The Case of Tiny Tim

Publish date: 2024-08-02

Every year around Christmas, the life of Tim Cratchit, better known to millions of fans of "A Christmas Carol" as Tiny Tim, is in peril. The Ghost of Christmas Present states the small boy's medical prognosis loud and clear, foreseeing "a vacant seat . . . and a crutch without an owner."

Charles Dickens's story of the transformation of the miserly Ebenezer Scrooge is a holiday allegory, brimming with events and characters with multiple symbolic meanings infusing a theme of sin and redemption. The visits of four ghosts on Christmas Eve jolt Scrooge, and his cold heart reawakens to discover the magic of Christmas. Scrooge opens his wallet and Tiny Tim is saved.

But from what, exactly, is Tiny Tim saved?

The precise nature of his illness has intrigued physicians and medical historians for decades, and it remains the subject of lively debate among scholars from England to Hawaii. Dickens is never specific about Tim's diagnosis, instead reporting a collection of vague symptoms that may have been common enough for his Victorian peers to identify, but which, more than a century later, baffle modern readers.

What we know is that Tim Cratchit is small for his age (hence his nickname ); that he suffers from a crippling disease requiring the use of a crutch and metal braces on his legs; that he is weak and sickly and expected to die in the near future. But it's also clear that whatever it was that ailed him was treatable in 19th century England for those able to afford good medical care.

The Author's Issues

The idea that Tim Cratchit may have suffered from a real illness is not as farfetched as it sounds. For starters, Dickens himself had a variety of health problems, experiencing symptoms that suggest he may have suffered from migraines, gout, bronchial asthma, renal tuberculosis and ischemic heart disease. Dickens's ailments have been the subject of articles published in medical journals, doctoral dissertations and scholarly newsletters.

Second, Dickens had a keen interest in health and illness, evidenced by the number of characters in his books who suffer from various ailments. Though the author had no medical training, doctors have frequently commended the accuracy of his descriptions of illnesses, many of which have now been diagnosed and labeled by modern medical science, but which were unnamed and untreatable in his day.

Finally, Dickens often modeled his fictional characters on people who had passed in and out of his life. It is widely believed that his crippled nephew Harry Burnett, who died from tuberculosis at age 9, was his inspiration for Tiny Tim.

If Harry Burnett was Dickens's role model for Tim, then tuberculosis would be the most likely diagnosis. Col. Charles Callahan, chief of the Department of Pediatrics and Pediatric Pulmonology at Tripler Army Medical Center in Honolulu, arrived at that conclusion after careful study of the possibilities.

Callahan was a pediatric pulmonology fellow when he was asked to write a textbook chapter on tuberculosis in children. That same December, after watching a movie version of "A Christmas Carol," he began to muse about Tiny Tim's illness.

"In my research, I was startled to find how prevalent TB was in England at that time," he said."It is estimated that half of the population of England was infected with TB in the late 19th century, and it was the single most common disease and cause of death in the western world."

Tuberculosis is primarily a disease of the respiratory system, and it is spread by coughing and sneezing. However, after infecting the lungs, it can manifest in other areas of the body, including the bones and joints. According to Callahan, Tiny Tim most probably suffered from Pott's disease, also known as tuberculosis spondylitis or spinal tuberculosis. Dickens never mentions that Tim had any sort of respiratory disease, but as Callahan explains, it is very common for children not to exhibit the symptoms that would normally be seen in adults.

"Children also don't cough hard enough to spread it, which would explain why Tim wasn't contagious and didn't infect his brothers and sisters," said Callahan.

Pott's disease most commonly occurs in children under the age of 10, which would fit Tiny Tim's age. The disease is crippling, causing deterioration of the vertebrae. Children will often be in pain, and experience weight loss, fatigue and fever. Left untreated, the disease can be fatal.

Callahan explored the possibility of other diseases with similar symptoms, including bone infections such as septic arthritis and hematogenous osteomyelitis, and leukemia with metastasis to the skeleton. But these conditions would cause Tim to be far sicker than indicated in the book, Callahan concluded, and 19th-century medicine was unable to effectively treat any of them, let alone provide a cure.

