ORIGINAL ARTICLE

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
A Upfal
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J Med Ethics; Medical Humanities 2005;31:3–11. doi: 10.1136/jmh.2004.000193

Jane Austen is typically described as having excellent
health until the age of 40 and the onset of a mysterious and
fatal illness, initially identified by Sir Zachary Cope in 1964
as Addison’s disease. Her biographers, deceived both by
Cassandra Austen’s destruction of letters containing
medical detail, and the cheerful high spirits of the existing
letters, have seriously underestimated the extent to which
illness affected Austen’s life. A medical history reveals that
she was particularly susceptible to infection, and suffered
unusually severe infective illnesses, as well as a chronic
conjunctivitis that impeded her ability to write. There is
evidence that Austen was already suffering from an
immune deficiency and fatal lymphoma in January 1813,
when her second and most popular novel, Pride and
Prejudice, was published. Four more novels would follow,
written or revised in the shadow of her increasing illness
and debility. Whilst it is impossible now to conclusively
establish the cause of her death, the existing medical
evidence tends to exclude Addison’s disease, and suggests
there is a high possibility that Jane Austen’s fatal illness
was Hodgkin’s disease, a form of lymphoma.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . .

Correspondence to:
Annette Upfal, School of
English, Media Studies and
Art History, The University
of Queensland, Brisbane
Qld 4072, Australia;
a.upfal@uq.edu.au

Accepted for publication
1 March 2005
. . . . . . . . . . . . . . . . . . . . . . .

T
he spectre of disease and early death hung
over Jane Austen in the final 2 years of her
life, as she continued to work on her novels,

whilst her body weakened and wasted and
ultimately failed her at the age of 41. The nature
of her illness had baffled her medical advisors,
and still remains a subject of controversy.
Current medical opinion, biographers, and ency-
clopaedic reference all lean towards a diagnosis
of Addison’s disease, which involves destruction
of the adrenal glands, but other medical opinion
surmises that Jane may have been suffering from
Hodgkin’s disease, a form of cancer. Both
diseases were unidentified and untreatable in
Austen’s lifetime, and the outcome was always
fatal.
The futility of this death from an illness that

now offers recovery, with the image of a dying
writer struggling to use a pencil, when a ‘‘pen
was become too laborious’’1 and above all, regret
for the novels that were yet to be written, have
added a sense of pathos to Austen’s iconic status.
Biographers generally date the onset of this fatal
illness, to the beginning of 1816, and close to her

40th birthday.2 She would live just 18 months
more. The mythic appeal of a ‘genius whose life
is cut tragically short’ magnifies the contrast
between the healthy, vital woman, struck down
by fatal illness at the height of her creative
powers, and the sad, wasted figure she became.
Biographers have also tended to follow this line
and ignore or trivialise previous episodes of
illness that are documented in Jane’s letters.
Deirdre Le Faye, for example, a pre-eminent
Austen authority, remarks that ‘‘up to the end of
1815, Jane had been remarkably free from
ailments.’’ She did qualify this, however, by
adding ‘‘So far as is known’’.3 In fact a medical
history is threaded through the surviving Austen
letters, which reveals that she suffered other, and
unusually severe and debilitating illnesses, and
was particularly susceptible to infection. There
were also episodes of a chronic conjunctivitis
that began in her early twenties, and became
increasingly frequent in later years, impeding her
ability to write. Despite traditional accounts, this
was not a case of a healthy person being
suddenly struck down with a fatal illness. New
medical evidence suggests that Jane was already
suffering from an immune deficiency and fatal
lymphoma in January 1813, when her second
and most popular novel, Pride and Prejudice, was
published. Four more novels would follow over
the next 5 years, written or revised in the shadow
of her increasing illness and debility. The final
novel, Persuasion, was published in January 1818.
But Jane had died 6 months earlier on 18 July
1817, and a fragment of a new novel lay
abandoned in her writing desk. Whilst it is
impossible now to conclusively establish the
cause of her death, the existing medical evidence
tends to exclude Addison’s disease, and suggests
there is a high possibility that Jane’s fatal illness
was Hodgkin’s disease, a form of lymphoma.
The importance of a close examination of Jane

Austen’s medical history goes far beyond the
satisfaction of establishing a retrospective diag-
nosis for her various symptoms, and intended for
an audience of medical professionals. Its sig-
nificance should be seen rather against a context
of the scant documentary evidence of Jane’s life,
and an intense public interest in everything
relating to her. The first biography, a Memoir, was
published in 1870. The early trickle of interest
since that date has become an avalanche of titles
concerning her in the past 50 years, with every
known aspect of her life and work placed under
scrutiny. But through it all, Jane Austen, the
person, remains an enigmatic and elusive figure.

3

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There is so much in her life that is missing. She kept no
diaries or personal journals, and her most revealing letters
were destroyed by her sister Cassandra after her death. Other
material was lost or distorted by family members half a
century later, in an effort to present a sanitised version of her
life, and it is very unlikely now that any new letter or
personal remembrance will emerge. The biographer is left to
rescan the existing inadequate evidence, and sometimes, very
rarely as in this case, the letters yield up something exciting
and new. These seemingly nondescript scraps of medical
history lead to insights that transcend the barriers of
Cassandra’s ruthless culling, and at times are startling and
almost voyeuristic in their intimacy. Knowledge of the illness
provides the detail of symptoms that would have been
excluded from the letters. Le Faye, the most recent editor of
Jane Austen’ Letters, notes that some letters have a line cut out,
relating to ‘‘physical ailment’’ and considers that Cassandra
simply destroyed any letter that ‘‘described physical symp-
toms rather too fully’’.4 A detailed medical history reveals the
extent to which illness impacted on Austen’s life, on family
relationships, on her ability to work, and even left its traces
on the last manuscripts. It offers a tangible impression of
Jane, the woman, coping with illness whenever possible, by
cheerfully dismissing it from her mind, and later struggling
to maintain her own good humour and a sense of normalcy
in her life, as the symptoms of disease overwhelmed her
body.
Illness was to dominate the first few months of her life as

well as the last. Her nephew and first biographer, JE Austen
Leigh, faced with an almost total lack of family letters or
other evidence was forced to admit that he knew ‘‘little of
Jane Austen’s childhood.’’5 By some quirk of chance, a family
letter describing her birth at Steventon Rectory on 16
December 1775 has survived, and forms an important, first
suggestion of a serious medical problem. Jane was born
4 weeks overdue, according to her parents’ calculations. Her
father even made a joke about it in this letter to his sister-in-
law, Susanna Walter.

