Newswise — One of the country's favorite holiday stories contains a medical mystery that over the years has tested medical sleuths.

A Christmas Carol, today best known as Scrooge, has transcended the boundaries of time since it was written in 1843 with its basic messages of good will to all mankind. And, now with the story easily available on video or DVD, it continues to remind us all to be kind to one another.

But, as we move further into the 21st Century, for some fans of the Charles Dickens classic, it still leaves one question unanswered. What exactly was wrong with Bob Cratchit's youngest son, Tiny Tim? As the World Wide Web has grown, theories of what ailed Tiny Tim have spread.

The symptoms

Thanks to the Ghost of Christmas Present, we know that Tiny Tim would soon die. We know that Tiny Tim used a crutch, was very small, and very sick. We also know that Bob Cratchit carried his son periodically, possibly a signal of muscle fatigue. From the Ghost of Christmas Yet to Come, we see the Cratchit house without Tiny Tim, and thus we assume that this confirmed the prediction made by the Ghost of Christmas Present.

Financially, we know that Scrooge didn't pay Bob Cratchit enough money. His meager salary was not enough to buy good food and medicine for Tiny Tim. Plus the Cratchit house was very small.

Historically, we know that Tiny Tim was growing up in London in the mid-1800s.

But, as all three ghosts, along with Scrooge's deceased partner, Jacob Marley, help Scrooge turn from a miser to a kind and generous man, fans of A Christmas Carol are also led to believe that the kind pay raise that Scrooge gave Bob Cratchit helped to save Tiny Tim. Bob would be able to afford good food and medicine.

A quick Internet search brings up several theories on what ailed Tiny Tim. According to Daniel J. Glunk, M.D., past-president of the Pennsylvania Medical Society and a practicing internist from Williamsport, Pa., all the theories have a certain degree of merit in making this literary diagnosis.

Could it be RTA?

The first theory is that Tiny Tim suffered from renal tubular acidosis (RTA), a kidney disease that makes blood too acidic.

"Tiny Tim is small, has malformed limbs, and periods of weakness," says Dr. Glunk. "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."

According to Dr. Glunk, RTA occurs when the kidneys fail to excrete acids into the urine. This causes a person's blood to remain too acidic. The result can be growth retardation, kidney stones, bone disease, and progressive renal failure.

"Doctors today can diagnose RTA by checking the acid-base balance in blood and urine samples," says Dr. Glunk. "Back then, when our fictional patient lived, they didn't have the tests we have today to determine this. But, they did know that his symptoms could be treated with alkaline solutions. With appropriate care at the time, Tiny Tim could have managed the condition we know today as RTA."

Dr. Glunk adds that doctors today have identified three types of RTA. Frequent doses of alkali, either as a bicarbonate or something that the body converts into a bicarbonate, are used to treat the disease. The long-term outlook for a child diagnosed with RTA, if not linked to another kidney disease, is positive. Many outgrow the disease, while others who aren't as fortunate simply manage their disease through medications and the help of a doctor. Provided they take their medications as prescribed by their doctors, they remain healthy.


Other Internet medical sleuths suggest that Tiny Tim could have suffered from a Vitamin D deficiency, commonly known as rickets.

Rickets was a widespread problem in locations with heavy smog and industry in the late 1800s and early 1900s. Since sunlight is a major source of Vitamin D, smog could play a role in the deficiency. And, we know that Tiny Tim lived in London, a city that can naturally be gloomy but also had problems with smog as England became industrialized.

According to Dr. Glunk, some signs of Vitamin D deficiency include soft bones, muscular weakness, osteoporosis, and joint pain. Without Vitamin D, the body can't absorb calcium, and thus has difficulty building and maintaining strong bones. That may be why Tiny Tim needed a crutch.

"Knowing London's environmental conditions at that time and knowing Tiny Tim used a crutch, it's reasonable to consider this disease, despite the fact that Vitamin D wasn't discovered until the early 20th Century, well after the time period used by Dickens in the story," said Dr. Glunk. "At the time, they could have unknowingly treated this condition through better foods that Scrooge helped to buy."

Although there have been advancements in medicine, Dr. Glunk says we shouldn't believe we've conquered this disease. "It doesn't occur often these days, but there are occasional reports that rickets still exists," said Dr. Glunk. "A person's diet may not be as good as it should, and with the fear of skin cancer, people are more aware of using sunblock."

Dr. Glunk doesn't recommend dropping sunblock from the beach list to fight a Vitamin D deficiency. In fact, sunblock is too important in fighting skin cancer, he says. Instead, he suggests drinking fortified milk and taking a Vitamin D supplement to prevent the disease. If a person were diagnosed with the disease, stronger dosages of Vitamin D would be used and diet changes probably would be recommended.

A Dickens conspiracy?

Finally, some Internet sleuths believe a conspiracy theory exists and that something other than a disease could have caused Tiny Tim's death. After all, the Ghost of Christmas Yet to Come only showed the Cratchit House without Tiny Tim and never said how he died. Fans of the classic story are only led to believe Tiny Tim died of what ailed him, but are not provided positive proof. Could it be a Dickens literary trick?

"Bah humbug," says Dr. Glunk. "In the spirit of the story, I'd like to think that it was Scrooge becoming a more generous person and enabling the Cratchits to provide better food and medicine for Tiny Tim that made the difference."

What is learned from Dickens and the medical mystery exercise?

Needless to say, it's nearly impossible to accurately diagnose what ailed Tiny Tim. And, Dickens didn't need to dwell on the details of Tim's disease because it wasn't necessary for the plot. However, Dr. Glunk says there are things we can learn from A Christmas Carol and the medical mystery exercise.

First, Dr. Glunk says it's important for both doctors and patients to work together. "If Tiny Tim were a real person, a doctor would want answers by asking questions or running some tests. Diagnosing Tiny Tim from what we know in the story might be a fun exercise, but there's so much we don't know and thus need to find out," he said. "So, the patient-doctor relationship would play a vital role in not only diagnosing, but also treating the disease."

Second, Dr. Glunk believes that a person's positive outlook on life can be very helpful in disease prevention and management. "Throughout the ordeal, Tiny Tim looked to the bright side. The story gives the impression that he was a happy little boy, who was thankful for what he had and who he was. I have to believe that his cheery attitude helped Tiny Tim overcome his disease."

Finally, Dr. Glunk suggests that we shouldn't forget the core message of Dickens' A Christmas Carol.

"Ultimately, it was kindness that made a difference," he said. "We have many uninsured and underinsured people in our country. They can't afford healthy food and good medicine. And, often they don't receive the health care they need."

Dr. Glunk continued by emphasizing the important role that charitable organizations and health clinics play.

"We all need to applaud and support the many volunteers and charitable organizations that help people like Tiny Tim and the Cratchits," Dr. Glunk said. "That's the spirit of the season that shouldn't be forgotten throughout the year."