The story of a little black bag

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                      The story of a 'little black bag'
                                          STEPHEN MORRIS
TODAY GENERAL PRACTITIONERS SEEM TO carry their gear in a variety of containers-and I
personally have come across hat boxes, music cases and even 'Fine Fare' carrier bags used for
this purpose. But why is there so much interest attached to that 'little black bag'?
     I think perhaps I became interested in doctor's bags during my first bout of tonsillitis at
the age of six. Despite the discomfort of my infected throat I managed to muster a singular
amount of childlike curiosity and, without a 'by your leave', delved into the open Gladstone
bag placed on the chair beside my bed. In those not so very far off days when general practi-
tioners had a little time to spare, the kindly doctor did not hastily grab the bag, but herself
removed certain things which were of particular interest to a small boy-namely, a throat lamp,
a thermometer, an auriscope, and 'oh joy' the best thing of all, a binaural stethoscope. The
use of all these items were demonstrated upon my Teddy Bear, and then for Teddy's benefit
(and of course the doctor's) upon me! Yes, the bag was indeed full of intrigue. Even the
syringe in its metal container was fascinating and funnily enough the use of this in later years
never really perturbed me.
     In a previous article', I endeavoured to describe the development of the doctor's bag
through to the present day. In that article I gave more detail of current trends in bags and their
content, rather than what had gone before. The doctor's bag as we have been brought up to
know it only came to the fore during the middle of the last century, and Barber2 illustrated his
article with a delightful picture of a bag used by his predecessor when starting in rural general
practice in 1890. Some of the instruments carried in that bag were horrific to say the least,
making the surgical procedures of the day look truly grucsomne. The bag of this era was per-
haps more devoted to midwifery than to carrying equipment used in day-to-day medical practice.
      To illustrate the various early types of bag, I have been fortunate to obtain from Messrs
Down Bros and Meyer & Phelps Limited of London, examples from their early catalogues. I
will discuss these in their chronological order.
      As previously stated midwifery claimed priority in the bag range and a catalogue of 1885
shows, as figure 4, the Barnes' Midwifery Bag, fully-fitted with all the instruments which the
doctor might possibly require. He might also have, in the post partum period, to administer a
blood transfusion, and in the same catalogue we see figure 15 illustrating a transfusion appara-
tus. It appears an amazing, somewhat Heath-Robinson type of contraption. (See figures 1
and 2)

                   Figure 1                                             Figure 2
   A Barnes' Midwifery Bag, fully fitted (1885)   Illustration from a catalogue of 1885. Transftusion
                                                              apparatus for use in midwifery
  Arbuthnot Lane, who was an assistant surgeon at Guy's Hospital at the turn of the century,
suggested a special bag to be devoted to diagnostic and emergency surgical equipment. This
was illustrated as figure 4230 in Down Bros catalogue of 1900. The contents of the bag in-
cluded various specula, all manner of diagnostic equipment, a complete urine testing outfit,
various solutions, chloroform and cocaine pellets for local anaesthesia, drugs and wallets of
J. ROY. COLL. GEN. PRACTIT., 1969, 18, 309
310                                                                               STEPHEN MORRIS
surgical instruments. Even when the bag was fully packed there was ample room for copious
surgical dressings, yet overall the bag was only 15 in. x 10 in. x 17 in. (See figure 3)
     Returning to midwifery bags, one particu-
lar type which I think singularly ingenious,
and I suppose rather amusing, is the Small
Bicycle Bag of 1914. This was the age of
the 'safety' bicycle, thus cycling was popular,
and to a doctor as necessary as motoring is
today. The Small Bicycle Bag was made of
strong cow-hide, being well-designed, fitted
and most compact, and for that more spacious
age, almost ideal. (See figure 4)
     The last two illustrations from the past
are. the 'G.P.' large-size midwifery bag, which                       Figure 3
was as usual fully-fitted, and a diagnostic and Illustration from catalogue of 1900. Diagnostic
emergency ' Attache Case' type, fitted and and emergency bag, as suggested by Mr Arbuthnot
with an improved safety-handle. Both these Lane, M.S., F.R.C.S. (assistant surgeon to Guy's
bags are from a catalogue of 1935. In some                           Hospital)
ways it is better designed than some modern
types, with a variety of drawers, many of which are too small to be of real value. (See figures
5 and 6)

