MUSEUM NOTES The story of a 'little black bag' STEPHEN MORRIS Nottingham 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 903/!. 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 chore. 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. Acknowledgements 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. REFERENCES 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.
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