July 18. At Winchester, Miss Jane Austen, youngest daughter of Rev. George Austen, Rector of Steventon, Hants, authoress of “Emma,” “Mansfield Park,” “Pride and Prejudice,” and “Sense and Sensibility.”
These paltry words announced Jane Austen’s death in the August 1817 issue of The Gentleman’s Magazine. Her obituary notice, shown in the image, is very like that published in the local Salisbury and Winchester Journal, except the Journal also commented on her character: “Her manners were gentle, her affections ardent, her candour was not to be surpassed, and she lived and died as became a humble Christian.”1 The magazine’s announcement can be viewed directly on p. 184 of the original magazine in Google Books or on p. 203 of the PDF version.
Jane Austen’s Symptoms
Austen was only 41 years old when she died of an undetermined cause. Austen herself believed bile was at the root of her suffering, and so she wrote her brother Charles in April, 1817: “I have been suffering from a Bilious attack, attended with a good deal of fever.”2 By May her health had deteriorated considerably, prompting a decision to travel to Winchester where she sought the care of Mr. Lyford, a prominent surgeon. On the day before she died, Austen was seized with faintness and other vague sufferings. Her sister, Cassandra, observed that she became easy after Mr. Lyford gave her medicine (most likely a dose of laudanum) to help her sleep.
Possible Diagnoses Based on 20th Century Medicine
The cause of her death has been the object of much speculation. Sir Zachary Cope studied Austen’s letters for clues to her illness and considered several possible causes of death, which conclusions he published in the British Medical Journal in 1964. His list of potential diagnoses are shown below.
- Tuberculosis. Symptoms include a bad cough lasting 3 weeks or longer, chest pain, coughing up blood or sputum, fatigue, weight loss, lack of appetite, and chills and fever. Today we know tuberculosis is an infection caused by a bacterium (specifically, Mycobacterium tuberculosis) that usually attacks the lungs.
In Austen’s lifetime the germ theory of disease had not taken hold. Thus, there was no disease called “tuberculosis” — the condition was not formally identified until 1882 — but a disease known as “consumption” was widely recognized. Medical ideas about consumption in Austen’s day reflected the lack of understanding about disease processes and included some causes that today are almost comical:3 hard drinking; confined or unwholesome air; violent passions, exertions, or affections of the mind; great evacuations such as sweating, diarrhea, diabetes, or excessive venery (sexual activity); the sudden stoppage of usual evacuations associated with bleeding piles, sweating of the feet, or a nosebleed; undergoing a sudden transition from a hot to a cold climate; frequent debaucheries (sex again!); infection, especially those caught by sleeping with the diseased (the best theory of the lot); and certain occupations, especially those where the practitioner is constantly leaning forward, pressing upon the stomach, such as cutlers, tailors, shoemakers, seamstresses, and the like.
“Consumption” included a good many diseases all lumped together: in children, marasmus (a form of severe malnutrition), mesenteric affections (that is, infection or disease of the intestinal lining), whooping cough (a contagious infection of the respiratory track marked by a peculiar cough with a “whooping” sound), and smallpox; in adults, diabetes, dysentery and syphilis were also classified as consumption. Nearly 1 in 4 deaths in London were attributed to consumption in 1803.4 Austen’s letters do not mention chest pain and coughing up blood, although she was enduring a recurring fever.
- Stomach cancer. Signs and symptoms include a poor appetite, unintentional weight loss, belly pain, heartburn or indigestion, nausea, and vomiting. Several of these symptoms were reported by Austen to her family or friends. Today stomach cancer is recognized as a complex, multifactorial disease involving genes, inflammation, and environmental factors such as diet, occupation, and infection with the H. pylori bacterium.
In Austen’s time a doctor would have recognized a scirrhus or cancer as being a hard “indolent tumor usually seated in some of the glands.” Its cause was believed to result from a suppressed evacuation, which explained why it was often fatal in women and “particularly old maids and widows.” Other causes included excessive emotions such as fear, anger, grief, and religious melancholy; eating food that is too hard for the stomach to digest; barrenness; indolence; celibacy; cold; and pressure on the stomach.3 Being unmarried and presumably celibate, a diagnosis of stomach cancer fit with Austen’s marital status, but these early 19th-century “causes” would not be considered sound today.
