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ECR 2014 / C-1997
Contents:
  1. R. Payson Moreland, O.D.
  2. Jessica Moreland, M.D. - Faculty Profile - UT Southwestern
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This article reviews Orwell's battles with bronchiectasis and tuberculosis, revisits bygone treatments of tuberculosis, and provides a unifying diagnosis encompassing his apparent infertility. Orwell was born as Eric Blair in Gaya, India. His father Richard was a starchy official in a sordid imperial bureaucracy, the Bengali Opium Service, overseeing the lucrative export of narcotics from the Indian subcontinent to China. His mother Ida was much younger, with bohemian, socialist, and literary inclinations. When Eric was a few months old, his mother brought him and his sister to England, while his father remained behind, an arrangement that was not unusual among Anglo-Indian families.

Richard Blair's family saw him rarely until his retirement on a modest pension in , having attained the rank of Sub-Opium Agent Class 1 [ ]. Eric had several episodes of bronchitis in infancy, including one when he was 18 months of age that was severe enough to confine him to bed for a week. Despite this, he appears hearty and chubby in childhood photographs. At the age of 8 years, he was enrolled in a preparatory school of probably average snobbery and brutality.

As a middle-class student accepted at reduced tuition because of his academic promise, he was under enormous pressure to bring luster to the institution by winning a scholarship to an elite English public school.


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His respiratory complaints also became more intense. Eric did win a scholarship to Eton, but he failed to apply himself to his studies. In , he went to Burma as an imperial policeman, seemingly destined, like his father, for a career in the obscurity of a bleak colonial outpost. His family was shocked at his gaunt appearance, attributable to recent pneumonia and dengue fever, and his now heavy smoking. Blair determined to become a writer, spending the next years on the wretched fringes of French and English society.

These experiences became the source material for his first book, Down and Out in Paris and London , published under the pseudonym George Orwell. If he was not infected with tuberculosis before, during childhood, or while in Burma, it is almost certain that he was exposed during these years of tramping, poverty, and vagabondage.

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Orwell had at least 4 bouts of pneumonia between the ages of 15 and 34 years [ 1 , p. His adult health was poor. Although Orwell stood 1. In , he was admitted with pneumonia to an archaic Parisian hospital, where treatments included cupping and mustard poultices.

R. Payson Moreland, O.D.

Orwell captured the callous attending physician's teaching rounds in a classic description:. There were many beds past which he walked day after day, sometimes followed by imploring cries. On the other hand if you had some disease with which the students wanted to familiarize themselves you got plenty of attention of a kind. I myself, with an exceptionally fine specimen of a bronchial rattle, sometimes had as many as a dozen students queueing up to listen to my chest. It was a very queer feeling—queer, I mean, because of their intense interest in learning their jobs, together with a seeming lack of perception that the patients were human beings.

After somehow surviving a bullet wound to the neck the bullet injured his brachial plexus, causing transient right arm paralysis, and injury to his recurrent laryngeal nerve left him with a permanently weak voice [ 3 , p. Orwell had fatefully and rather arbitrarily joined a militia dominated by anti-Stalin Trotskyites and anarchists. As the Stalinists increased in power in Spain, the anarchists and Trotskyites were purged.

Press accounts of these events, both in Spain and abroad, were widely distorted. Orwell was a marked man, but before fleeing Spain himself, he tried to secure the release of an arrested comrade in an act of quixotic recklessness [ 2 ]. Spain wrecked his health, but it also provided him with his great theme: the enmity of power and truth. Had Orwell died in Spain, he would likely be forgotten today, but paradoxically, the progression of his illness coincided with the flowering of his talent and with the writing of his 3 masterworks: Homage to Catalonia, Animal Farm , and Back in England in March , Orwell had an episode of major hemoptysis, and was treated at Preston Hall Sanatorium by his brother-in-law Laurence O'Shaughnessy, coauthor of a contemporary textbook on tuberculosis.

The clinical impression was chronic bronchiectasis of the left lower lobe, after the results of initial investigations for tuberculosis were negative [ 4 , p. Sanatorium treatment consisted of bed rest and maximum nutrition. As patients gained weight and manifested radiologic improvement, they were slowly allowed to increase their ambulation. Immobility was sometimes enforced in draconian fashion by sandbags on the shoulders or by swaddling patients like infants [ 10 , 11 ].

