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The British physician Zachary Cope reviewed the symptoms of Jane Austen’s last illness in 1964 and concluded that her death had probably been caused by Addison’s disease of the adrenal bodies (183). What persuaded him of the diagnosis of Addison’s was the discoloration of her face that she reported to her niece, Fanny Knight, in March 1817: “[I am] recovering my Looks a little, which have been bad enough, black & white & every wrong colour” (23 March 1817).
For some time Cope’s diagnosis was widely accepted, but in 1997 Claire Tomalin put forth the possibility of a “lymphoma such as Hodgkin’s disease—a form of cancer” (283), a diagnosis supported by Annette Upfal. Since then, other diagnoses have been proffered. Kathryn G. White suggests that Cope’s alternative possibility—tuberculosis—was responsible and was probably acquired through tainted milk. Carol Shields, herself a victim, suggested breast cancer (173-74). Laurie Kaplan has referred to a suggestion of ovarian cancer.
But a possible cause of Jane Austen’s death has been hiding in plain sight all this time: she had typhus as a child, and typhus can come back.
Just as a person who has had chickenpox can develop shingles later in life, so too can a person with typhus endure a recurrence. When it reappears, it is a recurrent or recrudescent typhus called Brill-Zinsser disease. The infective agent of epidemic, lice-borne typhus, Rickettsia prowazekii,1 lingers in the body, ready to pounce if the body’s immune system is weakened by another illness, malnutrition, or stress. We can never know for sure what disease ended Austen’s life. It may be that she died of Brill-Zinsser alone or in combination with another disease. Any combination of infectious agents, together with the devastating stresses of her final years or with the lingering effects—if any—of the childhood bout of typhus, could have been fatal. But it is impossible to ignore the role that Brill-Zinsser might have played since typhus, the source of Brill-Zinsser, is the one illness for which there is evidence in her life’s story.
“Banished from home”
Jane Austen was sent away from home at seven,2 a younger age than any of her siblings except George, her second brother, who suffered from an unidentified mental disorder and was sent to live with caretakers from a young age (Le Faye 22). In the spring of 1783 Jane was packed off to Oxford with her sister Cassandra, ten, and their cousin Jane Cooper, twelve, to live with Cooper’s aunt, Ann Cawley, who had been taking in students since the death of her husband Ralph, the principal of Brasenose College. Sometime during the summer, Cawley pulled up stakes and hauled the girls off to Southampton.
It was a fatal choice. Southampton was a vital port-of-call for soldiers and sailors of two wars, and even though typhus was always present, within weeks of the August 1783, disembarking of a ship from Gibraltar, “the town’s death-rate showed an alarming rise” (Le Faye 49). By September typhus arrived at Cawley’s house, and Jane, Cassandra, and Jane Cooper all succumbed. Cawley did not notify the families of their children’s illness, but Jane Cooper got word out,3 and when the two mothers—sisters Cassandra Austen and Jane Cooper—arrived, Mrs. Cooper became infected. She died on October 25, at the age of 47.
Jane Austen is said to have nearly died4 and was kept home for 18 months, convalescing. Then in the spring of 1785 she and Cassandra were shipped off to another school with no pretentions whatever to the kind of education that would have suited a girl of Jane’s intelligence.
Typhus
All it took was one louse. Somewhere a louse bit a person infected with typhus, and it in turn, seeking a blood meal, bit Jane. The bite itched; she scratched and thus rubbed the feces of the infected louse into her tissues. Because the quarters were probably crowded, the girls sleeping in one room, if not one bed, all easily became infected. Where body lice infestations are rare, and people have easy access to antibiotics, typhus is almost non-existent. In the United States, about fifteen cases of typhus are reported annually (“Typhus Fever”). But where lice are common and antibiotics rare, it is appalling, infecting more than 50,000 people in Burundi in 1986 (Pittendrigh 2).
