What was wrong with Tiny Tim?
D. W. Lewis
Department of Pediatric Neurology, US Naval Hospital, Portsmouth, Va.
One of the most endearing characters in English literature is Tiny Tim, the
crippled son of Ebenezer Scrooge's clerk, Bob Cratchit. Yet the nature of
Tiny Tim's multifaceted and implicitly reversible illness is a mystery and
open to debate and speculation. From details of the original manuscript and
the eight film versions, it is possible to construct a differential
diagnosis for Tim's short stature, asymmetric crippling disorder, and
curious intermittent weakness that would lead to his death, if untreated,
within a period of 1 year. Following the ghostly visitations, Scrooge vows
to assist the struggling Cratchit family financially, thereby making
available the best medical care money could buy. From review of pediatrics
texts from 1830 to 1850, a recommended treatment plan would have included
(1) general measures such as country air and exercise, and fish oils such
as cod and halibut (vitamin D), and (2) specific treatments of tonics
(containing combinations of belladonna, opium, sodium bicarbonate, sodium
citrate, and potassium chloride) emphasizing alkalis, and splinting and
bracing the limbs. Such treatments with vitamin D and alkalinization with
sodium bicarbonate and sodium citrate suggest the plausible speculation
that Tiny Tim had renal tubular acidosis (type I), a disorder that is
characterized by growth failure and, if left untreated, complicated by
osteomalacia with pathologic fractures, hypokalemic muscle weakness and
periodic paralysis, nephrocalcinosis leading to renal failure, and death. I
propose that Tiny Tim had distal renal tubular acidosis (type I).
