Jane Austen's Last Illness
Jane Austen died at 4:30 a.m. on 18 July 1817 at the age of
41 from an ailment the nature of which has never been
ascertained, or, so far as I am aware, seriously discussed.
No information was furnished by the doctors who attended
her, and her relatives were reticent about her illness, so that
we are compelled to rely chiefly on the few comments made
by the patient herself in the letters that have survived.
Fortunately Jane Austen was an accurate observer, and though
she made light of her troubles until near the end one can
rely on her definite statements.
The onset of her illness was insidious, but we know that
she began to have a feeling of weakness or tiredness round
about July 1816, and within a few weeks she experienced
severe pain in the back, for in a letter dated 8 September she
wrote to her sister saying:
"Thank you, my back has given me scarcely any pain
for many days. I have an idea that agitation does it as
much harm as fatigue, and that I was ill at the time of
your going away from the very circumstance of your going."
That comment is noteworthy. Three months later (16 December)
she refused an invitation to dinner, giving as a reason:
"I was forced to decline it, the walk is beyond my
strength (though I am otherwise very well)."
A month later, though she told her niece Caroline that she
felt stronger, yet in a letter to her friend Alethea Bigg she
for the first time confesses that her illness is serious:
"I have certainly gained strength through the winter and
am not far from being well; and I think I understand my
own case now so much better than I did, as to be able by
care to keep off any serious return of illness. I am more
and more convinced that bile is at the bottom of all I have
suffered which makes it easy to know how to treat myself."
"Serious return" and "all I have suffered" are significant
words. The self-diagnosis of "bile" must indicate some
gastro-intestinal irritation, probably nausea or vomiting or
both. Up to that time she appears to have been treating
Little information is available for the month of February
1817, though we learn that there was pain in one knee, which
was therefore wrapped in flannel, but in a letter dated 23
March and written to her favourite niece Fanny we find
"I certainly have not been very well for many weeks, and
about a week ago I was very poorly, I have had a good
deal of fever at times and indifferent nights, but am
considerably better now and recovering my looks a little,
which have been bad enough, black and white and every
wrong colour. I must not depend upon ever being blooming
again. Sickness is a dangerous indulgence at my time
She was evidently distressed by her changing facial appearance.
Two weeks later, on 6 April, a letter written to her brother
Charles tells of severer attacks:
"I have been really too unwell the last fortnight to write
anything that was not absolutely necessary, I have been
suffering from a bilious attack attended with a good deal
of fever.... I was so ill on Friday and thought myself so
likely to be worse that I could not but press for Cassandra's
return with Frank."
Obviously the attacks or crises were becoming more serious
and she was now apprehensive. The last two available letters
were written in May and show a rapid deterioration. On 22
May she wrote to her dear friend Anne Sharp a despairing
letter which, however, contains several important clues.
"In spite of my hopes and promises when I wrote to you
I have since been very ill indeed. An attack of my sad complaint
seized me within a few days afterwards - the most
severe I ever had and coming upon me after weeks of
indisposition, it reduced me very low.... My head was always
clear, & I had scarcely any pain; my chief sufferings were
from feverish nights, weakness and languor."
In the same letter she tells her friend that she had arranged
to go to Winchester so as to be under the care of a well-known
surgeon there, Mr. Lyford. The other letter was to her nephew
Edward and mentions that the appearance of her face was still
"I will not boast of my handwriting; neither that nor my
face have yet recovered their proper beauty, but in other
respects I am gaining strength very fast."
In this letter she also mentions that she was eating her
meals in a rational way and was employing herself, though
lying on the sofa most of the day.
Two other witnesses must now be called. First, just before
the move to Winchester her niece Caroline paid her a visit and
later she was able to remember that her Aunt Jane was sitting
down, dressed in a dressing-gown, looking very pale, and
speaking in a weak and low voice. This testifies to her anaemia,
for when in health Jane Austen had a rich colour. The last
and very important piece of evidence is to be obtained from
the letter in which Cassandra Austen describes the last few
hours of her sister's life in such moving words. The letter
was written to Fanny Knight on 20 July 1817. The important
passage is the following:
"On Thursday I went into the town to do an errand
your dear Aunt was anxious about. I returned about a
quarter before six & found her recovering from faintness
and oppression, she got so well as to be able to give me a
minute account of her seizure and when the clock struck 6
she was talking quietly to me. I cannot say how soon
afterwards she was seized again with the same faintness,
which was followed by sufferings she could not describe,
but Mr. Lyford had been sent for, had applied something to
give her ease & she was in a state of quiet insensibility by
seven at the latest. From that time till half past four, when
she ceased to breathe, she scarcely moved a limb."