- Myasthenia gravis, a relatively uncommon condition characterized by muscle weakness and fatigue that can be relieved by rest. The most common initial symptom is a weakening of the eye muscles that results in drooping of the upper or lower eyelid, which occurs in about 85% of patients; today it is treatable through surgery or medications that suppress the immune system. This diagnosis does not fit well with Austen’s symptoms, for there is no report of her having drooping eyelids.
- Pernicious anemia, a type of anemia in which the body cannot make healthy red blood cells because it lacks sufficient vitamin B12; low vitamin B12 in pernicious anemia arises from the lack of a protein called “intrinsic factor” made in the stomach. The main symptoms are fatigue, nausea and vomiting, and signs of nerve damage, including numbness in the hands and feet, muscle weakness, and a loss of reflexes. Austen displayed some of these symptoms (e.g., fatigue, muscle weakness, and digestive upsets), but not others. Today people with pernicious anemia receive regular muscle injections of vitamin B12, but nothing was known of this vitamin in Austen’s time. Pernicious anemia was first described by Thomas Addison in 1849. The vitamin B12 molecule was isolated in the laboratory nearly a century later, in 1948. Here, again, a few symptoms fit with Austen’s complaints, but no surgeon or doctor in Austen’s time would have had a name for this condition.
- Addison’s disease—named after the same Thomas Addison who described pernicious anemia—is a rare disease of the endocrine (hormone) system first described in 1855. The condition is characterized by a gradual and chronic worsening fatigue; loss of appetite; general overall weakness; low blood pressure and even fainting; muscle pains in the lower back, abdomen, or legs; and weight loss. These symptoms result from the inadequate secretion of hormones by the adrenal glands. Skin discoloration or bronzing, called hyperpigmentation, is also typical of the condition. Tuberculosis is the main cause of Addison’s disease.
Sir Zachary reviewed what little clinical evidence could be gleaned from Austen’s letters and concluded that she suffered from Addison’s disease. His scholarly article mentions Austen’s complaint that her face was “black and white and every wrong color” and concluded that a discolored face, when coupled with her fatigue and general languor, were signs of Addison’s disease. He believed she was the first recorded case of the condition.
Other diseases have also been considered. Claire Tomalin made a persuasive argument in her book, Jane Austen: A Life,1 that several of Austen’s symptoms do not fit with a diagnosis of Addison’s. Her complaint of recurring fevers, for example, are not typical symptoms of Addison’s disease, and the skin discoloration she experienced is also not a good fit. In Addison’s disease the skin darkens, giving a tanned look; it would not be described as “black and white and every wrong color,” as Austen described herself. Tomalin concluded that Austen might have suffered from Hodgkin’s lymphoma, a cancer of the body’s lymphatic system. (The lymph contains white blood cells and is part of the immune system.) Symptoms of Hodgkin’s lymphoma include a painless swelling of the lymph nodes found in the neck, armpit, or groin; persistent fatigue; fever and chills; loss of appetite; unexplained weight loss, sometimes amounting to as much as 10% of body weight; itching; and coughing, trouble breathing, or chest pain. Austen experienced a few of the symptoms associated with Hodgkin’s such as fever and fatigue, but she did not complain of swollen (lymph) nodes in her arm pits, coughing, or night sweats.
In 2009 Richard Allen Greene presented another view of Austen’s illness: she might have suffered for several years from a disease that affected her adrenal glands but died from a secondary infection like tuberculosis. In truth, we are not likely ever to know.
The Regency View of Austen’s Illness
Austen’s attending surgeon, Mr. Lyford, must have considered any number of diagnoses after examining Miss Austen. He might quickly rule out dyspepsia due to intemperance, knowing the lady was not prone to imbibing spiritous liquors excessively, and he could eliminate inflammation of the bowels, since she had no acute symptoms of abdominal pain.5 He might have considered stomach cancer because she was still a maiden and unmarried. A strong contender was bilious fever—a fever accompanied by frequent or copious evacuation of bile, either in vomit or in stools, although this condition tended to arise in late summer and dissipate as winter approached.3 Still, Austen had struggled with recurring fevers, fainting spells, and vague pains for several months, and a diagnosis of bilious fever might be reasonable.