But could Scrooge's benevolence save Tiny Tim from the ravages of tuberculosis? Yes, believes Callahan. While anti-tubercular drugs were not available, Scrooge's money could have sent Tim from his home in London to a sanitarium in the countryside. Fresh air, good nutrition and rest, along with a custom-fitted back brace, could have helped halt the progression of his disease or even put him into remission.

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Seeking A Cure

Tim's diagnosis is also dependent on whether one believes he is cured at the end of the story, or just remaining alive. With tuberculosis, a cure would be unlikely. So Donald Lewis, an associate professor at Eastern Virginia Medical School in Norfolk, set out to find a disease that was curable in 1843. He concluded that Tim may have suffered from a kidney disease called renal tubular acidosis, or RTA.

Lewis's interest in Tiny Tim arose when he was teaching diagnostic techniques and, like Callahan, studied Tim's symptoms and tried to fit them to a specific disorder. He then scoured pediatric textbooks from 1830 to 1850 to find out what illnesses were curable at the time.

Based on his symptoms, Lewis says, physicians would have treated Tim for tuberculosis, which was generically known as scrofula. In fact, Lewis says, doctors treated everyone for scrofula if they had a crippling disease.

"It was believed that scrofula produced excessive acids in the body," said Lewis, "And patients would be treated with alkali substances such as bicarbonate." Prescribed "tonics" of the era generally contained combinations of belladonna, opium, sodium bicarbonate, sodium citrate and potassium chloride.

In renal tubular acidosis, the body accumulates excess acids, which interfere with bone metabolism. According to the kidney specialists with whom Lewis conferred, untreated RTA would produce symptoms similar to Tim's, with short stature being an early sign of the disease. Eventually, the disorder can cause osteomalacia (softening of the bones), muscle weakness and fatal kidney failure. The osteomalacia would tend to affect one side more than the other, which would account for Tim's use of a single crutch.

But most important, in 1843 RTA was curable. "This disease process would explain the whole picture," said Lewis. "A lot of people have suggested tuberculosis, but the whole essence of the story is redemption and that Tiny Tim does not die. So that means that there's something that physicians were able to do to correct his illness, and that's in keeping with the theme of the story and the technology of the era."

Tuberculosis is difficult to treat even now, and certainly wasn't curable back then, continues Lewis. "Some people have also suggested polio, but that doesn't fit into the story either, because it isn't reversible."

"You have to buy into the essence of the story," Lewis said. "Something happens to Tim physiologically which heals him, and that is a parallel to Scrooge's spiritual rebirth."

Rickets has also been suggested as the unnamed illness. When Edward Ehlinger, director of the University of Minnesota's Boynton Health Service, polled his staff, the consensus was that Tiny Tim had this bone disease, which is caused by a deficiency of vitamin D. Ehlinger also favored the rickets diagnosis because of Tim's probable poor diet and the lack of adequate sunlight in the foggy, heavily polluted London of the 1840s.

Both Callahan and Lewis, however, ruled out diseases such as rickets, because a nutritional deficiency would have affected all of the Cratchit children, not just Tim. And by itself, rickets is not usually fatal.

In the end, is it really of any importance to diagnose Tiny Tim? Malcolm Andrews, a Dickens expert and professor of Victorian and Visual Studies at the University of Kent in England, believes the subject largely irrelevant.

"More important, though, is Tim's role as victim of social neglect, a direct casualty of the brutal laissez-faire system to which the unreformed Scrooge subscribes wholeheartedly," said Andrews. He adds that Dickens was not concerned about being "clinically" specific and that Tim's suffering is metaphorical.

Tim lives on at the end of the story, said Andrews, because Scrooge has reformed and becomes his second father. "It's as simple as that. This is a fable, not a piece of social history."

Perhaps Andrews has a point. The power of the story is really in the love that awakens in Scrooge after his redemption, and how that love is now able to transform the lives of those around him. The idea that love alone can overcome any physical malady may not be scientifically defensible. But it's a comforting thought for the holiday season.

Roxanne Nelson is a Seattle freelance writer.

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The Case of Tiny Tim