A Christmas Carol, a novella of 30,000 words, was written by Charles Dickens in six weeks in 1843. It has never gone out of print. The book’s sustained success has contributed to how Christmas is celebrated and introduced the phrases “Merry Christmas” and “Bah! Humbug”.

In Dicken’s now classic story, lowly, overworked, underpaid clerk Bob Cratchit has a disabled son, Tiny Tim. Tim is described as small and frail, with a “withered little hand”. He often rides on his father’s shoulder, being unable to walk well. The story says, “Tiny Tim, bore a little crutch, his limbs supported by an iron frame”. His exact illness or disorder is not clearly described; Dickens leaves that to our imagination. However, it is clear that Tiny Tim is seriously ill. When Ebenezer Scrooge is visited by The Ghost of Christmas Present, he is shown just how ill Tim really is, and that Tim will die unless he receives treatment. Then, when Scrooge is visited by The Ghost of Christmas Yet to Come, and shown the future, all he sees is “a vacant seat in the poor chimney-corner, and a crutch without an owner, carefully preserved.” And, as we near the end of the story, it is clear that Tiny Tim has survived and improved, only because Scrooge has altered his actions.

So, what are we to make of these clues? What did Tiny Tim probably have? Medical scholars have been interested in this for years.

We know Dickens was a master of description, and a keen observer of the London of his time. He had a knack for accurate medical depictions. We can read precise epilepsy descriptions in Oliver Twist and Bleak House. The Pickwick Papers gave us a classic picture of sleep apnea with obesity (and the term Pickwickian). He has described “rickety dwarfs”, dystonic movements (Uriah Heep), delirium tremens (Arthur Havisham in Great Expectations) and much more.

An examination of the environment of London of 1843 (when the novella was written) can provide important clues. Following the Great Fire of London in 1666, the city was rapidly rebuilt. Local wood was completely depleted for construction, and fuel for fires and warmth became mined coal rather than wood. The Industrial Revolution was fueled by coal and heavy manufacturing. Leaping energy consumption, development of railroads and steamships, and a 6-fold increase in coal output– all these led to blackened sooty skies in London. The working class was crowded into tenements with poor light exposure. The typical diet of the poor and middle class was high in starch and low in protein and fat. There was no garbage removal and effluent ran in open sewers.

Interestingly, the massive volcanic eruption of Tambora in Indonesia in 1815 may also have been a factor in London’s pollution. The ejected volume of sulfuric gas and ash that entered the atmosphere clouded the sky worldwide, creating the “year without a summer” during which there was summer snow, little sunlight, crop failure, and the death of hundreds of thousands of animals worldwide. Food costs skyrocketed and levels of malnutrition rose. The ash also blocked sun exposure. The ash effect lasted for at least three years, and the downstream effects of the crop failure and malnutrition lasted many years longer.

All this combined to create a haven for infectious diseases and rickets in London’s children. Russell Chesney, a physician at Le Bonheur Children’s Hospital in Memphis, wrote in his article in Archives of Pediatric and Adolescent Medicine, that he believes Tiny Tim likely had a combination of both rickets and tuberculosis. Many other scientists who have researched this issue agree.

Rickets, soft bones caused by Vitamin D deficiency, was first described in 1650, and believed to be due to infection or miasma (bad air). In fact, humans synthesize Vitamin D after exposure to sunlight. London’s thick polluted air led to dark skies, and the high sulfur dioxide content of the coal smoke absorbed more UV light rays, preventing people from synthesizing Vitamin D. In addition, children often worked in factories from dawn to dusk, and got no sun exposure. Their worried parents, concerned about the dangers of miasma, kept them indoors when they were home, unknowingly worsening the Vitamin D deficiency. Sixty percent of working-class Londoners of this period had some amount of rickets, and up to 90% of children then had bony changes consistent with rickets. In fact, it was often called “the English disease” because it was so prevalent in London.

Rickets causes soft weak bones, poor growth, back and leg pain and muscle weakness. This could certainly have led to Tiny Tim’s small size, frail bones, brace and crutches and inability to walk. Vitamin D is the treatment for rickets, and Scrooge’s money could have bought cod liver oil (rich in Vitamin D), healthy food, and time in the sun outside of the polluted city.

Tuberculosis is another likely culprit. TB (called consumption then) was rampant in 19^th century London, with nearly 50% of Londoners having signs of TB. It accounted for 25% of all deaths in that period. (Dickens’ sister Fanny died from tuberculosis). “Galloping consumption” usually occurred in the context of poverty, crowding, malnutrition, and other factors. We think of TB as a lung disease, but it can also infect bone. In particular, Pott’s Disease is TB of the spine, which can result in collapsed vertebrae, nerve damage, chronic pain, and inability to walk. Sounds like Tiny Tim to me!

Additionally, TB and rickets are known to occur together. Vitamin D deficiency, a problem for bones, is also a problem for the immune system. We know that the body is better able to kill TB organisms when the Vitamin D level is normal. Thus, improvement was often seen in TB sanitariums, where sunbathing was de rigueur. In the early 1800s, TB was not understood to be contagious, but was known to be chronic, and possibly curable with fresh air exposure, healthy food, and rest (which Scrooge could have provided for Tiny Tim and his family).

Pediatrician Donald W. Lewis, of Norfolk, Virginia, spent several years studying Tiny Tim’s condition, and has another idea. He suspects (in an article in American Journal of Diseases of Children) a potentially deadly kidney ailment now known as distal renal tubular acidosis (RTA). In this illness, the kidneys don’t excrete acid as they should, so acid accumulates in the blood, leading to a cascade of other problems, like short stature, crippled legs, rickets, and intermittent weakness. The treatment, primitive in the 1800s, would have been taking sodium bicarbonate (baking soda) to neutralize the excess acid.

Other possibilities? Perhaps Tiny Tim was born with cerebral palsy, giving him tighter spastic muscles, requiring a crutch and brace for walking. Or maybe he was born with spina bifida, which would give him a frail constitution and inability to walk. Polio could have caused a withered hand and weak leg. And any of the illnesses we have mentioned would predispose him to opportunistic infections like pneumonia (deadly in the pre-antibiotic era of 1840’s London). Thus, the specter raised of the crutch leaning by the fireplace, the owner gone.

Regardless of Tiny Tim’s affliction, Dickens wanted us to realize that both selfishness and poverty are deadly, and kindness can help save the giver and the recipient. Good lessons for 1843, and good lessons for today.

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