Howard Fischer
Uppsala, Sweden

“It’s better to die violently and not too old…‘natural’ death, almost by definition, means something slow, smelly and painful.”
– George Orwell, “How the poor die,” 1946

Many readers of the English author George Orwell (1903–1950) know that he died of pulmonary tuberculosis (TB). He wrote Animal Farm, 1984, four other novels, three nonfiction books, and hundreds of essays and newspaper articles. Orwell had a massive, fatal pulmonary hemorrhage while in University College Hospital, London in January 1950. He had a lifelong history of respiratory problems. As a child, he was described as being “bronchial” or “chesty,” meaning that this chubby, well-nourished child coughed often. After age ten, he had a chronic cough and several episodes of “bronchitis.” In Burma, where Orwell served in the Indian Imperial Police from age nineteen until twenty-four, he had pneumonia once as well as dengue, a tropical mosquito-borne viral illness that does not affect the lungs.

In Paris, researching a book on and living with the working poor, he was hospitalized with influenza in 1929 at age twenty-six. He had pneumonia at least four times between the ages of fifteen and thirty-four (1918–1937). He was shot in the throat in Spain, fighting for the Republicans during the civil war. In 1938, he received a diagnosis of bronchiectasis (see below), although a note added later to his records included a diagnosis of TB. He apparently was not told of this. Three years later, in 1941, he was diagnosed with “bronchitis” and in 1947, finally received an official diagnosis of TB at the age of fourty-four.^1-4

Could Orwell have had undiagnosed asthma? Neither Orwell nor his biographers reported the respiratory distress or “air hunger” seen in severe asthma attacks. There are references to him wheezing as a child. A variant of asthma, called cough-variant asthma, manifests as a cough and not a wheeze. A heavy smoker like Orwell would be constantly coughing—which he seems to have done most of his life—if that variant were his problem. Also, reactive airway disease (asthma) predisposes individuals to pneumonia.

At this point, we need to introduce another medical problem that Orwell thought (possibly correctly) he had. He considered himself sterile. After eight years of marriage, he and his wife Eileen were disappointed that they had not had a child. He had not, as far as he knew, fathered children with other women, including during his younger days in Burma. Eileen had fibroids of the uterus (benign tumors), which may have had some role in preventing pregnancy.⁵

If we take recurrent pulmonary disease and infertility as Orwell’s medical problems, we have a number of suspect diagnoses. Cystic fibrosis (CF), a disorder with a genetic basis, leads to abnormal water and electrolyte transport that results in the production and accumulation of thick mucus. Respiratory difficulty and recurrent lung infections result. In addition, 97% of men with CF are infertile because of a congenital absence of the vas deferens. The vas, or ductus deferens, is a tube that transports sperm from the epididymis (an appendage of the testicle) to the ejaculatory ducts. Normal spermatozoa are produced, but they cannot go anywhere. Children with CF did not usually live longer than six months at the beginning of the twentieth century, and not much more than sixteen years in the 1970s. Occasionally, CF is diagnosed in an asymptomatic man during a search for the cause of azoospermia.⁶

A congenital condition known as immotile cilia syndrome, or primary ciliary dyskinesis, results in the ineffectiveness of the microscopic, hair-like cilia lining the respiratory tract.

Mucus, containing trapped debris and micro-organisms, cannot be swept out of the respiratory system. Children with this condition have a year-round cough, upper respiratory infections, chronic rhinitis, and recurrent otitis media (middle ear infections). Sinusitis is rarely seen in this condition, but patients may have bronchiectasis.^7,8 Bronchiectasis is a dilation of larger airways (bronchi), with ineffective clearance of airway mucus. Symptoms include cough, increased pulmonary secretions, and shortness of breath on exertion.