One further fact must be mentioned. Henry Austen, Jane's
favourite brother, whom she had nursed through a serious
illness in 1815, who greatly encouraged her writing and helped
to get her novels published, and who seemed to be very prosperous,
went bankrupt in March 1816. This was a terrible
mental shock to Jane, and might well have precipitated any
disease susceptible of being influenced by mental shock.
Here then we have the story of an illness coming on soon
after a severe mental shock, beginning with an insidious languor
and a pain in the back, progressing steadily yet with definite
periods of intermission, and attended by critical attacks of
faintness and gastro-intestinal disturbance, yet unaccompanied
by any noticeable pain anywhere, whether in abdomen, chest, or
head. During the intermissions, the intelligence was acute and
the appetite good. The end came in one of the crises in which
faintness was a very noticeable feature.
No doubt many of the above symptoms might be accounted
for by a number of conditions, but there are very few diseases
which could account for them all. There is no symptom
indicative of intracranial or intrathoracic disease, unless we
regard the attacks of faintness as of cardiac origin. Nor, apart
from bilious attacks, is there any symptom that incriminates the
abdominal viscera, and bilious attacks are common accompaniments
of various diseases.
The increasing lassitude and weakness might make us suspect
myasthenia gravis, but in this disease we should expect some
interference with speech or with chewing of food or even
swallowing, and we should not expect the gastro-intestinal
disturbances. Another disease that begins insidiously and has
intermissions is subacute bacterial endocarditis, but in this
disease gastro-intestinal attacks are uncommon and severe
fainting crises rare or unknown.
There are indeed some abdominal diseases that give no signs
and yet may progress and cause no other symptoms than great
weakness and anaemia. Tabes mesenterica and some other
forms of tuberculosis should also be considered, but such other
conditions are not attended by acute painless crises. Latent
cancer of the stomach might cause severe anaemia and weakness
before it became obvious, but should not give rise to prolonged
fainting attacks, and with cancer the course is progressively
downhill. Yet after reading all the evidence many times I
had almost come to the conclusion that cancer of the stomach
would most readily account for most of the symptoms when
I bethought myself of two pathological conditions, either of
which would account for most of them - Addison's or
pernicious anaemia, and Addison's disease of the suprarenal
capsules. Neither of these diseases had at that time been
recognized, and when Thomas Addison made his investigations
he at first found difficulty in discriminating the one from the
other. Both give rise to an insidiously developing weakness
and languor, to anaemia, and to severe gastro-intestinal
disturbances. Both are liable to intermissions during which
the patient feels much better and is hopeful of recovery. Yet,
in the absence of all laboratory assistance, Addison found one
symptom that, in the majority of cases, enabled him to
distinguish between the two conditions, and that was the
appearance of the skin. In the disease which he found constantly
associated with a pathological condition (usually tuberculosis)
of the suprarenal bodies he noted that the skin in
certain parts changed to a darker colour, usually brown but
sometimes almost black, and the face was nearly always affected.
He summarized the main distinguishing features as follows:
"The leading and characteristic features of the morbid
state to which I would draw attention are: anaemia, general
languor and debility, remarkable feebleness of the heart's
action, irritability of the stomach and a peculiar change
of colour in the skin."
In some cases the dark patches of the skin are mingled with
areas showing a lack of pigment - a true black and white
Though I had read the letter of 23 March 1817 many times,
it was long before I realized the true significance of that
symptom which is almost pathognomonic of Addison's disease
in Jane Austen's pathetic lament:
"Recovering my looks a little, which have been bad
enough, black and white and every wrong colour."
Again, when she wrote to her nephew two months later
she was distressed that her face had not recovered its beauty.
There is no disease other than Addison's disease that could
present a face that was "black and white" and at the same
time give rise to the other symptoms described in her letters.
Addison's disease is usually - Wilks said always - due to
tuberculosis of the suprarenal capsules, and it is likely that
it was so in Jane Austen's case. The disease ran its course
rapidly, indicating an active pathological process that might
well account for any fever. Pain in the back has been noted
in Addison's disease by several observers.
If our surmise be correct, Jane Austen did something more
than write excellent novels - she also described the first recorded
case of Addison's disease of the adrenal bodies.
Note.- The extracts quoted above are taken from Jane
Austen's Letters, collected and edited by R.W. Chapman. 2nd