                                                     Figure 4
                               Illustration from a catalogue of 1914. The Small
                                        Bicycle Midwifery Bag, fully fitted


                       Figure 5                                        Figure 6
                                                Illustration from a catalogue dated 1935. Diag-
 Illustration from a catalogue of 1935. The 'G.P.'
        large size Midwifery Bag, fully fitted  nostic and emergency bag Attach6 Case' type,
                                                         fitted with improved safety-handle
     And so, after having had a glimpse of bags from the past, let us examine the development
in designi and content. Nowadays the general practitioner only has to carry about with him
drugs and equipment which he might need in a dire emergency, and those instruments which
are required for his day-to-day work. So, it would seem then that the best idea is a combined
emergency and day-to-day bag (midwifery obviously requires a separate bag), but there are some
who would prefer to use two separate bags; to find oneself with the wrong bag at the wrong
THE sTORY OF A 'LITTLE BLACK BAG'                                                                 311
time can be terribly frustrating; it may mean a long trek back to the car-or even in some cases
the surgery-to fetch the equipment or drug that is needed. As Craddock3 so rightly contends,
when very busy it is tempting to omit an examination if the instruments required are not im-
mediately available.
     When choosing a new bag, or case, certain points should be borne in mind. These will
relate to 'size', 'weight' and 'weight when packed', 'internal capacity', 'design' and lastly
'durability'. Another deciding factor will be the type of practice in which the bag is to be used.
A country doctor needs a much larger and more capacious bag than would his town counter-
part. To carry about a cumbersome bag or case with every possible type of drug and instrument
-"just in case they're needed"-may be feasible in a rural practice, although the very fact
that this may need to be carried across fields and up long, winding, muddy cart tracks, does rather
put one off. Even for the country general practitioner, a case no larger than 16 in. x 10 in. x 5j in.
will prove adequate if the contents are well chosen and lightweight disposable items are used
as far as possible. However I know of one long-established country doctor who found the
usual chest-of-drawers type of case a bit too finicky as the items and drugs seemed to get moved
about from drawer to drawer-so he went to his local branch of Woolworth's from which he
purchased a medium-sized suitcase which he soon found ideal for his needs.
   While on the subject of the country doctor's bag, Millar4 gives a clear account of his bag, but
Pickworthand Westwood5 describe how in their
rural practice they make use of three Lynmouth
cases in which is carried enough material to
deal completely with any one specific job-
including maternity. This had been achieved
satisfactorily for 15 months, by using the
principle of pre-packing the cases, each group
of materials being in its own colour-coded box.
Thus the amount of each item was kept to a
minimum. Because by this method very little
room was taken up in the case, a far greater
variety of gear and drugs could be carried but
enough for one job only. Careful day-to-day
checking and refilling of the boxes was
necessary, but could be done by one of the
practice ancillaries and not necessarily by the                         Figure 7
doctors themselves. A list of the contents of The ' Lynmouth case as described by Dr K. H.
each box was kept as a permanent fixture on Pickworth and Dr J. Westwood in 1964. It has
the lid. This is a good idea, but perhaps for three spacious drawers for instruments, drugs and
some would constitute too much of a daily                sundries. In smooth or long-grain hide
     Before leaving the subject of bags used in a rural general practice, I must emphasize that
the well-loved Gladstone or 'Kit' bag is still popular, due primarily to its worthwhile capacity
and the durability of its long-grain hide. The instruments and drugs are usually kept in wallets
and boxes, but the bag has a washable, detachable lining provided with ample pockets for various
odds and ends. As regards containers for ampoules and other small bottles of tablets for
injection with distilled water, it has been found that the old standby-a clean 2 oz. tobacco tin
is invaluable. It is also grand for holding suLch things as suppositories and small tubes of oint-
ment. A label saying what is in the tin should be attached to the lid. One useful item I have
come by is an oblong plastic case holding eight tubes, in which can be carried various tablets or
capsules of the doctor's choice. This was presented by May & Baker Limited.
      For every-day use in a busy town or suburban practice the general practitioner can now get
by with just a small attache case, perhaps an ideal being the one provided with a single drawer.
On a great number of occasions even this need not be taken into the house, for general practi-
tioners always appear to be blessed with coats of many pockets in which will be found a pad of
E.C.1O's and Med.3's, a B.N.F. (and perhaps MIMS), a binaural stethoscope, some disposable
tongue depressors, a throat torch, a clinical thermometer in a spirit-proof case and various
other odds and ends-all of which create a noticeable bulge likely to cause unfavourable
comment from the doctor's wife! Items that are carried in the case will most probably include
312                                                                                   STEPHEN MORRIS