Until antibiotics were developed in the mid-twentieth century, there was nothing that could cure typhus. In an 1813 treatise on fevers, an Edinburgh physician, A. P. Wilson Philip, laid out contemporary methods to “diminish the excitement of the blood” in feverish patients, including those with typhus (265). All the alternatives seem harsh and dangerous for a weakened invalid. Bloodletting was common, and Austen describes times when it was used by her family members.5 Philip recognized the debilitating effects of bloodletting, but his preferences seem just as injurious and traumatic to the patient. He called instead for “dilution” and “refrigerants.” Dilution of the blood was accomplished by the use of emetics, including mercury and antimony (both toxic) given in “nauseating doses” (246), and clysters (enemas), all of which must have deprived patients of needed nourishment. The refrigerants he recommended began with a cold room, not more than 35 or 40 degrees, because he considered sweating to be “unfavorable” to the patient (248). Most important was cold water: “The most effectual way of using cold water externally in fever, is by affusion. The patient is stripped naked, and a bucket of cold water is thrown over him. The temperature of the water should be from 40° to 60°; the quantity from three to five gallons” (250).
We don’t know either the course of the disease in Austen or the treatments she received. In general, the impact of typhus is milder in children than in adults. Typhus can kill between 10 and 60 percent of those infected, with vulnerability rising with age (Vyas). Medical texts don’t distinguish between the symptoms of typhus for children for and adults, but for either it was a horrifying disease, one of the great scourges of humankind.
That lice were the infecting agents of epidemic typhus wasn’t discovered until 1909 by Charles Nicolle who won a Nobel Prize for his work (Barrett 1122). After an incubation period of a week or two, a person with typhus experiences an excruciating headache with a fever rising to a high of 104° Fahrenheit, which can linger for as long as two weeks. In a few days, most of the body is covered in a rash, which in severe cases can seep blood or become hemorrhagic. Blood pressure falls, the spleen can enlarge, and the vascular system can collapse causing shock; the renal system can fail, and the kidneys can’t screen toxins; the brain can swell, pneumonia can develop, and bruises can become gangrenous (“Epidemic Typhus”). Complications associated with typhus include diminished blood volume, vessel inflammation resulting in obstruction and gangrene, blood clots or thrombosis, circulatory collapse, uremia or kidney failure, inflammation of the heart muscle, heart failure, liver infection, respiratory failure, inflammation of the spinal column or brain, and seizures (“Typhus Fever”).
A patient may also suffer from pain in the back, joints, and chest, conjunctivitis, and hearing loss. Due to the high fever, a victim might be plagued with delirium or stupor (McPhee 1281-22).6 In severe cases, blood clots forming in the blood vessels and organs can cause the blood supply to be cut off so that tissue dies (necrosis), leading to black patches on the body. The gangrene can lead to the loss of toes and other extremities (Taber’s 2257). Typhus also causes facial discoloration, observed by nineteenth-century physicians. One, in 1881, described the “dusky countenance” of a typhus patient (Loomis 561); another, in 1858, “suffused eyes—dusky skin” (Upham 372); a third, in 1874, suggested a reason: “the face has a dusky hue, from the retardation of the circulation through the capillary vessels (“Fevers” 167).
Brill-Zinsser disease
If typhus is rare in the western world, Brill-Zinsser is even rarer. Nowadays, with antibiotics to treat the original typhus, it is estimated that between 10 and 20 percent of typhus patients have recurrences (Olson 70), but what the rates were in Austen’s time is unknown. The rate of recurrence of shingles to chickenpox is also 10 to 20 percent, about 500,000 cases in the United States every year (Roxas 102). Brill-Zinsser can be reliably diagnosed through tests so that physicians don’t have to rely on self-report and fallible memories.
In 1910, Nathan Brill described clinical cases of a disease of unknown origin that in 1934 Hans Zinsser showed to be caused by recrudescent typhus (Barrett 1122). Brill-Zinsser is usually described as temperate: “Symptoms and signs are almost always mild and resemble those of epidemic typhus, with similar circulatory disturbances and hepatic [liver], renal [kidney] and CNS [central nervous system] changes. The remittent febrile course lasts about 7 to 10 days. The rash is often evanescent or absent. Mortality is nil” (“Epidemic Typhus”).
