Sir.—I read with interest the article by Lewis1 in the December 1992 issue of AJDC. This fascinating article suggests that Tiny Tim had RTA type 1 to account for his crippling disorder so dramatically presented in eight film versions, illustrated books, and hundreds of stage presentations. This is an intriguing possibility because it represents a potentially reversible form of childhood rickets. Nevertheless, I believe that there are a number of points that render untenable this diagnosis, made some 150 years after the publication of A Christmas Carol.
First, the osteomalacia evident in RTA type 1 is symmetrical whereas Tiny Tim's crippling disease was asymmetrical. Renal tubular acidosis rarely involves the hands to the extent described in Dickens' famous story. Furthermore, RTA rarely leads to death. I am not aware of any deaths due to RTA, although it is theoretically possible, as indicated in the quotations from Rodriguez-Soriano's article
CHESNEY RW. Bah Humbug. Am J Dis Child. 1993;147(8):818. doi:10.1001/archpedi.1993.02160320020008