Dear Sister,
You have doubtless been for some time in expectation of
hearing from Hampshire, and perhaps wondered a little
we were in our old age grown such bad reckoners but so it
was, for Cassy certainly expected to have been brought to
bed a month ago.6

But was it just a case of bad reckoning? It seems very
unlikely considering that the Austens had six children
already and from the evidence of this letter, had never
previously miscalculated their dates. Birth was always a
worrying and disruptive time for any family. Childbirth was
managed at home without medical assistance, and even if the
birth were trouble free, the new mother would be kept in bed
for at least 2 weeks. Somebody else would have to run the
household and arrangements were made well in advance. It
was vital to these arrangements that the estimated confine-
ment date was as accurate as possible. It was simply too
important to get wrong.
A normal pregnancy is calculated as 40 weeks from the last

menstrual period, and over 80% of births occur between the
38th and 42nd week. Only 5% continue, as in Jane’s case,
after the 43rd week.7 A pregnancy that continues after
42 weeks is considered postdate, and the fetus may be
severely at risk. There is a heightened risk of birth injury or
death, and over 20% of postdate infants show signs of
wasting of tissues - a medical condition known as post-
maturity, which in severe cases can be fatal. If a pregnancy is
postdate, the modern obstetrician will usually order tests to

monitor the fetus and to decide whether or not to intervene.
In the 18th Century it was a matter of letting nature take its
course.
The postmature infant was described by the classic

authority, SH Clifford,8 as showing signs of late-onset
wasting of tissue, due to placental insufficiency. If a
pregnancy is prolonged, the placenta begins to degenerate
and the fetus may receive inadequate nutrients from the
mother, resulting in soft tissue wasting.9

According to her father’s description, Jane Austen seemed
normal at birth, and this is quite consistent with post-
maturity:

Last night the time came, and without a great deal of
warning, everything was soon happily over. We have now
another girl, a present plaything for her sister Cassy and a
future companion. She is to be Jenny and seems to me as if
she would be as like Henry, as Cassy is to Neddy.10

The fetus continues to grow in the womb and the infant is
long and thin, with some tissue wasting. It is interesting that
George Austen noted a close resemblance to his fourth son,
Henry, born 4 years earlier. Both children had hazel eyes, but
Henry was also very tall for his age.11 and the father must
have noticed that this baby too, seemed quite long.
A close inspection of the baby may have shown signs of

tissue wasting, which caused the skin to hang in loose folds,
especially on the arms and legs. There would be signs in
behaviour as well, including listlessness, irritability, and
feeding problems which would persist for some time, with
the baby failing to thrive, and incessantly irritable. Various
studies reveal the stress placed on the mother-child relation-
ship, with postmature babies described as ‘‘difficult’’ by their
mothers. They also had more severe illnesses in the first year
of life. These findings also applied to postdate babies who did
not show obvious signs of tissue wasting at birth, and the
problems were more severe for those born after 43 weeks
(Sims, p 291).7

Jane would have been frail and probably ill in the first
months of her life and this seems to be confirmed by her
christening in the church being delayed until she was almost
four months old (Le Faye, p 27).3 According to Mrs. Austen’s
child-rearing practice, the baby was weaned at 3 months, and
then sent to a ‘‘good woman’s’’ for at least a year, a farm
worker’s wife, who lived in the nearby village of Deane.12

Jane was moved there sometime after her April christening,
and certainly before the first week of June, when her parents
were on holiday in London.13

The circumstances of Jane’s birth raise the possibility of an
immune deficiency, related to postmaturity, (Beers, p 1026)9

and her medical history of both unusually severe infections
and chronic infection, is consistent with an immune dis-
order. But there is also a compelling argument against this. A
child with an immune deficiency in the 18th Century would
be extraordinarily lucky to survive to adult life. Most
disorders that present from birth would render her suscep-
tible to fatal chicken pox, or if she were lucky enough to
survive, she would have been at the very least severely
disabled by it. One factor, however, that might have
preserved the young Jane’s life was the isolated location of
her family home, and consequent lack of exposure to
childhood epidemics.
Steventon, Jane’s loved home for the first 25 years of her

life, was a remote village in the Hampshire Downs, about
7 miles south-west of Basingstoke. Access was by a narrow
and winding dirt lane, full of potholes, and in wet weather
became virtually impassable. The village itself was just a
straggle of farm labourers’ thatched cottages, each with its

4 Upfal

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own small garden, and set in a pretty, wooded valley close to
a stream and the village green. The rectory was a short
distance from the end of the village, and stood on the corner
of a 3-acre block, with its own dairy and small farm, and a
tiny stone church high on the hill behind it, just glimpsed
behind a screen of sycamores and elms.
Reverend George Austen leased a nearby 200-acre farm as

well as farming his own glebe land. Mrs Austen had her
dairy, poultry yard, piggery, vegetable garden, and beehives
to supply the house. Bread was baked, and beer was brewed
and stored in the cellar, together with a large supply of Mrs
Austen’s honey mead and some homemade wine. The
rectory’s self-sufficiency extended to the education of the
children. The Austen boys were educated at home by their
father, until entering university or the navy. Apart from two
brief periods, he supervised the formal education of his
daughters as well. The Austen biographer Claire Tomalin
notes that in an age when ‘‘few families were spared the
deaths of several children,’’ the Austens did not lose a single
one of their eight children (Tomalin, p 6).2