A few case studies, however, show that it can also be severe. In the 1990s two Croatian men were diagnosed with Brill-Zinsser: the first, a 59-year-old, had fever, chills, severe frontal headache, photophobia (acute sensitivity to light), meningeal irritation and rash; the other, 62, had enlarged and painful cervical lymph nodes (located in the neck) and atypical pneumonia. Both had fevers of 102-104° F, which lasted for about ten days until the appropriate antibiotic was administered; the fevers disappeared within twenty-four hours (Turčinov et al. 1737). In two other cases, the patients originally caught typhus in concentration camps. A 54-year-old man in California came to a hospital in 1974 with headaches, sore throat, rash, abdominal pain, and a fever that spiked to 103° F. Tests revealed that he had been ill for three weeks with some other infection that had possibly weakened him, and recrudescent typhus in the form of Brill-Zinsser attacked on its heels (Reilly 338). In 1972 a woman in Montreal, 48, was admitted to a hospital suffering from high fever, chills, muscle pain, weakness, anorexia, headache, and a rash. Her fever rose to 104° F, and she suffered visual hallucinations, until treated (Portnoy). All four were cured, but the woman endured malaise for weeks after her successful treatment. The doctors in Montreal concluded: “Not all patients with Brill-Zinsser have a benign course. Some are exceedingly ill and deaths have been reported as a result of this recurrent infection” (Portnoy). So Brill-Zinsser could pass lightly over victims, barely leaving a trace, or it could kill them.
If Austen did have Brill-Zinsser disease with symptoms similar to typhus, why didn’t her doctors recognize it? After all, typhus was common then—epidemic during the wars with America and France—and doctors must have been sadly familiar with it. The truth is that typhus was the last illness they would have considered. Assuming that they were told by Jane or her family members that she had had typhus as a child, they would have ruled it out as a diagnosis. Having had typhus, she was immune to typhus. Without the knowledge that an old infection could recur, diagnosis was an either or proposition: either the condition was typhus, or, if she had had it already, it could not have been typhus. This fact would have been easily validated by observation in times of epidemics: those who had had typhus would not have caught it during an epidemic. An 1858 report comparing typhus and typhoid noted, “An attack of either confers an immunity from future attacks of itself, but not of the other” (Murchison 305). Nicolle said in his Nobel Prize acceptance speech in 1928, “We have known for a long time that primary infection of typhus confers immunity in man in almost all cases and that this immunity lasts a lifetime.”
“In my beginning is my end”
Anyone reading Jane Austen’s letters is left breathless by her accounts of dancing, long walks, shopping, playing the piano, touring London, swimming, exchanging a mind-numbing number of visits, and playing battledore and shuttlecock as well as skittles with raucous nieces and nephews. And, of course, writing six classic novels. Her letters mention several ailments: “hooping cough” (7-8 January 1807), colds (15-17 June 1808 etc.), headaches (29 January 1813 etc.), face pain (15-16 September 1813 etc.), and month-long eye problems (?mid-July 1814). She seems remarkably active and healthy, but there are gaps in her extant letters to Cassandra—only one letter in the four years between May 1801 and April 1805; a space of two years between the letters of January 1809 and April 1811—that might well hide indispositions from us.
In October 1815, she went to London and nursed her brother Henry through “a bilious attack with fever” (17-18 October 1815). He was dosed with barley water and bled, but by November 26 he was still feverish and taking medicine for his stomach and an aperient (laxative). She left in December; if she became ill through infection or from the stress of nursing Henry, it wasn’t immediately apparent. Within seven months, however, symptoms materialized. She wrote her niece, Caroline Austen, on 23 January 1817, “I feel myself getting stronger than I was half a year ago.” “Half a year ago” was late July or early August 1816, the time she was finishing Persuasion. On 4 September 1816 she wrote Cassandra a letter that has been heavily excised: the first two pages and the top of the third are missing (Letters, n. 318). Her first extant reference to failing health is in the next letter, where she talked of a continuing backache (8-9 September 1816). From then on Jane Austen was undoubtedly and openly ill.
