With his little single crutch and sweet smile, Tiny Tim has been stealing our hearts year after year in “A Christmas Carol,” the quintessential holiday story written by Charles Dickens and published in 1843.
We watch as Scrooge battles his demons – and spirits – to find the way in his heart to save Tiny Tim from a premature death, which was all too common in the period of the story’s setting in the mid-1800s.
Dickens never names the crippling disease that hindered Tiny Tim’s ability to walk and left him weak, but could be overcome through treatment made possible by Scrooge. Over the decades, medical experts turned sleuths have theorized that it might have been tuberculosis, rickets, or cerebral palsy, according to articles like a 2021 review in the Archives of Pediatrics and Adolescent Medicine.
We put it to the experts at UTHealth Houston to help us sort out what Tim might have had and how Scrooge could have changed the course of his life.
The environment of London at that time was not conducive to good health for anyone, much less the child of hardworking, but financially stretched, parents. The skies were dark and heavy with pollution from burning coal during the Industrial Revolution, blocking out much of the sun’s ultraviolet light that is critical for vitamin D synthesis. Many people, including children, worked 10-hour days, arriving and leaving in the dark.
That lack of natural sunlight and nutritional sources of vitamin D could lead to rickets, which affected 60% of children in working-class London families at that time, and it seems logical that Tiny Tim might have suffered from it.
“Tiny Tim could definitely have had rickets. They used to call rickets ‘the English disease’ because it was so prevalent in London,” said Kristine A. O’Connor, MD, assistant professor in the Department of Pediatrics with McGovern Medical School at UTHealth Houston. “They thought it was a transmittable disease, so they would keep children in the house and bundle them up, making it worse.”
Rickets affects bone development, leading to soft, weak bones. Poor growth, pain in the spine and legs, and muscle weakness are symptoms. Since vitamin D is the treatment for rickets, Scrooge’s money could have allowed Tim to go to a sanatorium in the country away from London’s smog, eat fresh fruits and vegetables, and take cod liver oil, which is rich in vitamin D.
O’Connor said that in severe cases of rickets, children can die from complications such as hypocalcemic seizures and cardiomyopathy. A more likely scenario is that rickets also would have made him more susceptible to severe infectious diseases, like tuberculosis, which affected 50% of children of working-class parents.
“I think he did have tuberculosis of the spine,” said Pushan Jani, MD, MSc, associate professor of pulmonology in the Department of Internal Medicine at McGovern Medical School. “The primary organ involved in tuberculosis is the lungs, but when it gets into the bloodstream, it can affect other organs including the brain and spine.”
Tuberculosis of the spine, known as tuberculosis spondylitis or Pott’s disease, can result in bone destruction, weakness in the legs, and deformity. Other symptoms of tuberculosis include weight or appetite loss, fever, and fatigue, according to the National Library of Medicine.
Jani referred to a 1997 article in the Journal of Infectious Diseases that reported the discovery of a gravesite marked by a stone with the name “Timothy Cratchit” and the years “1839-1884.” According to the article’s author, Charles W. Callahan, DO, the discovery created a stir when the skeletal remains beneath the stone were of a man “approximately 40 years of age wearing a frame of metal and leather on his legs and lower back.”
“The skeleton had similar changes of someone infected with tuberculosis of the spine,” Jani said. “There were no good treatment options back then. At that time, most people were treated by sending them to sanitoriums and people without enough money would not have been able to afford that.”
Jani said he doesn’t think that a sanitorium would have made a big difference in Tiny Tim’s disease progression, but O’Connor pointed out that better nutrition and access to vitamin D could have made the disease progress slower.
“The story doesn’t say if he was cured or just better,” she said. “It might have improved him and helped him live longer.”
Another disease that may have led to Tiny Tim’s reliance on a crutch is cerebral palsy, which is a disorder caused by a nonprogressive injury to the developing brain that leads to problems with movement and posture.
“It’s hard to know for sure, but I do think it’s possible that he had cerebral palsy,” said Stacey L. Hall, DO, associate professor in the Department of Physical Medicine and Rehabilitation at McGovern Medical School. “The story paints a picture of him having weakness and a limp on one side, which could have been hemiplegic cerebral palsy.”
Hall said many of the cerebral palsy patients she sees have a vitamin D deficiency, and Tiny Tim might have had a double burden with rickets.
“We check for vitamin D deficiencies in children with cerebral palsy because they are at risk for having fragile bones. This could make the impairments from cerebral palsy worse if it leads to a fracture or rickets,” Hall said.
While cerebral palsy is not a fatal disease, more severely impacted children are at risk for pneumonia, she said, and that risk would have been even greater in the mid-1800s when overall health care was poor.
Fortunately, as anyone familiar with the story knows, Scrooge sees the light, thanks to his late-night visitors and becomes a new man.
“He has no further intercourse with Spirits,” Dickens wrote,” but lived upon the Total Abstinence Principle, ever afterwards; and it was always said of him, that he knew how to keep Christmas well, if any man alive possessed the knowledge. May that be truly said of us, and all of us! And so, as Tiny Tim observed, God bless Us, Every One!”
UTHealth Houston is the proud presenting sponsor of Alley Theatre’s “A Christmas Carol.”
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