According to family tradition, Jane did become danger-
ously ill however, within a few months of being sent away to
school. In April 1783, Jane, aged 7 and Cassandra, 10, were
sent with their 12 year old cousin Jane Cooper to Oxford, to
board with Mrs Ann Cawley, the widowed sister of Dr
Cooper. Sometime later in the year Mrs Cawley moved her
few pupil boarders to Southampton and was soon in the
midst of an epidemic of ‘‘putrid fever’’, which was raging in
this town by late August. Jane and Cassandra were both
infected, but Mrs Cawley did not inform their parents (Le
Faye, pp 47-49).3 Fortunately, Jane Cooper wrote to her own
mother, who came immediately in her carriage to rescue all
three and move them to her home in Bath.14 In some
accounts both Mrs Austen and Mrs Cooper arrived to take
their daughters home, but all agree that Jane Austen nearly
died of this illness. In one version her life was saved by a
remedy that the mothers brought with them.15

The ‘‘putrid fever’’ was in fact epidemic typhus, brought to
Southampton that August by troops returning from service in
Gibraltar (Le Faye, p 48).3 It is associated with cramped,
insanitary conditions, and transmitted to humans in faeces of
the human body louse. The symptoms include a constant
headache and high temperature. About the fourth day the
characteristic pink spots appear and rapidly darken and cover
the whole body, only excluding the face, palms and soles of
the feet. After 14 days, in uncomplicated cases, the
temperature drops and the patient spontaneously recovers.
The disease can be extremely serious in adults, and mortality
increases with age, and is as high as 60% in persons aged 50
years or more (Beers, p 1228).9 Mrs Cooper was 47 years of
age, and became fatally infected and died at her home in
Bath on October 25th. In these fatal cases, death occurs from
heart failure about day 14 of the illness.16

Mrs Cawley may have been negligent in not contacting the
Austens, but perhaps she was aware that this disease is
characteristically mild in children up to the age of ten.17 In
any case, it would have been out of the question to take the
girls home to the rectory, where they might introduce the
infection to their brothers, or worse still, Mr Austen’s 3 or 4
pupil boarders. The fear of infection in an age when no
adequate treatment was available, is reflected in Sense and
Sensibility in the Palmer family’s immediate abandonment of
their home when Marianne Dashwood’s illness is described
by the apothecary as ‘‘having a putrid tendency’’ and he
allows ‘‘the word ‘infection’ to pass his lips.’’18 Mrs Palmer
had left with her baby within the same hour.
No other scrap of medical evidence remains from Jane’s

childhood. The major resource for a medical history consists
of her own surviving letters, including 97 to her sister

Cassandra, written over a 20 year period. Unfortunately,
these only date to 1796, when Jane was already aged 20.
Despite Cassandra’s censorship, these letters, supplemented
by other evidence, do provide medical insights, and reveal for
example that Jane suffered from chronic conjunctivitis, with
the first episode occurring in January 1799, when she was
aged 23:

Wednesday – I have had a cold and weakness in one of
my eyes for some days, which makes writing neither very
pleasant nor very profitable, and will probably prevent my
finishing this letter myself. My Mother has undertaken to
do it for me. . . .
This complaint in my eye has been a sad bore to me, for I
have not been able to read or work in any comfort since
Friday, but one advantage will be derived from it, for I
shall be such a proficient in music by the time I have got rid
of my cold, that I shall be perfectly qualified in that science
at least to take Mr Roope’s office at Eastwell next
summer.19

In a letter written 2 weeks later, the problem had
worsened, and spread to both eyes,20 indicating a viral
infection.21 The first symptoms would seem like a ‘‘cold in
the eye’’ with redness, watering, and itching, followed by
sensitivity to light, (photophobia), and discomfort that could
quickly become severe. The eyelids would look sore and swol-
len. This condition is often called ‘‘red eye’’ because of bleed-
ing under the conjunctiva, and the white of the eye becomes
bright red either in part, or totally (Macpherson, p 214).16

The discomfort of her eye did not prevent her from
attending a ball a few nights later, but her account of this ball
contains the rueful comment ‘‘I do not think I was very much
in request—People were rather apt not to ask me till they
could not help it;—One’s consequence you know varies so
much at times without any particular reason.’’22

Biographers have seized upon this statement as evidence
that Jane, unlike the heroines of her novels, was physically
unattractive. But a young lady at a ball who was suffering
from the ‘red eye’ was unlikely to be ‘very much in request’. It
not only affected her appearance. Her partners would be
concerned about catching a possible infection. No wonder
gentlemen were ‘apt not to ask till they could not help it.’ Her
last comment gives an insight into the way she viewed her
own illness. She had dismissed the problem of her sore eye so
effectively from her mind, she was unconscious of its effect
on others.
She attended another ball the following week, with a

predictable aggravation of her symptoms.

My eyes have been very indifferent . . . keeping them so
many hours open on Thursday night, as well as the dust of
the ball-room, injured them a good deal. I use them as little
as I can, but you know and Elizabeth knows, and
everybody who ever had weak eyes knows, how delightful
it is to hurt them by employment, against the advice and
entreaty of all one’s friends.23

There is no cure for the virus, and treatment, then, as now,
would focus on relief of symptoms, and avoiding further
environmental irritants. Cold compresses and lubricants
might be used, and the patient restricted to a dark
environment. Recovery is usually spontaneous within 3 to
6 weeks. But in severe cases, that continue longer, there is
inflammation of the cornea (keratitis), with marked photo-
phobia, pain in the eyes, and some temporary blurring of
vision (Barza, p 799).21

Jane Austen’s lifelong health problems and final illness 5

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Jane’s case must have been severe, because there is a
reference to her eyes in the next surviving letter, written
4 months later, a day after her arrival in Bath on a family
visit. ‘‘I find no difficulty in doing my eyes.’’24 This comment
implies that Cassandra had been acting as nurse, and
treatment for the conjunctivitis was still necessary.
The January letters describe the onset of acute conjuncti-

vitis. By May, the infection had become chronic, and would
persist, with remissions and recurrences over the years. At
first there might be long gaps between recurrences, and the
attacks would never be as long or severe as that first episode.
In the final years of her life, the recurrences would be more

frequent and disabling. In September 1813, she was staying
with her brother Henry at his house in London, and there is
the one exasperated comment. ‘‘My eyes are quite tired of
dust and lamps.’’25 Her niece Caroline Austen, who as a child
often visited the Austen cottage at Chawton, also remem-
bered Aunt Jane having problems with her eyes:

