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doi: 10.1097/01.NT.0000427573.64426.fe
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Neurology Debuts in Masterpiece Classic's ‘Downton Abbey’: Does It Make the Grade?

Avitzur, Orly MD [AKA Lady Brain]

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ARTICLE IN BRIEF

The popular Masterpiece Classic series, “Downton Abbey,” puts neurology in the limelight as its complex casts of characters deal with an array of neurological issues. Neurologist Orly Avitzur, MD, grades the treatment of each condition for accuracy.

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The award-winning PBS show, “Downton Abbey,” aired its season 3 premiere on Jan. 6, drawing 7.9 million total viewers, (its highest total yet), according to Nielsen Ratings. Among the fans of this World War I-era British costume epic are a cadre of physicians who've filled the blogosphere with their opinions of the drama's medical adventures and misadventures.

Arguably the best story lines have focused on neurologic injuries and ailments. But just how accurately are they depicted? See if you agree with this Neurology Today scorecard.

1. Sudden coital death from stroke (Season 1, episode 3)

Grade: C–

In season 1 episode 3, Lady Mary becomes smitten with Kemal Pamuk, a dashing Turkish diplomat who comes to visit Downton Abbey with a family friend. After an arduous hunt (the literal kind, for fox, that is), Pamuk ultimately seduces the eldest Crawley sister in her own bed, and, inconveniently, dies. When her mother, the Lady Cora, asks her how this has happened, she replies, “A heart attack…or a stroke…he was alive and suddenly he cried out and then he was dead….”

So just what is the risk for dying in flagrante delicto due to a ruptured cerebral aneurysm? According to a 2011 article in Stroke, sexual intercourse is one of eight triggers that increase the risk for subarachnoid hemorrhage — making it 4.3 times more likely than with no sexual activity. Alas, in late November of 1912 in the UK, there were few forensic autopsies, leaving us to only speculate about the pathogenesis of what has become known as “Lady Mary's Shame.” As is typical for the indomitable Downton family, few tears were shed for Mr. Pamuk, who several hours earlier had foreshadowed his own demise, saying, “Sometimes we must endure a little bit of pain in order to achieve satisfaction.”

2. Post-Traumatic Stress Disorder (PTSD) following combat (Season 2, episode 3)

Grade: A+

In April 1917, Lang is hired to replace Bates as Lord Grantham's valet. A recent war veteran, he's been “invalided out” by psychoneurosis, AKA shell shock. Lang exhibits extreme anxiety and episodic disorientation, in one scene awakening the staff from screams during a nightmare that left him drenched with sweat. But only O'Brien, the usually scheming Lady's maid, seems to recognize his medical condition and offer sympathy. Lord Grantham, in contrast, seems perplexed, confiding in his wife, “I don't understand it; he seemed so solid when I met him, even taciturn, now he's a bundle of nerves.” And Thomas, the evil footman, predictably refers to Lang as “the looney one.”

By World War II, the affliction became known as “battle fatigue,” “combat exhaustion,” and “war stress”; and in the Vietnam War as “Post-Vietnam Syndrome.” Today, PTSD is recognized as one of the most commonly observed psychological sequela of combat exposure. Almost a century post-Downton, 30 percent of veterans treated by the Veterans Administration are now diagnosed with PTSD upon their return from Iraq or Afghanistan, although hurdles in meeting the demands for treatment persist.

3. Amnesia and foreign accent syndrome (Season 2, episode 6)

Grade: D–

No good soap would be complete without an outrageous amnesia storyline. Measured even against the most heretofore preposterous media depictions — box office successes “50 First Dates,” “The Bourne Identity,” and the 2011 bestseller, Before I Go to Sleep — “Downton Abbey” falls short.

In November of 1918, a badly disfigured Canadian officer arrives at Downton, claiming to be Patrick Crawley, the Earl of Grantham's first-cousin-once-removed, deceased successor to the estate. Previously believed to have drowned on the Titanic, the newly-resurrected Patrick alleges to have survived the oceanic disaster by being rescued from the freezing North Atlantic waters after having been mistaken for a Canadian. Conveniently, the heir-in-question claims to have suffered from amnesia, but like all such dramas that demand reversal of story arc with sudden recall, a wartime explosion restores his memory.

Although a 2012 Ergonometrics study concluded that individuals may be at risk for cognitive injury after removal from a cold environment, the duration of the proposed dysfunction in faux-Patrick's case is far in excess of the sixty minute recovery period monitored by the researchers. In fairness, Patrick offers alternative hypotheses of a possible blow to the head and shock, in addition to cold immersion hypothermia. Even more inexplicable is Patrick's newly adopted Canadian accent, acquired in adulthood. While there are legitimate case reports of psychogenic and neurogenic foreign accent syndromes, this is more likely a case of an opportunistic imposter, as Lord Grantham's investigation ultimately suggested.