Nervous consumption might also prove a worthy diagnosis. The widely respected Dr. Buchan described this wasting disease as one in which patients endured considerable fever, indigestion, weakness, and a lack of appetite.3 (Austen experienced these symptoms except that her appetite was good.) Regency surgeons were likely familiar with Dr. Reid’s treatise on consumption, in which the estimable doctor stated baldly that the primary cause of a predisposition to pulmonary consumption was temperament, and women were more liable to consumption because they were more complicated and irritable than men and, therefore, more prone to “derangement.”6 If Miss Austen expressed any anxiety about her condition or life circumstances, Mr. Lyford might have reached a diagnosis of nervous consumption.
What Mr. Lyford thought about Austen’s facial skin discoloration can only be guessed. Other than erysipelas or Saint Anthony’s fire (a disease of the skin caused by an acute streptococcal infection that causes a bright red rash) and cow pox, the dozen or so medical texts I consulted — all published in the late 1700s or early 1800s — had no entries for skin discolorations or other skin conditions. Nonetheless, 12 medical texts is a small sample and it is probable that information about skin discolorations is out there, but I simply have not found it.
How would Mr. Lyford have treated Austen’s symptoms? Bloodletting was his first line of defense in addressing her fever complaint. In choosing this intervention he may have consulted Dr. Clutterbuck’s treatise on fever. Dr. Clutterbuck recognized fever as being an inflammation of the brain and wrote that “there are few cases of inflammation that are not capable of being relieved by it [venesection or bloodletting].”7 Even though bloodletting was considered valuable as a supporting treatment, Dr. Clutterbuck cautioned against taking large quantities of blood from a patient who was already weak and debilitated. Nonetheless a loss of six or eight ounces of blood was not likely to be harmful and might provide relief, in his opinion.7 In the case of a feverish inflammation, he might also have prescribed a saline draught and an electuary of Peruvian Bark mixed with sugar or honey and water.3 For general relief he would employ a tincture of opium (laudanum). If Mr. Lyford reached a diagnosis of nervous consumption, he would advise a light diet low in animal foods; a little exercise, if possible; and the wearing of loose clothing.6
Treating Mind and Body
Dr. Buchan’s treatise on the prevention and cure of diseases – commonly called Domestic Medicine – was very popular in Austen’s day: the eleventh edition was published in 1790 and the book was still being published in 1859. Being concerned with methods of promoting health through a wholesome diet and exercise, Dr. Buchan believed in paying careful attention to a patient’s temper of mind:3 “Fear, anxiety, and a fretful temper, both occasions and aggravate diseases” [sic]. Thus, choosing to divert Austen’s mind “from anxious thought,” Mr. Lyford began with words of encouragement, telling her he “would cure her.”8 His words must have had an effect, for Austen told her nephew that she was lying “‘upon the sopha’” during the day and “eating her meals ‘in a rational way.’” She believed her attacks of “fever, bile and violent pains” were a thing of the past, but her respite did not last long, and she underwent a steady decline.8 After the surgeon gave her a sleeping draught on that last evening, Austen moved nary a muscle through the night. It seems Mr. Lyford could not cure her, and she died peacefully early the next morning at half-past four, her head resting on a pillow laid across Cassandra’s lap. The cause of her death is not known.
- Claire Tomalin. Jane Austen: A Life. London: Penguin Group, 1997, pp. 272, 287-288.
- Oxford World’s Classics. Jane Austen: Selected Letters. Oxford: Oxford University Press, 2009, p. 210.
- Buchan, William. Domestic Medicine or, a Treatise on the Prevention and Cure of Diseases, by Regimen and Simple Medicines. (Boston, 1811), pp. 92, 115, 136-137, 143, 189-190, 313, 448. (Available on Google Books)
- Bateman, Thomas. Report on Diseases of London and the State of the Weather from 1804 to 1816. (London, 1819), p. 23. (Available on Google Books)
- Willan, Robert. Reports on the Diseases in London. (London, 1801), pp. 132, 164-165. (Available on Google Books)
- Reid, John. A Treatise on the Origin, Progress, Prevention, and Treatment, of Consumption. (London, 1806), pp. 161, 175, 187, 197, 205. (Available on Google Books)
- Clutterbuck, Henry. An Inquiry into the Seat and Nature of Fever. Part 1. (London, 1807), p. 237. (Available on Google Books)
- Nokes, David. Jane Austen: A Life. Oakland: University of California Press, 1998, pp. 513-515. (Available on Google Books)