She could throw the spilikens for us, better than anyone
else, and she was wonderfully successful at cup and ball—
She found a resource sometimes in that simple game,
when she suffered from weak eyes and could not work or
read for long together.26

Years earlier, in that first episode of acute conjunctivitis,
Jane had expressed her frustration at not being able to read
or work as she wished. But she was a young woman then,
with hopes and interests quite apart from her writing. At
Chawton, her writing and books was the centre of her life.
She tried to ignore the increasing symptoms of her disease,
and continued to write, only to be defeated at times by
episodes of conjunctivitis, when the work had to be put aside.
The first major period of creative writing was at Steventon,

although her work was not published until many years later.
Jane was aged 20, the same age as Elizabeth Bennet when
she wrote the first draft of Pride and Prejudice. The early
versions of Sense and Sensibility and Northanger Abbey were also
written in this period. According to family tradition, Jane,
then aged 25, was so distressed to leave Steventon that she
fainted on being suddenly told that her father was retiring
and they were moving immediately to Bath.27 After their
arrival in May 1801, there is a gap of more than 3 years in the
letters, a sure sign of problems, which Cassandra censored.
Mr Austen died in January 1805, leaving his widow with a
tiny income, which was supplemented annually by her sons.
Jane herself was penniless. The three Austen women had no
settled home, and were expected to save expenses by making
long visits amongst their relatives.28

On 2 July 1806, they made a final move from the cheap
lodgings in Bath, and, as Jane later expressed it, ‘‘with what
happy feelings of escape!’’29 The trio then set off on a round of
family visits, where Jane became infected with an unusually
severe case of pertussis or whooping cough, whilst staying
with their rich Cooper relatives in Staffordshire. The Austens
arrived on 14 August, and remained for about 5 weeks, as one
by one, the young Cooper children went down with this
illness (Le Faye, pp 157-8).3 In this case there was no
question of leaving to escape the infection. Whooping cough
was then overwhelmingly a disease of babies and young
children, and adults were not considered to be at risk. The
disease is very uncommon after the age of ten (Macpherson,
p 634).16 If an adult is infected, the symptoms are usually
mild, and described as catarrhal, and the duration of the
illness is short and considered as ‘‘troublesome, but rarely
serious’’ (Beers, p 2308).9

Towards the end of their stay, Jane contracted the
infection, and by the time the Austens reached their new

lodgings in Southampton on 10 October, she was becoming
progressively worse.
Whooping cough usually resolves within 3 to 4 weeks, but

severe cases can persist up to 3 months. As the illness
progresses to the second or spasmodic stage, the patient
develops the frequently recurring attacks of violent and
convulsive coughing, followed by the whoop, a loud and
distinctive in drawing of breath. Large amounts of mucus are
expelled and there is frequent vomiting. This stage usually
lasts 2 weeks, but in severe cases can continue for more than
a month, and often with respiratory complications, including
broncho-pneumonia (Beers, pp 2306-8).9

There is one surviving reference by Jane Austen to this
illness, in a letter written 2 months later to Cassandra:

A few days ago, I had a letter from Miss Irvine . . . She
supposes my silence may have proceeded from resentment
of her not having written to inquire particularly after my
hooping cough, and […]. She is a funny one.30

Miss Irvine was a distant relative and family acquaintance
who lived in Bath. If news of Jane’s whooping cough had
circulated even amongst her acquaintances in Bath, she must
have been seriously ill, and her own family had been
concerned for her recovery. The second stage of the illness
was severe and prolonged enough for Cassandra to send out
anxious letters to family members and friends, and for letters
of enquiry to be made to Southampton about her progress.
Miss Irvine obviously felt guilty that she had not ‘‘inquired
particularly.’’
Jane’s letters from Southampton show that in October

1808 she suffered another infective illness, which may also
have become chronic.

Saturday, October 1—Mr Lyford called on tuesday to say
that he was disappointed of his son and daughter’s
coming, and must go home himself the following morng;—
and as I was determined that he should not lose every
pleasure I consulted him on my complaint. He recom-
mended cotton moistened with oil of sweet almonds, and it
has done me good.—I hope therefore to have nothing
more to do with Eliza’s receipt than to feel obliged to her
for giving it as I very sincerely do.31

The complaint is revealed in her next letter as being with
her ear, and she mentioned hearing loss. Mr Lyford was the
elderly surgeon who had looked after the Austens at
Steventon, and knew the family very well due to his frequent
attendances on Mrs Austen. His call on them at Southampton
was a social visit. It is interesting the way Jane trivialises her
need for medical advice, and jokes that it is all for Mr Lyford’s
benefit. In fact her symptoms had been severe and prolonged
enough for Cassandra to enclose a suggested remedy with the
letter Jane had received that day from Godmersham in Kent.
Jane was almost certainly suffering from otitis externa, an

infection of the outer ear, and possibly associated with a
painful boil in her ear. Her symptoms would have included
itching and severe pain accompanied by a foul smelling
discharge. There would be a gradual onset of hearing loss as
the ear canal became swollen and filled with debris from the
discharge (Beers, p 669).9 These symptoms had persisted for
more than 2 weeks in her case, and must have been very
distressing.
If the itching is treated, the inflammation will usually

subside. The modern treatment would probably include
removing the infected debris, ‘‘followed by careful packing
of the external ear with some soothing lotion’’ (Macpherson,
p 182).16 This is essentially the same treatment that Mr Lyford

