Downton Abbey: Medicine then and now

Downton Abbey: Medicine then and now

If you have not yet seen the fourth episode of the third season of Downton Abbey and wish to be surprised by it, read no further. And if you aren’t watching PBS’s addictive costume drama currently set in 1920–and, seriously, why aren’t you?–read on anyway.

This is about medicine, then vs. now.

First, to recap the medically relevant aspects of the story: Lady Sybil, age 24, the youngest daughter of Lord and Lady Grantham, is about to deliver her first baby, a little prematurely. It’s assumed that she’ll have the baby at home, in the family estate, but there’s some controversy about who should attend her. Her mother favors the local family doctor, Richard Clarkson. while her father wants a specialist, Sir Phillip Tapsell, obstetrician to the aristocracy.

Both men are summoned, Sir Phillip as a houseguest, and they argue about Sybil’s condition. Clarkson thinks that Sybil’s confusion and swollen legs are signs of eclampsia, also called toxemia, a potentially lethal condition in which a woman has seizures during pregnancy or soon after delivery. He feels her only hope of survival is to have a cesarian section at the hospital–itself a high risk procedure in the pre-antibiotic era. Sir Phillip thinks the local doctor is overreacting, and that Sybil is fine. She indeed seems to be so, and delivers a healthy baby girl. But the next day, as her horrified family and the two doctors watch helplessly, she begins having seizures and dies.

Once I stopped bawling about poor Lady Sybil–oh, c’mon, you know you did, too–I got to thinking about how medicine has and hasn’t changed since 1920, as portrayed in this well-researched show.

What seems unfamiliar, at least in the developed world, thankfully, is Lady Sybil’s fate. In the early 20th century it was not at all uncommon for women to die in childbirth (from infections, hemorrhage, and eclampsia). Today, due to prenatal care, including screening for eclampsia’s precursor pre-eclampsia (all those blood pressure and urine checks during the third trimester) and the availability of treatments for eclampsia, infections, etc., pregnancy and delivery are much safer. In the developing world, however, the World Health Organization estimates that approximately 800 pregnant or peripartum women still die every day.

What seemed, to me, very familiar in this episode was the conflict between the family doctor and the specialist. While, as a primary care doctor (a modern-day Clarkson, so to speak) I enjoy a collegial relationship with the many specialists to whom I refer patients, there is, at times, a certain tension between our perspectives. Often, it can be summed up like this: I know more about the patient, while the specialist knows more about the disease. Usually we pool our knowledge, but once in a while we clash. A surgeon may be puzzled, or even irritated, by a patient’s reluctance to have a particular operation which he knows will be helpful. What I may know, with equal certainty, are the reasons for the patient’s hesitation. When Sir Phillip pooh-poohed Sybil’s swollen legs (“some women have thick ankles!”) and Dr. Clarkson countered that he’d known the young woman her whole life and was sure that she did not have thick ankles … you know for whom I was rooting.

Perhaps the most striking aspect of the episode, from a medical point of view, was both doctors’ inaction once Sybil started seizing. There was nothing to be done, so they did nothing. CPR would not be invented until 1960, there were no effective treatments for eclampsia, there was no point in rushing to the hospital. The doctors did play a role, though–one which I think is undervalued today: that of companion, and witness to death and suffering.

With health professionals and patients alike now re-evaluating whether it’s wise or desirable to spend 25% of Medicare resources during the last months of life, often on invasive treatments that decrease the quality of a patient’s life without increasing it’s length, we doctors may find ourselves more often in a palliative rather than “do everything at any cost” mode.

We’ll never again stand by and watch a woman die of eclampsia–thank goodness–and we won’t wear dinner jackets or silk dressing gowns (alas), but we may be more like our professional ancestors than we acknowledge.

Suzanne Koven is an internal medicine physician who blogs at In Practice at Boston.com, where this article originally appeared. She is the author of Say Hello To A Better Body: Weight Loss and Fitness For Women Over 50

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  • Miranda Fielding

    I admit it, I bawled too! But I have to ask you, since I’ve practiced radiation oncology for 30 years–was the sequencing–delivery then death accurate? Pardon my ignorance, but I thought that once the baby was delivered, the symptoms went away. Thanks for this great essay. Now if you can tell me which sister Tom Branson will end up with, I’d appreciate it!

