renal tubular acidosis (RTA). With this condition, acid accumulates in the blood, creating a cascade of problems. If untreated, RTA can cause short stature, crippled legs, withered hands, intermittent weakness, and the other symptoms that afflicted Tiny Tim. But it would have been reversible if Scrooge had intervened in time, Lewis explained.2

Daniel J. Glunk, an internist in Williamsport, Pennsylvania, also believed that Tim suffered from RTA because this kidney disease has a propensity to make the blood too acidic. “Tiny Tim is small, has malformed limbs, and periods of weakness,” the doctor noted in a 2007 interview with the Pennsylvania Medical Society. “These all can be the result of RTA. Plus, the fact that Tiny Tim’s condition is fatal if left untreated, but reversible if proper medicine is used, helps to guide medical sleuths to RTA.”3

What is your diagnosis of Tiny Tim?

Distal renal tubular acidosis (RTA)

Regardless of what Tiny Tim’s diagnosis may have been in real life, it makes one grateful to live in a high-income nation in the 21st century, when access to vitamin D and treatment for renal tubular acidosis (which usually involves taking sodium bicarbonate or sodium citrate) are readily available. In the end, a gentler, kinder Scrooge gets Tiny Tim what he needs to walk again. So, it’s happy holidays all around in A Christmas Carol. Here’s hoping it is a very happy holiday season for all of you as well.

Mike Hennessy Jr.

President and CEO, MJH Life Sciences

For references, see the original article.

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