Austen reported a sad list of symptoms in her final letters. Some are congruent with Brill-Zinsser, and some aren’t. Mercifully there was no stupor. “I have so many alleviations & comforts to bless the Almighty for!—My head was always clear, & I had scarcely any pain; my cheif sufferings were from feverish nights, weakness & Languor” (22 May 1817). She was even able to write twelve chapters of an interestingly new departure called “Sanditon.” These are the symptoms she recorded:
Bile: “Bile is at the bottom of all I have suffered, which makes it easy to know how to treat myself” (24 January 1817); “I have been suffering from a Bilious attack” (6 April 1817). There were similarities between the symptoms of bilious fever and typhus. Austen noted this when she described the plight of a Mrs. Cooke who was “very dangerously ill, but is now I hope safe. . . . [A]t that time the Disorder was called of the Typhus kind, & their alarm considerable—but yesterday brought me a much better account from Mary; the origin of the complaint being now ascertained to be Billious, & the strong medicines requisite, promising to be effectual” (30 January 1809).
Weakness: “the walk [to Wyards, the home of Anna and Ben Lefroy] is beyond my strength” (16 December 1816); “I . . . can so perfectly well walk to Alton, or back again, without the slightest fatigue that I hope to be able to do both when Summer comes” (23 January 1817); “I am . . . quite equal to walking about & enjoying the Air . . . by sitting down & resting a good while between my Walks, I get exercise enough” (13 March 1817).
Muscle/joint pain: “my Back has given me scarcely any pain for many days.—I have an idea that agitation does it as much harm as fatigue” (8 September 1816); “I am almost entirely cured of my rheumatism; just a little pain in my knee now & then” (20 February 1817); “I have still a tendency to Rheumatism” (26 March 1817).
Fever: “I have had a good deal of fever at times & indifferent nights” (23 March 1817); “a good deal of fever” (6 April 1817).
Discolored skin: I am “recovering my Looks a little, which have been bad enough, black & white & every wrong colour (23 March 1817). Was her skin patchy with these colors, or did they appear in succession? Anna Lefroy called her complexion “mottled” in a memo to James Edward Austen-Leigh for his memoir of Jane: “Her complexion [was] of that rather rare sort . . . A mottled skin, not fair, but perfectly clear & healthy in hue” (158). Or was she troubled by dramatic changes in her coloring, going from one extreme to another including the frightening pallor Caroline Austen remembered from her last visit: “She was very pale” (Le Faye 247)? We don’t know whether the “dusky” faces of typhus patients appeared in sufferers of Brill-Zinsser. The necrosis of typhus seems too extreme to have been considered discoloration.
Weakened nervous system: “I am ashamed to say that the shock of my Uncle’s Will brought on a relapse, & I was so ill on friday & thought myself so likely to be worse that I could not but press for Cassandra’s returning” (6 April 1817).
Discharge and/or hemorrhagic bleeding: “This Discharge was on me for above a week, & as our Alton Apothy did not pretend to be able to cope with it, better advice was called in. Our nearest very good, is at Winchester, where there is a Hospital & capital Surgeons, & one of them attended me, & his applications gradually removed the Evil” (22 May 1817). The discharge might have been of blood, if she suffered a typhus-related illness, because bleeding through the nose, eyes, ears, and mouth, and hemorrhage of the bowels were often noted (Lippe 70-71). In addition, Jane’s mother, Cassandra Austen, wrote Anna Lefroy, “Mr. Lyford [Austen’s attending physician] supposed some large Blood Vessel had given way,” which might have been his explanation for a hemorrhage (Austen-Leigh 230).
I know how to treat myself: With this declaration in the letter of January 24, 1817, Austen brings up the question of treatment. Given the measures described by Philip, the Edinburgh physician, we have to consider to what degree the treatments used to heal her may actually have contributed to her death. Since Henry’s bilious fever was treated with bloodletting and laxatives, it is possible that such weakening treatments were also used on her. Whether she was subjected to the draconian water treatments for her fever, we don’t know. But we do know that mercury was part of the medical arsenal in her family. Her seven-year-old niece Harriet, Charles’s daughter, suffered headaches brought on by “water on the brain.” She was treated with mercury to draw off the water; mercury could be used since she was young enough “not to have the Head hardened” (23 March 1817).
Jane Austen died on July 18, 1817.
