What Was Wrong With Tiny Tim?

Masen G. asks: Given the symptoms in the story, what was Tiny Tim sick with that a little money for 19th century medical care was able to fix?

tiny-timIn Charles Dickens’ holiday classic, A Christmans Carol, the character of Tiny Tim dies in one timeline, but is saved by Ebenezer’s Scrooge’s charity in another. Although Dickens scholars have posited a range of maladies that can either cause death or be alleviated by throwing money at it, a recent study has led to the conclusion that he likely suffered from both tuberculosis (TB) and rickets, as you’ll soon see.

The Story

In the well-loved Christmas tale (it has never been out-of-print since it was first published in 1843), the protagonist (so to speak) is Ebenezer Scrooge, the miserly boss of Bob Cratchit, who lives with his family in poverty while Scrooge enjoys an easy life. One member of the Cratchit family, Tiny Tim, struggles with a crutch and has iron bars on his legs, but the name of his illness is not given.

As the story progresses, Scrooge is visited by four ghosts who show him the error of his miserly ways. During the last of these visitations, the Ghost of Christmas Yet to Come shows Scrooge (among other things) that Tiny Tim has died of his ailments.

Ultimately, however, Scrooge repents and becomes more generous with the Cratchit family. In the new timeline, Scrooge’s altruism transforms him into a “second father” to Tiny Tim, who survives.

The Culprit

Different scholars have suggested a variety of ailments including cerebral palsy, TB, nutritional deficiency, rickets, spine injury, polio and renal tubular acidosis; this latter is a good candidate, since it can have a deleterious effect on a skeleton, yet be easily reversed by treatment with alkaline salts.

Rickets (a bone disorder) is also popular candidate among historians as 60% of London’s children at the time (between 1820 and 1843) had the disease; although today we know rickets is caused by a vitamin D deficiency, at the time, there was only speculation as to the disease’s cause.

Likewise, TB is also a popular suggestion for the culprit, as nearly 50% of those London children also had symptoms of a tuberculosis infection. Although not a cure, the symptoms of TB can be greatly alleviated by strengthening the immune system.

Each of these disorders, given circumstances of poor nutrition and hygiene, could have led to Tim’s death.

The Study

Published in the Journal of the American Medical Association Pediatrics in 2012, Dr. Russell W. Chesney’s “Environmental Factors in Tiny Tim’s Near-Fatal Illness,” seems to solve the riddle, and begins with an examination of the lives of the poor in London during the first half of the 19th century.

Living Conditions

In the worst parts of London, the poor lived in filthy, crowded conditions shaded by soot-filled skies. This latter, caused by the burning of coal which put sulfur and other particles between the sun and London’s inhabitants, absorbed most of the UV-A and UV-B rays. While this saved them from sunburns (see: What Causes Sunburns), it had detrimental effects to other parts of their health. Pertinent here is that UV-B absorption by the skin is key to vitamin D synthesis in humans. So most Londoners only way to get vitamin D was diet.

Diet

For the poor, the foods naturally high in vitamin D, like fish, certain fats, liver, milk or eggs, were out-of-reach. Thus, the poor children of London were highly susceptible to rickets (such that it was termed “the English disease.”)

The Cratchit children would certainly have been included within this group, as the family was forced to live on Bob’s meager 15 shillings a week (enough to buy only 4 loaves of bread) as well as whatever sister Martha earned as a milliner’s (hat maker’s) apprentice.

Co-Occurring Diseases

Adding insult to injury, children with rickets were more susceptible to respiratory diseases like pneumonia and TB. Thus, Chesney concludes that Tim had both diseases.

How Money Helps

By simply adding dairy and fish (and more calories) to Tim’s diet, Scrooge’s newfound generosity would have provided sufficient vitamin D to cure the rickets and boost Tim’s immune system.

In addition, if that generosity included trips to the country, the fresh air and extra sunshine would’ve helped as well.

What Dickens Knew

As noted above, although the cause of rickets wasn’t known when A Christmas Carol was written, there is evidence that Dickens and others believed that nutritional deficiencies and unhealthy living played a part.

On June 24, 1865, Dickens wrote: “One of the worst forms of scrofula – rachitism, or rickets . . . arises under the influence of chilly dwellings an insufficient alimentation [nourishment]. . . and milk deprivation in infants.”

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Bonus Facts:

  • The discovery of the cause of rickets coincided with increased understanding of vitamins – particularly A and D. In 1919, Edward Mellanby, after conducting experiments with various diets on puppies (poor dogs), discovered a link between lack of “either fat-soluble A” or something pretty similar. That similar factor, vitamin D, was discovered by Elmer McCollum and Marguerite Davis in 1921.
  • Tuberculosis, formerly called consumption (see: Why Tuberculosis was Called Consumption), is an infectious disease caused, usually, by Mycobacterium tuberculosis. Like other bacterial infections, it is sometimes treated with antibiotics, although they are not always successful due to the unique structure of the mycobacteria.
  • In recent years, two forms of antibiotic-resistant TB have emerged, multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB). With MDR-TB, the bacteria are resistant to both of the most common anti-TB drugs, isoniazid and rifampicin, but may still be susceptible to other well-known and effective antibiotics. With XDR-TB, the bacteria are resistant to both of the common treatments, all the fluoroquinolones (strong antibiotics like Cipro and Avelox), as well as a number of other antibiotics like amikacin and capreomycin. In fact, in 15 Iranian patients infected with XDR-TB in 2009, the bacteria were found to be resistant to every anti-TB drug tried.
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