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prescribed. Oil of sweet almonds is a soothing and non-
allergenic oil that is still used in alternative medicine to treat
eczema or dermatitis. Mr Lyford’s advice was to pack the ear
with a piece of cotton material that had been moistened with
the oil. The treatment was effective. A week later, Jane
described herself as cured. ‘‘I am much obliged to you for
enquiring about my ear, and am happy to say that Mr
Lyford’s prescription has entirely cured me. I feel it a great
blessing to hear again.’’32 There are no further references to
ear problems in her letters, although there were probably
recurrent episodes of otitis. But she could now manage the
infection and treat the symptoms as soon as they appeared.
Jane’s history of unusually severe and chronic infections

suggests an immune deficiency or perhaps the presence of
some underlying infection such as Tuberculosis, which was
then very common. In early Tuberculosis, the disease may
remain latent for years or have no overt symptoms
(Macpherson, p 601).16 But in the absence of further
evidence, this issue cannot be resolved, and remains
speculative.
Early in 1809 Jane’s immensely wealthy brother Edward

Austen Knight finally offered his mother the rent free
occupancy of one of the houses he owned in Chawton
village, close to his own estate. It was Jane’s first settled
home in the 8 years since leaving Steventon Rectory, and
she lived there for the rest of her life. Her novels were
published in this Chawton period, with Sense and Sensibility
appearing in October 1811. There is a gap in the letters from
January 1809 to April 1811, and again from June 1811 until
the end of October, 1812. The letters that Cassandra
destroyed may have included references to new medical
problems, and it is possible that Jane contracted her fatal
disease during this period. The nature of this disease remains
controversial, and apart from the widely accepted Addison’s
disease, other possibilities might include leukemia, Hodgkin’s
disease, non Hodgkin’s lymphoma, Tuberculosis, and sys-
temic Vasculitis. But the evidence provided in Jane’s letters of
1813, points to the presence of a lymphoma, possibly
Hodgkin’s disease.
In January 1813, Pride and Prejudice was published, and a

few months later Jane was experiencing symptoms of severe
neuralgia, mainly documented in the diary of her niece,
Fanny Knight. Edward and his family occupied the Great
House at Chawton that summer whilst their main residence,
Godmersham, was being painted. The Great House was just a
short walk from the Austen cottage, and there are frequent
references to Aunts Jane and Cassandra in the diary. On 18
July there is an entry of Aunt Jane suffering from ‘‘a bad face
ache,’’ and episodes of pain continue for at least the next
2 weeks. On 2 August Fanny notes that Aunt Jane ‘‘slept here
and suffered sadly with her face.’’33

These episodes of neuralgia persisted. On 15 September,
Jane had just arrived at her brother Henry’s house in London
with the Knights and would continue with them to
Godmersham. The following day she wrote reassuringly to
Cassandra that she had ‘‘no pain in my face since I left
you.’’34 But a week later, at Godmersham, she admitted that
the pain had returned, and ‘‘rather severer than it had been
lately. This has worn off however and I have scarcely felt
anything for the last two days’’.35

These symptoms describe a facial or trigeminal neuralgia
associated with a previous infection of herpes zoster or
shingles. This most severe form of neuralgia involves any one
of the three divisions of the trigeminal nerve of sensation to
the face. In herpes zoster, a virus invades the ganglia of the
nerves, causing inflammation, and the resulting severe pain.
Sometimes however, there is post herpatic pain that may
recur over months or even years. In cases of immune
deficiency, the acute stage of the infection may exceed

2 weeks, and the post herpatic pain is likely to persist longer
and to be more severe (Beers, pp 1294-5).9

Herpes zoster is caused by the varicella-zoster virus, the
same virus involved in chicken pox, but zoster is a disease of
adults rather than children. Zoster occurs most often in
immune-depressed or elderly persons. ‘‘Most adults who
acquire the disease have had chicken pox in childhood’’
(Macpherson, p 275).16

Fanny Knight’s younger sister Lizzie also remembered her
aunt’s sufferings with neuralgia. She described how some-
times she saw Aunt Jane walking along the path from
Chawton village to the Great House, and obviously in pain,
‘‘with head a little to one side, and sometimes a very small
cushion pressed against her cheek, if she were suffering from
face-ache, as she not unfrequently did in later life’’ (Le Faye,
p 27).33

Jane Austen’s neuralgia affected the second division of the
nerve and the pain would have been focused in the cheek and
upper jaw. The pain affected one side of the face, and would
be episodic, sometimes recurring about the same time each
day whilst the attack lasted. Pain could also be precipitated
by cold, or by taking a mouthful of hot or cold fluid. One
medical text describes the pain as ‘‘devastating’’, and that
for some patients who suffer frequent attacks, ‘‘the pain
may be so intolerable as to make life a burden’’ (Macpherson,
p 598).16

Jane was a very private person, and the pain must have
been intense for her to walk out in public with a cushion
pressed to her face. It also shows the level of her
determination to disregard pain and illness. Most people
would have remained at home and tried to relieve the
symptoms. She continued her social engagements with her
family, even though the walk to the Great House was enough
to bring on the pain. There was pain every day, but that
didn’t stop her from making the journey to London and
Godmersham. Far from feeling that life was a burden, the
letters she wrote in the midst of the attack are quite cheerful.
In that first letter from Godmersham, she is in ‘‘high glee’’
and ‘‘delighted.’’ The letter begins and ends with a joke.36

Herpes zoster is very unusual in a young person, and
indicates a pre-existing immune deficiency, associated with a
lymphoma, such as Hodgkin’s disease. In Jane’s case, this
must have pre-dated 1813. It is even possible that Jane
already had a fatal lymphoma when her first novel, Sense and
Sensibility was published in October 1811.
The herpes zoster virus can be activated by systemic

disease, particularly Hodgkin’s disease. Infections with
herpes zoster are common in patients with this disease.37

The relationship is so pronounced that one study recom-
mends that patients diagnosed with Hodgkin’s disease be
educated in early self-diagnosis of herpes zoster in order to
receive prompt treatment.38 Hodgkin’s disease is a form of
cancer, and in Jane’s time, there was no possible treatment.
There is persuasive evidence that Jane suffered from
Hodgkin’s disease, and within a few years it would end her
life.
Recent medical evidence suggests a close association

between Hodgkin’s disease and a previous history of
infectious mononucleosis (glandular fever).39 Glandular fever
is commonly described as the ‘‘kissing disease’’ which is
hardly compatible with the familiar image of Jane as a prim
and inexperienced spinster. In fact that image is very
misleading. In her youth, at Steventon, ‘‘she was established
as a very pretty girl,’’ (Austen, p 5)26 and attended balls and
assemblies at the age of sixteen. The few surviving letters of
her early twenties suggest that Jane was quite adept at light-
hearted flirtations. There is a reference to one unwanted
admirer trying to steal a kiss, whilst another tried to trap her
alone with him, and in another letter she has been reproved