Austen’s last years were anything but tranquil. Everything she valued—a secure home with the peace to write—was threatened by Henry’s March 1816 bankruptcy, which imposed financial losses on the family. It also deprived her of the opportunity to build on contacts in London that might have enabled her to secure speedier publication and more money for her writing. Her brother Edward’s legal dispute over his estate, which began in 1814 and was not resolved until after her death, hit at the very core of her security. And the loss of a hoped-for bequest in the will of her uncle, James Leigh-Perrot, that would not only have helped ameliorate the effects of those crises but would also have given her security and perhaps even a few indulgences, was shattering (as the letter of 6 April 1817 suggests). These stressors might well have brought forth a recurrence of a devastating childhood disease.
There are enough similarities between the symptoms of Brill-Zinsser disease and the ailments Jane Austen suffered in her last years to justify proposing it as either the cause of her death or a contributing factor. As with many aspects of Austen’s life, however, we will probably have to reconcile ourselves to never being sure. If Brill-Zinsser was to blame, then her having been sent away to school at seven, from a home where her father took in students, takes on even greater significance. She lost the freedom and indulgence of a treasured child, or as she described it in Emma, “the sports and the nonsense, the freaks and the fancies of a child never banished from home” (461). Jane Austen suffered acutely from the loss of home, a theme that appears in all her novels. That she could have died as a result of that loss is unbearable.
Jane Austen died at 41. Her brother Francis lived to the age of 91. Imagine the additional riches she would have bestowed on the world if she had been given fifty more years. Notes 1. Rickettsia is a family of infectious agents that causes Rocky Mountain spotted fever as well as murine, endemic, and scrub typhus. Typhus is carried by body lice, rarely by head lice. Typhoid fever is a separate illness.
2. For a fuller discussion of the reasons for Austen’s early schooling, see Linda Robinson Walker, “Why Was Jane Austen Sent Away to School at Seven? An Empirical Look at a Vexing Question.”
3. Ann Cawley’s behavior seems inexplicable. It is possible that she too was stricken and simply unable to write. Austen recreated Jane Cooper’s historic rescue of the victims of an evil “Dutchess” in “Henry and Eliza,” written between 1787 and 1790, when she was 11-13. The story, dedicated to Jane Cooper, ends, “[S]he raised an Army, with which she entirely demolished the Dutchess’s Newgate, snug as it was, and by that act, gained the Blessings of thousands, & the Applause of her own Heart” (Minor Works 39).
4. Did Jane Austen nearly die? James Edward Austen-Leigh, Jane Austen’s nephew and biographer, doesn’t mention the illness at all. The tradition seems to have begun with Elizabeth Jenkins. In her 1949 Jane Austen she states unequivocally that “Jane nearly died” (12) but does not cite a contemporary source. Since then, without attribution, later writers have also claimed that the typhus was nearly fatal. These include Halperin (25), Le Faye (49), Nokes (80), Tucker (18), and Tomalin (37). Austen herself mentioned a child dying of typhus away at school, but with no reference to her own illness: “the Welbys have lost their eldest son by a putrid fever at Eton” (7 January 1807).
5. Rev. George Austen was cupped during his last illness (21 January 1805), and Henry Austen, Jane’s brother, had forty ounces of blood taken in two days (17-18 October 1815). Her mother had her blood drawn by leeches (16 September 1813).