These extreme restrictions may have served a physiologic purpose. Bed rest diminished functional residual capacity and minute ventilation, leading to less static and dynamic tension on the cavity walls and mechanically favoring cavity closure [ 10 ]. A therapeutic effect was sometimes ascribed to a sanatorium's supposedly salubrious location; this was perhaps true of sanatoria in the mountains, because of the protective effect of hypoxia [ 12 ].

Orwell's condition improved significantly over several months, and he was discharged. In , he saw the Harley Street pulmonologist Herbert Morlock, who thought he had nothing more serious than chronic bronchiectasis [ 3 ]. Morlock's breezy optimism delighted Orwell and strengthened a tendency toward denial of illness on Orwell's part, common among patients with tuberculosis before and since.

During the Second World War, Orwell's precarious health stabilized somewhat because of sulfapyridine therapy [ 3 ]. This probably did little for his tuberculosis [ 14 ] but may have temporarily quelled his chronic bronchiectasis. In , depressed by the death of his wife and sick of the urban squalor of London, Orwell moved to the sodden, remote, windswept Scottish island of Jura. While writing the first draft of , Orwell's health declined precipitously.

He developed fever and night sweats, and he lost 13 kg in weight. Orwell described his pneumoperitoneum therapy in matter-of-fact fashion:.

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Collapse therapy aimed to close tuberculous cavities. Cavity formation is the most ominous event in the pathogenesis of tuberculosis. Liquefaction and expulsion of caseum allows tubercle bacilli to flourish in an environment of higher oxygen tension optimal growth of Mycobacterium tuberculosis occurs at a partial pressure of oxygen level of mm Hg.

Bacilli may then spread to other regions of the lungs via the bronchi, as well as infect other people.


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The enormous number of bacilli in tuberculous cavities, compared with the solid caseum, make drug-resistant tuberculosis a likely outcome if an inadequate number of drugs are used or if the duration of therapy is too brief [ 15 ]. It had long been noted that some patients with tuberculosis remitted if spontaneous pneumothorax occurred. As early as , the Scottish physician James Carson advocated artificial pneumothorax therapy, arguing that normal respiration and pulmonary elastic recoil hindered the healing of tuberculous cavities [ 16 ].

The anaerobic conditions created by collapse therapy may also have forced M. Artificial pneumothorax therapy was frequently limited by the presence of pleural adhesions. Air embolism was another dreaded and often deadly complication [ 10 , 16 ]. Phrenic nerve crush and pneumoperitoneum, which collapsed the lung from below, had the advantage of relative freedom from lethal complications and was also useful for patients with lower lobe disease, like Orwell. However, many patients did not achieve adequate pulmonary collapse, and phrenic nerve paralysis, although usually reversible, impaired respiration in the contralateral lung because of mediastinal flutter [ 10 ].

In thoracoplasty, the posterior and lateral sections of several ribs were stripped off the periosteum, and the lung pushed inward, usually in 2 or 3 operations. The preserved periosteum regenerated ribs in the collapsed position, stabilizing the chest wall and minimizing the risks of chest wall paradoxical motion and impaired cough [ 10 , 16 , ]. Less satisfactory materials were also used, including paraffin, fiberglass, olive oil, gauze, rubber, bone grafts, pectoral muscle flaps, and fat grafts, using omentum, lipoma tissue, or abdominal wall fat from the same patient or from another patient [ 16 , 23 ].

Ideally, the plomb was removed after the periosteum had regenerated a stable bony plate in the collapsed position, minimizing the risk of infection or migration of the plomb [ 19 , 24 ]. Plombage collapsed the lung in a single operation. Because the first rib and spinous transverse processes were not removed, it also resulted in less-severe chest and spinal deformity than thoracoplasty [ 10 , 19 ].

Retrospective data suggest a significant benefit for collapse therapy. Postmortem examination of patients treated with collapse therapy showed that cavities were reduced to fibrous clefts [ 16 ]. The pneumoperitoneum therapy stoically endured by Orwell may have influenced the depiction of the tortures of Winston Smith in the Ministry of Love in [ 3 ].

Another reflection of Orwell's illness may be seen in Winston Smith's severe cachexia:. But the truly frightening thing was the emaciation of his body. The barrel of the ribs was as narrow as that of a skeleton: the legs had shrunk so that the knees were thicker than the thighs…the curvature of the spine was astonishing. The thin shoulders were hunched forward so as to make a cavity of the chest, the scraggy neck seemed to be bending double under the weight of the skull. At a guess he would have said that it was the body of a man of sixty, suffering from some malignant disease.