Bronchiectasis, which Orwell was told he had in 1938, may result from ciliary disorders, CF, immune deficiency, or respiratory infections such as TB, whooping cough, measles, or adenovirus infection.⁹ The other part of the immotile cilia syndrome is infertility, because the spermatozoa are also immotile.¹⁰ Today the condition is diagnosed by nasal or bronchial biopsy and electron microscopic examination of the tissue, or by measuring nasal nitric oxide concentration, which is decreased in this condition.¹¹

Young syndrome consists of bronchitis, bronchiectasis, and chronic rhinitis, the latter disappearing after adolescence. Patients have “obstructive azoospermia” because of thick mucus clogging the epididymis, the testicular appendage where sperm mature and are stored. The incidence of Young syndrome decreased when mercury was removed from teething medicine.¹² Some authors have wondered if Young syndrome is even “an entity in its own right.”¹³

TB of the epididymis in a man with pulmonary TB is another “lung disease-infertility” combination to be considered.¹⁴

As noted earlier, Orwell received a diagnosis of bronchiectasis in 1938 following an episode of hemoptysis (coughing up of blood). A late addendum to his medical chart indicated that TB was confirmed. It has been speculated that this diagnosis was added after culturing Mycobacterium tuberculosis from Orwell’s sputum, or by a positive guinea pig inoculation test. A recently discovered letter Orwell sent to the editor of a Soviet literary magazine in 1938 was tested with advanced technology. It was found to contain M. tuberculosis. Thus, he had come in contact with the bacterium no later than his return home from Spain. However, he could have become infected (with the infection remaining latent for decades) in India, where he spent the first year of his life, or in Burma.¹⁴ His doctor in 1938 was a TB specialist and his wife’s brother. Maybe no one was told the true diagnosis until nearly ten years later, when Orwell had been having fevers, night sweats, and weight loss (TB symptoms all) for two years.^15,16

Orwell was addicted to nicotine. Nearly every photo of him shows him with a cigarette in his mouth. Indarwrites, “Cigarette smoke so permeates his stories that it almost stains one’s fingers to read them.”¹⁷ He started smoking before going to Eton, when he was about thirteen years old. In his first published book, Down and Out in Paris and London (1933), he mentions smoking forty-one times. In Orwell’s time, more than 80% of men in the UK smoked. He smoked about 170 hand-rolled cigarettes per week. He was shot in the neck during the Spanish Civil War, and “as soon as he was stabilized in a field hospital…, he immediately asked the nurse for a cigarette.” Even after the diagnosis of pulmonary TB, he continued to smoke.¹⁸

None of the medical or biographical commentators on Orwell’s life seem willing to offer a single underlying diagnosis. If I had to choose (although this is not a diagnosis pediatricians are usually called upon to make), I would consider immotile cilia syndrome the most likely.

References

1. David Taylor. Orwell: The Life. London: Vintage, 2009.
2. George Orwell. A Collection of Essays. New York: Harvest, 1981.
3. John Ross. Shakespeare’s Tremor and Orwell’s Cough. New York: St. Martin’s Press, 2012.
4. John Ross. “Tuberculosis, bronchiectasis, and infertility: What ailed George Orwell?” Clin Infect Dis, 41(11), 2005.
5. Ross, “Tuberculosis.”
6. “Cystic fibrosis.” Wikipedia.
7. Fabian Sommer. “Rare diseases of the nose, the paranasal sinuses, and the anterior skull base.” Laryngrhinootolgie, 100 (Suppl 1), April 30, 2021.
8. A. Barbato et al. “Primary ciliary dyskinesia: A consensus statement on diagnostic and treatment approaches in children.” European Respiratory Journal, 34, 2009.
9. Jaafar Imam and Alexander Duarte. “Non-CF bronchiectasis: Orphan disease no longer.” Respiratory Medicine, 166, May 2020.
10. Ross, “Tuberculosis.”
11. Ross, “Tuberculosis.”
12. A.K. Arya et al. “Does Young’s syndrome exist?” J Laryngol Otol, 123(5), 2009.
13. Ross, “Tuberculosis.”
14. Ross, “Tuberculosis.”
15. Jason Daley. “Did George Orwell pick up TB during the Spanish Civil War?” Smithsonian, August 2, 2018.
16. Daley, “Did George Orwell.”
17. Josh Indar. “Bumming smokes in Paris and London: George Orwell’s obsession with tobacco.” Popmatters, June 18, 2009. https://www.popmatters.com/94064-bumming-smokes-in-paris-and-london-orwells-obsession-with-tobacco-2496026879.html
18. John Sutherland. Orwell’s Nose: A Pathological Biography. London: Reaktion Books, 2016.