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by Cassandra for openly flirting with a young man at a
private ball. One rather malicious former neighbour described
Jane in the Steventon years as ‘‘the prettiest, silliest, most
affected husband-hunting butterfly she ever remembers’’ (Le
Faye, p 81).3 Glandular fever is more common among
adolescents aged 15–17,’’ (Macpherson, p 381)16 and whilst
no records remain for those years of her life, it cannot be
excluded.
Hodgkins disease, or lymphadenoma is a ‘‘condition in

which the lymphatic glands all over the body undergo a
gradually progressive enlargement’’ (Macpherson, p 277).16

The cause is unknown, but there is evidence suggesting an
association with a pre-existing immune deficiency.40 As the
disease spreads there can be a wide range of symptoms,
including gastric and bone involvement. There is a consider-
able degree of anaemia, and the patient becomes progres-
sively weaker. The progress of the disease can be slow or
intermittent, with periods when the patient feels some
improvement. The outcome however, before modern che-
motherapy and radiotherapy, was always fatal.
In 1814, the letters are cheerful as ever, although once

again a small batch of letters have been destroyed. Pride and
Prejudice had proved a great success and Mansfield Park was
published in May. Jane also began writing a new novel,
Emma, in January. Her brother Henry acted as her agent in
negotiations with publishers and Jane needed to visit him in
London three times this year. There are a few references in
the letters to tiredness, but no specific mention of illness
other than a cold.41

In early March 1815, in a letter to her niece, Anna Lefroy,
Jane seems to have been referring to an episode of illness.
Unfortunately, most of the page has been torn away. Only a
scrap remains at the bottom, and continues ‘‘I cannot
flourish in this east wind, which is quite against my skin
and conscience’’.42 Typically, she has trivialised her illness,
and turned it into a joke.
Cold weather itch is quite common in winter, when the

skin tends to become dry, and Jane seemed to be blaming the
effect of the cold east wind on her skin. But itching, or
pruritis, without skin rash, can be an early symptom of
Hodgkin’s disease, particularly in women.43 It is also a
common complaint of patients with this disease and it has
been reported that over 85% of patients will experience
pruritis at some stage of their illness (Kaplan, p 120).37 ‘‘It is
characterised by symptoms of burning and intense itching
occurring on a localized skin area, usually the lower legs’’
(Cavalli, p 109).43 As the disease advances, the pruritis
becomes generalized. The itching is severe enough to induce
intensive scratching, leading to multiple, blood encrusted
excoriations and scabs on the trunk and/or lower legs
(Kaplan, p 120).37

Any further references to this illness have not survived.
After this letter, there is a gap of 6 months before the letters
begin again. In August 1815 Jane Austen began work on
Persuasion. The writing would continue somehow through
increasing bouts of illness and family problems.
A family crisis occurred in October, when Henry Austen

suffered a life threatening illness. His sister Jane was staying
with him in London at the time, whilst he helped her to
arrange the publication of Emma. She wrote to Cassandra on
17 October, describing Henry as ‘‘not quite well – a bilious
attack with fever.’’44 Cassandra seems to have destroyed the
letters that quickly followed, with their details of Henry’s
deterioration and danger. Just 1 week later, Henry was
thought to be dying. His brothers Edward and James and
sister, Cassandra, came immediately to London and the
brothers were there a week until Henry was out of danger.
Cassandra however, was away from Chawton for a month,
which must have been extremely inconvenient for James

Austen’s wife, Mary, who had to stay with Mrs Austen until
Cassandra’s return.45 This arrangement could only be justified
if Jane was also ill or at least not well enough to nurse her
brother. Jane’s illness seems to be confirmed by Caroline
Austen’s report that ‘‘In the earlier stages of her malady, my
Aunt had had the advice, in London, of one of the eminent
physicians of the day’’ (Austen, p 15).26 This was probably Dr
Matthew Baillie, who was treating Henry Austen in this
illness, and was one of the Prince Regent’s physicians
(Le Faye, p 225).3 She may have consulted him about the
pruritis, and other unspecified symptoms. Emma was
published at the end of December, 2 weeks after Jane had
returned to Chawton, and she never visited London again.
Henry Austen in his Biographical Notice of Jane Austen wrote

that ‘‘the symptoms of a decay, deep and incurable, began to
show themselves in the commencement of 1816. Her decline
was at first deceitfully slow; and until the spring of this
present year [1817], those who knew their happiness to be
involved in her existence could not endure to despair’’
(Austen, p 138).1

Biographers have accepted this dating as the beginning of
her illness, but it can also be interpreted as the date when
family members realised that something was seriously
wrong. Her niece Caroline also considered that ‘‘Aunt
Jane’s health began to fail some time before we knew she
was really ill’’ (Austen, p 13).26 In March 1816, there was a
new family crisis when Henry Austen was declared bankrupt
following the sudden failure of his London bank, and his
brothers suffered heavy losses as well’’ (Austen, p 47).45

Jane’s health also was deteriorating. At the beginning of
May, Edward Knight and his daughter Fanny came to
Chawton cottage for 3 weeks, but Jane was too weak to
accompany Cassandra and Fanny on their daily walks. The
day after the Knights returned to Kent, Jane and Cassandra
set off to try the spa waters of Cheltenham for 2 weeks.
Johanna Schopenhauer, who visited Cheltenham in this
Regency period, noted in her travel diary that this spa catered
especially for those with ‘‘skin ailments, scurvy and such
complaints.’’46 Jane may have been seeking treatment for her
skin and the worsening problem of the pruritis.
On their way home, the sisters paid a visit to very old

friends, the Fowle family at Kintbury. During their stay, the
family ‘‘received an impression that Jane’s health was failing
– altho’ they did not know of any particular malady’’
(Austen, page 14).26 When they returned home on 15 June,
Jane was even weaker and needed the donkey carriage to
move about. In July, she attributed a pain in her back to her
distress on Cassandra going away for a few weeks. Despite
her illness, she completed Persuasion in August. In September,
the family called in a well-known physician, Dr. White, for
his opinion. Typically, Jane laughed about this visit, and
intended ‘‘nursing myself up now, into as beautiful a state as
I can.’’47