This is usually attributed to high levels of proinflammatory cytokines, although the precise mechanism remains elusive. Even with current treatment, tuberculosis is associated with a prolonged anabolic block [ 26 , 27 ]. Streptomycin was not commercially available in the United Kingdom, but Orwell purchased it from the United States using his royalty money from Animal Farm , and he obtained an import license through the political connections of the publisher David Astor.

Orwell improved with receipt of streptomycin, but he unluckily developed a rare adverse effect, toxic epidermal necrolysis [ 28 ], which he described with startling detachment:. A sort of rash appeared all over my body, especially down my back … after about three weeks I got a severe sore throat, which did not go away and was not affected by sucking penicillin lozenges.

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Jessica Moreland, M.D. - Faculty Profile - UT Southwestern

It was very painful to swallow and I had to have a special diet for some weeks. There was now ulceration with blisters in my throat and in the insides of my cheeks, and the blood kept coming up into little blisters on my lips. At night these burst and bled considerably, so that in the morning my lips were always stuck together with blood and I had to bathe them before I could open my mouth.

Meanwhile my nails had disintegrated at the roots. The progress of Orwell's illness is difficult to map. He seemed to have inherited bronchiectasis, a condition that would have made him susceptible to lung infection from birth. His recurrent influenza and bronchitis, his persistent cough, and his several bouts of pneumonia would be symptoms of that susceptibility.

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But the condition would also make him especially vulnerable to tuberculosis, and he might well have been infected since childhood. By the time he was finally diagnosed with tuberculosis at the age of 35, he had exposed himself to risk on several occasions. Because Orwell may have been sterile, it is tempting to seek a unifying diagnosis linking his respiratory and fertility problems.

Orwell and his wife Eileen had a childless marriage for 8 years before they adopted a son in Eileen blamed her husband for their fertility problems [ 5 ], although her uterine fibroids may have been a contributing factor. These were symptomatic enough that she required a hysterectomy in , dying unexpectedly of a reaction to anesthesia. Orwell also believed he was responsible for their failure to conceive. Little is known of Orwell's early sexual relationships, but Orwell suspected he was infertile prior to his marriage to Eileen.

Orwell also confided his doubts about his fertility to Pamela Warburg, the wife of his publisher [ 1 ], and to his friend Rayner Heppenstall [ 2 ]. There is no definitive evidence that Orwell was infertile, and even if he were, his infertility may have been unrelated to his respiratory problems. However, there are at least 4 intriguing explanations for the apparent conjunction of infertility and bronchiectasis in Orwell's case.

Men with cystic fibrosis CF are almost always infertile as a result of congenital bilateral absence of the vas deferens [ 29 ], and infertility is an increasingly common reason for the diagnosis of CF in adults [ 30 ]. However, the duration of survival for CF was brief in the preantibiotic era [ 29 ], and it seems implausible that Orwell lived until the age of 46 years with CF and tuberculosis. Primary ciliary dyskinesia immotile cilia syndrome is an autosomal recessive genetic disease characterized by recurrent upper respiratory tract infections and bronchiectasis.

In the patients with circulatory disorders, analysis of the clinical circumstances establishes the convergence of synergistically acting factors in the causation of the fasciitis-panniculitis syndrome. The circulatory impediment is insufficient to induce the syndrome, but it apparently acts as a predisposing factor such that it amplifies the inflammatory-cicatrizing response to one ordinary damage or another. Awareness of the multifactorial etiopathogenesis of the fasciitis-panniculitis syndrome in patients with circulatory disturbances ushers in a novel perspective of therapeutic intervention at multiple levels.

Unable to display preview. Download preview PDF. Skip to main content. Advertisement Hide. The fasciitis-panniculitis syndrome in circulatory disorders of the limbs. Original Articles. This process is experimental and the keywords may be updated as the learning algorithm improves. This is a preview of subscription content, log in to check access. Sem Arthritis Rheum — Google Scholar. Shulman LE Diffuse fasciitis with hypergammaglobulinemia and eosinophilia.

A new syndrome. J Rhematol 1 suppl A pathologic study of twenty cases. Am J Pathol — PubMed Google Scholar. Semin Arthritis Rheum — Black CM Scleroderma-clinical aspects. J Int Med — Falanga V Localized scleroderma. Med Clin North Am — Ann Intern Med — J Hyperbaric Med — Michaels RM Eosinophilic fasciitis complicating Hodgkin's disease. J Rheumatol — Am J Dermatopath — Int J Dermatol — Prog Rheumatol — Br Med J — Little, Brown and Co: Boston, pp — Arch Dermatol — Pathophysiology, prevention and management.

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