Lady Sybil’s death in Downton Abbey: how right and wrong are her doctors?

The fictional ITV drama Downton Abbey, first aired in 2010, offers a glimpse of what obstetric care was like in 1920. In Season 3, a much admired character, Lady Sybil Branson (Crawley), is in early labour at home, attended by Richard Clarkson, a local GP, and Philip Tapsell, a knighted obstetrician. Dr Clarkson diagnoses pre-eclampsia based on ankle oedema, proteinuria, an undersized foetus, and confusion. He insists that Sybil should be taken immediately to hospital for caesarean section. Sir Philip disagrees and recommends home birth. Sybil’s father, Lord Robert Crawley, sides with the esteemed obstetrician.

Lady Sybil finally gives birth vaginally. The joy, however, is short-lived as she soon develops a decerebrate posture and dies. Robert’s wife Cora blames Robert. To help the couple reconcile, Dr Clarkson later reluctantly rationalises that Sybil’s condition was such that hospitalisation would not have saved her. How right, or wrong, is either doctor?

SIR PHILIP’S RECOMMENDATION

In the late 19th century, mortality from toxaemia was 20–30%.¹ Then, in 1900, Stroganov presented his experience with 92 eclamptic patients with five deaths. He called for avoidance of stimulation of the parturient (still practiced today) and heavy sedation with morphine and chloral hydrate.¹ In spite of the neonatal depression caused, his method was quickly adopted worldwide. Subsequent experience showed that Stroganov’s method was associated with maternal mortality of ≤4%, with infant mortality at 20%.¹ Before Stroganov, treatment for toxaemia was immediate delivery, if necessary by caesarean.

It is possible that toxaemia is also on Sir Philip’s mind but he does not want to alarm everyone, and burden the parturient with a journey to the hospital. He may have hoped that a quick delivery will resolve the problem. Philip reminds Dr Clarkson of the dangers of aggressive interventions. In 1892, Green had noted that six of 10 pre-eclamptic patients had died in whom labour had been induced.² Similar reports of dismal results after operations had followed.

Up till the end of the 19th century, caesareans meant unbearable pain and usually maternal death from haemorrhage or sepsis. Fortunately, for women in 1920, spinal anaesthesia had already been demonstrated in 1898.³ Nitrous oxide (N₂O) was introduced in the 1880s and chloroform had by then been in use for decades.³ Carbolic acid had spectacularly reduced deaths from sepsis in surgery and had first been introduced into obstetrics in 1870 by Bischoff, who had visited Lister in Glasgow.⁴ Uterine suturing and extraperitoneal caesarean had also slashed the incidence of sepsis.⁴ Unfortunately for the Downton contemporaries, it was not until 1928 when penicillin was discovered, and sulphonamides became available in 1935.¹ Ergot had been utilised since the early 19th century.⁴ Blood grouping had been discovered in 1900 and storage in citrate-glucose solution had been practiced since 1917.¹ All in all, the mortality rate for caesarean section had greatly improved by the early 20th century, dropping to 8.1% in the 1900s.⁵ ‘Once a caesarean, always a caesarean’, a dictum since 1916⁵ until recent years, may also have affected Philip’s decision.

DR CLARKSON’S RECOMMENDATION

Dr Clarkson rightly suggests that the treatment for pre-eclampsia is prompt caesarean. As Stroganov had written, most eclamptic convulsions stopped after delivery.¹ At the dawn of the 20th century, maternal mortality from eclampsia was 20–30%,² much worse than 8.1% for caesarean.⁵ Although not mentioned, assisted vaginal delivery, including the use of forceps in a proper delivery suite, may be all that was required.

SYBIL’S TERMINAL EVENT

Sybil’s final decerebrate posturing is most likely brain herniation from a stroke. Although external chest compression had already been described before 1920, the standardisation of cardiopulmonary resuscitation did not arrive until decades later.

CONCLUSION

The weight of evidence suggests that Sybil is better off hospitalised. Sir Philip wrongly claims that toxaemia is rare. In his defence, though, his mismanagement is probably not all attributable to an inflated ego. Both doctors forget to use a sphygmomanometer (already available a decade earlier). As for Dr Clarkson, the family’s long-time trusted physician and friend, his argument that Sybil’s chance of survival at the hospital is ‘infinitesimal’ helps the family heal but contradicts his own earlier professional opinion, and may undermine trust with the family in the long run along with the lesson that needs to be learned by Sybil’s sisters, who themselves will be at higher risk of developing toxaemia of pregnancy.