Through the first months of winter, she felt that she was
improving, and this is quite consistent with the progress of
Hodgkin’s disease. On 23 January 1817, Jane noted that she
was ‘‘getting stronger than I was half a year ago,’’48 and a
letter to a close friend the following day is just as optimistic.
She added, ‘‘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.’’49

Three days later, in this spirit of optimism, she began work
on a new novel, the fragment now known as Sanditon, and
worked steadily through February and into March.
On 20 February she wrote to her favourite niece Fanny that

‘‘I am almost entirely cured of my rheumatism; just a little
pain in my knee now and then, to make me remember what
it was and keep on flannel, - Aunt Cassandra nursed me so
beautifully.’’50 On 13 March she wrote hopefully ‘‘I am got

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tolerably well again,’’51 but on 18 March she abandoned the
manuscript after a severe bout of illness.
On 23 March she wrote to Fanny again, including a

description of other and distressing symptoms:

Many thanks for your kind care for my health; I certainly
have not been 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.52

The rest of this long letter is full of family news and good
humour, and characteristically begins with a joke. But just
1 week later, there was another severe episode of ‘‘Bilious
attack, attended with a good deal of fever’’, and Jane’s letter
to her brother Charles on 6 April attributes this ‘‘relapse’’ of
her ‘‘complaint’’ to the shock of her uncle’s will.53

Jane’s 12 year old niece, Caroline Austen, saw her, for the
last time, during the early part of April. Aunt Jane was
keeping to her room, and the visit was a very short one.
‘‘I was struck by the alteration in herself - She was very
pale - her voice was weak and low and there was about
her, a general appearance of debility and suffering’’ (Austen,
p 15).26 A few days after Caroline’s visit, there was another
episode of fever, which Jane described in her letter of
Thursday 22 May:

An attack of my sad complaint seized me . . . the most
severe I ever had - and coming upon me after weeks of
indisposition, it reduced me very low. I have kept my bed
since the 13.of April, with only removals to a Sopha. Now,
I am getting well again, and indeed have been gradually
tho’ slowly recovering my strength for the last three weeks.
I can sit up in my bed & employ myself . . . My head was
always clear, and I had scarcely any pain; my cheif
sufferings were from feverish nights, weakness and
Languor. - This Discharge was on me for above a week,
& as our Alton Apoth 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 and capital
Surgeons, and one of them attended me, and his
applications gradually removed the Evil. - The conse-
quence is, that instead of going to Town to put myself into
the hands of some Physician as I should otherwise have
done, I am going to Winchester instead.54

Despite the optimistic tone of this letter, she had secretly
written her will on 27 April, and left it, unwitnessed, in her
writing case (Le Faye, p 248).3 On 27 May, she wrote cheer-
fully from Winchester, but in a shaky, uneven hand. ‘‘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.’’55 Two days later she states that:

My attendant is encouraging, and talks of making me
quite well. I live chiefly on the sofa, but am allowed to walk
from one room to the other.56

But immediately after this letter, the fever returned again.
Jane’s brother James made frequent visits to Winchester, and
wrote to his son, James Edward, on 12 June, preparing him
for news of Jane’s death.

The symptoms which returned after the first four or five
days at Winchester [30 May] have never subsided, and

Mr. Lyford has candidly told us that her case is desperate. .
. . It is some consolation to know that our poor invalid has
hitherto felt no very severe pain - which is rather an
extraordinary circumstance in her complaint. I saw her on
Tuesday [10 June] and found her much altered, but
composed and cheerful. She is well aware of her situation
. . . Lyford said he saw no signs of immediate dissolution,
but added with such a pulse it was impossible for any
person to last long.57

But the following day:

Suddenly she became much worse - Mr. Lyford thought the
end was near at hand, and she believed herself to be
dying - and under this conviction she said all she wished to
say to those around her (Austen, pp 16-17).26

The youngest brother Charles, who had been summoned
urgently from London, arrived early on 13 June to find ‘‘my
sister very ill’’ but notes on 15 June, ‘‘Jane a shade better.’’
He made another diary entry on 19 June before returning to
London; ‘‘Jane a little better. Saw her twice and in the
evening for the last time in this world as I greatly fear,
the Doctor having no hope of her final recovery’’ (Le Faye,
pp 251-2).3

On 19 June also, Mrs. Austen passed on the latest report
from Winchester.

Jane has had a better Night than she has had for many
weeks, and has been comfortable all day, Mr. Lyford says
he thinks better of her than he has ever done, tho must still
consider her in a precarious state.58

Caroline Austen recorded that: ‘‘Contrary to any expecta-
tion . . . Aunt Jane continued very cheerfully and
comfortable, and there began to be a hope of, at least, a
respite from death’’. During these months of illness, Jane’s
‘‘sweetness of temper never failed her; she was considerate
and grateful to those who attended on her, and at times,
when feeling rather better, her playfulness of spirit prevailed,
and she amused them, even in their sadness . . . I need
scarcely say she was dearly loved by her family (Austen,
pp 16-17).26

On Monday 14 July Mrs Austen wrote again to Anna
‘‘Charles Knight came this morning: he saw her [Jane]
yesterday, and says she looked better and seemd very
cheerful’’.59 The following morning, St.Swithin’s Day, Jane
felt energetic enough to compose some comic verses about
the saint, which she dictated to Cassandra. But that same
evening the fever returned. Cassandra noted ‘‘a visible
change, she slept more and much more comfortably, indeed
during the last eight and forty hours she was more asleep
than awake. Her looks altered and she fell away.’’ Late on
Thursday afternoon Cassandra returned from an errand to
find Jane recovering from a ‘‘seizure’’ of ‘‘faintness and
oppression.’’ Another quickly followed, and she suffered for
about half an hour before Mr Lyford arrived and ‘‘applied
something to give her ease and she was in a state of quiet
insensibility’’ that continued until her death in the early
hours of the following morning.60 Mr Lyford supposed some
large blood vessel had given way.61