a pair of disposable gloves, finger stalls and a tube of KY jelly lubricant, a small supply of
cotton wool, some of which is packed tightly into a jar and already soaked in spirit, a straight
cutting needle also in spirit, being attached by its point to the cork of the bottle, pleximeter. a

                  Figure 8                                                 Figure 9.
The 'Kit' Bag. In strong black or brown long-        The 'Brief' Bag. In black or dark brown cow
                 grain hide                          hide, fitted with a removable washable lining for
                                                     bottles and instrument. This bag comes in various
                                                     sizes, and is perhaps the traditional ' little
                                                                          black bag '.
small diagnostic set, an aneroid sphygomanometer, a nasal speculum, one bottle each of Clinistix
and Albustix, disposable syringes-2ml, 5ml, and 10ml, and a variety of surgical instrumnents and
dressings, but these need only be simple and enough to deal with lacerations which could easily
be managed without referring the patient to a casualty department. The use of Steri-Strips or
Dumbell sutures has made this problem simpler. Kellock6 found much benefit from having to
hand in his case, an Aberdeen neonatal mucous extractor. This proved its worth times without
number where babies, and even older children were choking with secretions. Also carried
are containers for sending specimens to the local pathology laboratory, a Talquist or Hawkesly
haemoglobinometer, notepaper and envelopes, other executive council forms in common use
-and the drugs.
      It would not be right for me to discuss this last form of content to your bags, and I will
make do by saying that every man has his own favourite drugs which he has used over the years,
come to trust, and finds are those consistently required in his type of practice. McConaghey7,
has conveniently divided those drugs carried in general practice up into 'life savers', 'pain
removers', 'tranquillizers' and 'temporizers'. This last group are more for the benefit of anxious
relatives rather than for the urgent need of the patient, as the necessity to give some form of
immediate treatment when called in an emergency is naturally great-emphasized even more so
in the hours of darkness. By being able to start treatment immediately in giving a few tablets,
from one's own bag, to tide the patient over until such time as the prescription is made up, he
will-again as Craddock8 observes-be responsible for much symptomatic relief, and will
occasionally abort a serious illness. This is just good general practice.
      Nothing changes faster than the face of modern medicine, thus it is expected that the general
practitioner's 'little black bag' will also change, but whatever form it may eventually take it will
alway! be the symbol of family medicine.
     I am indebted to Mr G. Maurice Down of Down Bros. and Meyer & Phelps Limited for supplying
various illustrations used in this article. Also a warm word of thanks to my friend Dr A. M. Kellock for
all his kind and valuable assistance.
1. Morris, Stephen (1968). GP Vol. 5. 19, 12.
2. Barber, Geoffrey (1957). Practitioner. 179, 621.
3. Craddock, Denis (1958). Introduction to general practice. London. H. K. Lewis & Co.
4. Pickworth, K. H-., and Westwood, J. (1964). Practitioner. 192, 401.
5. Millar, A. P. (1966). Brit. med. J. 7, 1114.
6. Kellock, A. M. (1968). Personal communication.
7. McConaghey, R. (1958). Med. press. 121-126.
8. Craddock, Denis (1958). loc. cit.