4. Matthew's spinal cord injury (Season 2, episodes 5 and 7)

Grade: F

In mid-1918, Matthew returns from the battlefront in France paralyzed from the waist down, having suffered a spinal cord transection according to Dr. Clarkson. He is told that he will never walk again, have sex, or father children. Matthew tells Lavinia, his fiancée, to forget him and sends her home, while Mary attempts to nurse him back to health. But wanting Mary to get on with her life, Lady Cora calls Lavinia back, and the young woman insists that she loves him — wheelchair or not. As the residents of Downton try to return to normal activity following the armistice of Nov. 11, 1918, Matthew reports that he has begun to feel his legs. Although Dr. Clarkson calls it an illusion, one day soon after that, seeing Lavinia drop a heavy tray, Matthew suddenly leaps to his feet.

While a report in BMC Emergency Medicine 2011 recounts the case of a 34-year old man who exhibited complete motor recovery after acute paraparesis caused by spontaneous spinal epidural hematoma, Matthew's dramatic recovery from paraparesis is more the stuff of fiction than real life, even by 2013 medical standards. To add just a touch of medical veracity, Dr. Clarkson later admitted that he had had made a mistake. When Sir John Coates had evaluated Matthew, he had diagnosed a case of spinal shock. Dr. Clarkson had disagreed with him and hadn't wanted to raise everyone's hopes, so he had failed to mention the possibility. Never mind that it is now many months following the spinal cord trauma, and recovery from spinal shock is typically measured in weeks.

5. Sir Anthony's right arm paresis (Season 2, episode 8, The Christmas Special)

Grade: C

During season 1, middle Crawley daughter, Edith, falls for the much older Sir Anthony Strallan. The romance has progressed by season 3, but blaming a debilitating injury to his arm serving in WWI, he initially rejects her. During the Christmas Special, Sir Anthony tells Lady Edith, “I took a bullet in the wrong place and it seems to have knocked out my right arm.” No additional explanation — neurologic, orthopedic, or otherwise — is provided for his disability, so Edith is just as unsure about his prognosis as we are, and asks, “Not forever, surely?” To which Sir Anthony responds, “Well, the upshot is, I'm afraid the wretched thing is now no use to man or beast,” not exactly clarifying the situation or answering the question.

Later, Sir Anthony tries again: “I'm a cripple. I don't need a wife, I need a nurse. And I couldn't do that to someone as young and lovely as you.” Eventually, Edith prevails and he proposes. But in season 3, after a jubilant Edith walks down the aisle with her father, Sir Anthony (and his arm) jilts Edith at the altar.

6. Sybil's eclamptic seizures (Season 3, episode 4)

Grade: B+

Sybil, the youngest and most beloved Crawley daughter, who followed her heart to marry the Crowley's Irish chauffeur (at the risk of disinheritance by her father), returns to Downton Abbey, heavily pregnant. In hardly the first difference of medical opinion in the British season, Dr. Clarkson, the Crawley family doctor, contends in no uncertain terms that Sybil is suffering from pre-eclampsia, and recommends that she undergo a urine test. However, Sir Philip, the obstetrician brought in to deliver the baby, downgrades the import of Sybil's thick ankles to the stress of childbirth, and vetoes the need for both the test and C-section. In the most poignant three-hanky- tear-jerker-of-a-scene to date, Sybil succumbs to an untimely death after suffering from both delirium and seizures.

According to a 2010 historical overview of preeclampsia-eclampsia, magnesium sulfate was first introduced in 1906 to manage the condition, and it was not until the 1920s that its parenteral application was demonstrated to be both efficacious and safe. But at Downton Abbey, it was only July of 1920, so the writers just squeaked by in terms of offering this remedy as an elegant compromise and sparing poor Sybil's life. Moreover, those wordsmiths could have allowed Sybil to die quietly instead of stretching the scene out capturing every tonic-clonic second, but as Violet Crawley, the Dowager Countess of Grantham, said in anticipation of seeing Mary's reaction to meeting Matthew's fiancée, “I hate Greek drama, you know, when everything happens off-stage.”

Dr. Avitzur, a neurologist in private practice in Tarrytown, NY, holds academic appointments at Yale University School of Medicine and New York Medical College. She is an associate editor of Neurology Today and chair of the AAN Practice Management and Technology Subcommittee.

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FOR FURTHER READING:

• Vlak MH, Rinkel GJ, Algra A, et al. Trigger factors and their attributable risk for rupture of intracranial aneurysms: a case-crossover study. Stroke 2011;42(7):1878–1882.

• Report on VA Facility Specific Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) Veterans Coded with Potential PTSD – Revised December 2012: http://1.usa.gov/GYn47O
• Muller MD, Gunstad J, Glickman EL, et al. Acute cold exposure and cognitive function: evidence for sustained impairment. Ergonomics 2012;55(7):792–798.

• Leandro U, et al. Complete motor recovery after acute paraparesis caused by spontaneous spinal epidural hematoma: case report. BMC Emerg Med 2011; 11: 10.

©2013 American Academy of Neurology

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