Sir Zachary Cope, in an article in the British Medical
Journal in 1964, was the first to offer a diagnosis of Jane
Austen’s illness.62 He considered that she was suffering from
Addison’s disease, secondary to Tuberculosis of the supra-
renal glands, in which fatigue, increasing weakness, and
crises or relapses in times of mental stress, are characteristic

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symptoms. Night fevers, however, are not symptoms of
Addison’s disease, as a correspondent, FA Bevan, pointed out
in the following issue of the journal. Bevan suggests an
alternative diagnosis of Hodgkin’s disease, ‘‘could account for
all the symptoms mentioned, including the skin pigmenta-
tion and the initial pain in the back.’’ He cites the case of his
own patient, with confirmed lymphadenoma, whose disease,
‘‘which was without marked enlargement of superficial
lymph nodes, ran a similar acute course to Jane
Austen’s.’’63 Despite this immediate challenge to Cope’s
diagnosis of Addison’s disease, his article has been cited in
Austen biography and literary studies for the past 40 years,
and Addison’s disease is generally accepted as the cause of
her fatal illness. The new edition of Le Faye’s authoritative
biography of Jane Austen, published in the past year, again
cites Cope, and repeats his claim ‘‘that early in 1816 she
[Austen] fell victim to the then unrecognised Addison’s
Disease’’ (Le Faye, p 236).3

Cope points to evidence of Addisonian crises, triggered by
emotional stress, and considers that Jane’s disease was
‘‘precipitated’’ by the ‘‘severe mental shock’’ of Henry
Austen’s bankruptcy in March 1816. But the existing medical
evidence supports a much earlier date for the commencement
of her fatal disease. He also considers that the shock of her
uncle’s will brought on another Addisonian crisis in April
1817. In fact this episode is not a relapse or crisis, but part of
a cyclical pattern of fever which can be traced from early
February 1817, and continued until her death.
Jane’s own letters in the last 4 months of her life,

documenting these periods of night fever of 1 or more weeks,
which she described as her ‘‘complaint’’, alternating with
similar afebrile periods, provide evidence that she suffered
from Hodgkin’s disease. This cyclic pattern of fever, known as
the Pel-Ebstein fever, is ‘‘a classic clinical sign in Hodgkin’s
disease . . . When fever occurs, it usually peaks in the evening,
and falls precipitously in the early morning hours, resulting
in drenching night sweats.’’64 It is also associated with
significant haemolysis, and an autoimmune haemolytic
anaemia (Kaplan, p 121).37 Kaplan suggests that there is
increased red blood cell destruction during periods of high
fever, and refers to a study which measured the mean loss of
haemoglobin in a fever period as 14 percent. This finding is
consistent with Jane’s increasing weakness after each attack.
Pel-Ebstein fever is an ominous symptom, indicating ‘‘far
advanced disease’’ (Kaplan, p 117),37 and a standard
reference describes it as ‘‘virtually diagnostic of Hodgkin’s
disease.’’65

Cope considers that Jane’s description of her face in
March, 1817, as being ‘black and white and every wrong
colour’ is ‘‘almost pathognomonic of Addison’s disease’’
(Cope, p 272).62 The hyperpigmentation or tanning of the skin
associated with Addison’s disease, however, is inconsistent
with her being described as ‘‘very pale’’ shortly afterwards in
April (Austen, p 15).26 Cope also suggests that ‘‘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’’ (Cope, p 272).62

He had overlooked Hodgkin’s disease.
Idiopathic thrombocytopenia purpura, is a rare syndrome

associated with Hodgkin’s disease (Cavalli, p 111).43 and is a
further haematologic complication that may occur in the
advanced or terminal stage of the disease.66 It may affect the
face and can be devastating to the patient.67 The symptoms
begin with a scattering of red spots, which gradually progress
to purple, then darken again, and in some cases turning
black. A few days later the spots gradually begin to resolve,
and change in colour like a bruise, turning green before
fading to a yellowish brown and disappearing. This is
consistent with Jane’s letter of 25 March describing her

looks as ‘‘recovering again,’’ and in April, they had gone
completely when she was described as ‘‘very pale.’’ The
‘‘black and white and every wrong colour’’ of her face
describes this process in contrast to the underlying severe
anaemia. New crops may soon appear and the process begins
again, and in Jane’s letter of 27 May, the purpura had
returned.68

Tuberculosis was frequently associated with Hodgkin’s
disease in the 19th Century, with pathologists observing
Tuberculosis in about 20% of autopsies on patients with
Hodgkin’s disease. One authority of this period considered
that ‘‘tuberculosis follows Hodgkin’s disease like a shadow,’’
and it is possible that Jane had this disease as well as the
fatal lymphoma (Kaplan, p 236).37

Jane Austen’s biographers have seriously underestimated
the extent to which illness affected her, throughout her life,
and mistakenly continue to describe her fatal illness as
Addison’s disease. While no strict proof is available, there is a
high possibility that a lymphoma such as Hodgkin’s disease
caused her early death. This disease, unknown in Jane’s
lifetime, was identified by the work of Thomas Hodgkin in
1832. Her final letters, written some fifteen years earlier, with
their clear, observant assessment of her symptoms, may
describe the first recorded case of Hodgkin’s disease.

ACKNOWLEDGEMENTS
I wish to acknowledge the substantive contribution of Ian Frazer to
this paper, in his kind assistance in discussing the issues involved,
and suggested revisions to the manuscript.
Professor Ian Frazer, FAA FTSE MBChB(Edin) MD(Melb) FRCPAD
FRCPA Professor/Director, Centre for Immunology and Cancer
Research, University of Queensland, Australia.

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10 Upfal

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