6. The word “typhus” is taken from the ancient Greek word for “smoke, vapour, conceit, vanity and stupor” (Compact Edition of the Oxford English Dictionary, 1971) Works Cited Austen, Jane. The Works of Jane Austen. Ed. R. W. Chapman. 3rd ed. Oxford: OUP, 1933-69. _____. Jane Austen’s Letters. Ed. Deirdre Le Faye. Oxford: OUP, 1955. Austen-Leigh, J. E. A Memoir of Jane Austen and Other Family Recollections. Ed. Kathryn Sutherland. Oxford: OUP, 2002. Barrett, Alan D. T., and Lawrence R. Stanberry. “History of Rickettsial Diseases.” Vaccines for Biodefense and Emerging and Neglected Diseases. London: Academic P (Elsevier), 2009. 1122. Cope, [Vincent] Zachary. “Jane Austen’s Last Illness.” British Medical Journal 18 July 1964: 182-83. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1816080/pdf/brmedj02559-0078.pdf Epidemic Typhus: Rickettsiae and Related Organisms.” Merck Manual. 2007. http://www.merck.com/mmpe/sec14/ch177/ch177c.html “Fevers.” The American Cyclopedia: A Popular Dictionary of General Knowledge. Ed. George Ripley and Charles Anderson Dana. Vol. 7. New York: Appleton, 1874. 64-71. [Google Books] Halperin, John. The Life of Jane Austen. Baltimore: Johns Hopkins UP, 1984. Jenkins, Elizabeth. Jane Austen. New York: Minerva, 1949. Kaplan, Laurie. “A Dangerous Indulgence.” Jane Austen’s Regency World 27 July 2004: 22-25. http://www.janeausten.co.uk/regencyworld/pdf/illness.pdf Le Faye, Deirdre. Jane Austen: A Family Record. 2nd ed. Cambridge: CUP, 2004. Lippe, AD. “Hemorrhage in Typhus Fever.” The Hahnemannian Monthly 2.2 (Sept. 1866): 70-72. 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ICAAC Symposium on Emerging Infections 1999. 67-72. Philip, A[lexander] P[hilips] Wilson. A Treatise on Febrile Diseases, Including the Various Species of Fever, and All Diseases Attended with Fever. 3rd ed. Vol. 1. London: Underwood, 1813. [Google Books] Pittendrigh, Barry R., John M. Clark, J. Spencer Johnston, Si Hyeock Lee, Jeanne Romero-Severson, and Gregory A. Dasch. “Proposal for the Sequencing of a New Target Genome: White Paper for a Human Body Louse Genome Project.” http://phumanus.vectorbase.org/sections/Docs/org_docs/phumanus/BodyLouseGenomeWhitePaper.pdf Portnoy, J., J. Mendelson, and B. Clecner. “Brill-Zinsser Disease: Report of a Case in Canada.” CMA Journal lll (20 Jul. 1974): 166. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1947607/pdf/canmedaj01586-0050.pdf Reilly, Philip J., and Robert W. Kalinske. “Brill-Zinsser Disease in North America.” The Western Journal of Medicine 133.4 (Oct. 1980): 338-40. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1272328/ Roxas, Mario. “Herpes Zoster and Postherpetic Neuralgia: Diagnosis and Therapeutic Considerations.” Alternative Medicine Review 11.2 (2006): 102-13. http://www.thorne.com/altmedrev/.fulltext/11/2/102.pdf Shields, Carol. Jane Austen. New York: Penguin, 2001. Taber’s Cyclopedic Medical Dictionary. 20th ed. Philadelphia: Davis, 2005. Tomalin, Claire. Jane Austen, a Life. New York: Knopf, 1997. Tucker, George Holbert. Jane Austen the Woman. 1994. New York: St. Martin’s, 1995. Turčinov, Drago, Ilija Kuzman, and Boris Herendić. “Failure of Azithromycin in Treatment of Brill-Zinsser Disease. Antimicrobial Agents and Chemotherapy 44.6 (June 2000): 1737-38. http://aac.asm.org/cgi/reprint/44/6/1737.pdf “Typhus Fever.” Medical Disability Advisor. MD Guidelines. 1991-2010. http://www.mdguidelines.com/typhus-fever Upfal, Annette. “Jane Austen’s Lifelong Health Problems and Final Illness: New Evidence Points to a Fatal Hodgkin’s Disease and Excludes the Widely Accepted Addison’s.” Medical Humanities 31 (2005): 3-11. http://mh.bmj.com/cgi/content/full/31/1/3 Upham, J. B. “Dr. Upham’s Illustrations of Typhus Fever in Great Britain, Drawn from Original Observations.” Boston Medical Surgery Journal 58 (10 June 1858): 372-78. Vyas, Jatin M. “Typhus.” Medline Plus. 28 Sept. 2008. http://www.nlm.nih.gov/medlineplus/ency/article/001363.htm Walker, Linda Robinson. “Why Was Jane Austen Sent Away to School at Seven? An Empirical Look at a Vexing Question.” Persuasions On-Line 26.1 (Win. 2005). White, Kathryn G. “Jane Austen and Addison’s Disease: An Unconvincing Diagnosis.” Journal of Medical Ethics; Medical Humanities 35 (2009): 98-100. http://press.psprings.co.uk/mp/december/98_mh1453.pdf
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