  • LastoftheZucchiniFlowers

    Pre-eclampsia/eclampsia was also dramatised in the OTHER great Brit drama of a slightly later era in “Call the Midwife” in two different episodes. These dramatisations differed in the patient’s presentation AND in the outcomes (won’t spoil in case readers decide to watch) and while the 50′s offered SOME advancements to the treatment modalities the net effect was the same: once the seizure occurred, maternal mortaliity was a given. While Sybil’s post-partum eclampsia was dreadful to witness, I too was stunned by the sheer inaction of Clarkson and Sirwhatshisname. I kept wanting them to rush to her side and INTERVENE!!!! Alas, it was not to be. Amid all that lush velvet, satin and indulgent gilded age accutrements, the lady died in her bed surrounded by stunned and disbelieving family members and appalled, HELPLESS physicians. Honorable mention though, for Dr. Clarkson’s post-funeral reassurance to Lady Grantham that her daughter would not, in all likelihood, have survived the C-section which made it possible for Cora to forgive her sputtering, almost-repentant and crestfallen husband for insufferable adherence to the aristocratic protocol. Recall however, that it was Clarkson in an earlier episode who was reluctant to inject adrenalin into the pericardial sac of an otherwise doomed infirmary patient with ‘dropsy’. Were it NOT for the strident protestations of Isobel (Mrs. Crawley), the patient would continued circling the drain until death. Clarkson was oddly resigned to his imminent death (and that of William from his combat injuries later on) with that phrase, “…he won’t be saved…”
    While it’s great fun to imagine what practice in that era would have been like, I remain bound to Woody Allen’s maxim that “I wouldn’t want to live in any period before the discovery of antibiotics.”
    PS – delivery of the baby in PE/E, while often curative, does NOT guarantee mother will not have a seizure thus the close PP monitoring of such patients.
    PS – Delightfully written piece and thank you!

    • Miranda Fielding

      Thanks everyone–I know I get too wrapped up in my shows (don’t get me started about Grey’s Anatomy!) but I’ve learned something from this essay and the discussion.

    • http://www.facebook.com/beau.ellenbecker Beau Ellenbecker

      “PS – delivery of the baby in PE/E, while often curative, does NOT guarantee mother will not have a seizure thus the close PP monitoring of such patients.”

      I saw this become alarmingly true in Germany. Had a young mom with pre-eclampsia deliver, leave the hospital 48 hours later and then go home and have a full on 2 minute seizure at home about 24 hours later. Husband brought her to my clinic where her BP was 160′s/90′s and she was complaining of nausea. Scary. Didn’t know it could hit that late, given the mantra has always been “delivery is the cure”

  • http://www.facebook.com/shirie.leng Shirie Leng

    I know, hard to watch them watch her die. I’m an anesthesiologist and that scene made me twitch to do something. I hadn’t realized that CPR had been invented so recently. I guess had I been there I wouldn’t have been able to do anything either.
    On the subject of primary care vs specialty, I think that episode was a beautiful illustration not just of medical hierarchy but also of social hierarchy. Both still exist today.

  • SBornfeld

    Carson shudda fixed it.

  • http://www.facebook.com/people/Chagai-Dubrawsky/604353306 Chagai Dubrawsky

    The tragedy of Pre-eclampsia is well known.The cause for it is unknown.
    In the quest to know why,I noticed that up to present:Obstetrics and neonatology is practiced along the guidlines of H.E.L.L.P.(Weinstein 1982)
    In HELLP there is not place,neither mention of H.D.L..Consequently,when
    the expecting mother’s blood pressure goes up,the blood level of HDL drops.(and vie versa)
    When the HDL,one day,drops too fast and too much,her blood pressure zooms up to malignant levels.That is when the mother is under stress,and the fetus in fear of its life.It feels the need to escape.
    When this pregnant woman present to the OB,and found to be severly hypertensive,C/section must be perform STAT,within five minutes.
    Failure to do so,means big lawsuit.”Falling of the cliff” of the mother and fetus must be prevented at all costs.(Yes,they call it falling off the cliff!!!)
    The mother and the premature newborn end up in intensive care unit,why?
    Their HDL is low.Both are very sick.Once you raise the H.D.L.,all problem solved.
    women deserve better that having to go through such a misery,after which they do not want to be pregnant again.
    It is written in story of Garden of Eden,that when God chased the couple
    ;Adam and Eve,He cursed the woman:In pain though shall have children
    .Are we in the modern society trying to show the women,what real pain
    mean? References?enough to satisfy your curiosity.

  • buzzkillerjsmith

    Downtown Abbey; no way. There are very few things more irritating to this American than an English accent, Monty Python excepted of course.

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