THE PHYSICIAN'S "little black bag" has long been a common, everyday symbol of the medical profession. It has represented many things in the minds of many people, ranging from the contemptuous belief that it contained only evil smelling and tasting concoctions of little value at one extreme, to the open-mouthed, awe-inspired belief of children in days gone by who were told that it was the receptacle from which new baby brothers and sisters were plucked. . . .

With such a variety of opinions from which to choose, how often is it thought of in its true light--that of a container of equipment and medications which when combined with the knowledge of the physician gives relief to the suffering and often is the difference between life and death? With such an important role to fulfill, should not the contents of the bag be selected with care? Obviously there is a ridiculous extreme to which one could go in either direction, from that of containing only a few pieces of medical equipment on the one hand, to being a veritable mobile pharmacy on the other. . . . A common practice in many communities is for the patient to be sent directly to the hospital if he is particularly ill or to give a prescription to the less ill, the prescription to be filled at the nearest pharmacy. As a rule this system works. However, there are some patients who possibly do not reach the hospital alive who might have been saved by some home treatment prior to the arrival of the ambulance. . . .

It is an obvious fact that a pediatrician would not need the same armamentarium as would the internist, the cardiologist, or the general surgeon. However, there are certain emergencies likely to be met at any time or place which could be treated on the spot, often with dramatic results. . . . Examples of the more common medical emergency to be encountered might be acute heart failure or pulmonary edema, insulin shock, severe asthma, bichloride of mercury poisoning with the patient having just previously swallowed the poison, paroxysmal tachycardia, acute heart pain of coronary origin, severe acute throat, or pulmonary infections. . . .

What should be in the bag? The following list of drugs will be mentioned with a few remarks concerning their usefulness:

1. Morphine Sulphate (hypodermic tablets grain 1/4). Sydenham wrote in 1680, "Among the remedies which it has pleased Almighty God to give to man to relieve suffering none is so universal and so efficacious as opium." This statement is still true if amended by replacing "opium" with "opium derivatives" and adding "and similar-acting synthetic drugs." No medical bag is properly stocked without morphine, Pantopon, or Dilaudid, although some physicians prefer Dolophine, Demerol, or other new synthetic morphine-like drugs. . . .

2. Apomorphine. (Average dose 5 mg., maximum dose 10 mg.) This alkaloid, obtained synthetically from morphine, produces immediate and often violent vomiting through its action on the central nervous system. It should be administered only after extremely careful consideration has been given to its dangerous properties. . . .

3. Digitalis. In 1875 William Withering of Birmingham, England, wrote his classic, An Account of the Foxglove and Some of Its Medical Uses, presenting principles which if followed today would benefit many patients. This is one of our best but often misused drugs. In the minds of certain present-day practitioners a diagnosis of heart disease is naturally followed by the administration of digitalis. Digitalis or similar-acting cardiac glycosides should be administered primarily for relief of uncontrolled auricular fibrillation, instances of myocardial insufficiency (congestive failure), and for impending failure. . . .

4. Sedatives. A common task encountered by the physician seeing patients in the home is that of allaying anxiety, combating tension, and promoting sleep. The barbiturates, although grossly abused, are excellent drugs to be used in this regard. Of the many preparations on the market, a representative of the long-acting drugs and a representative of the short-acting drugs are all that will be needed in the bag. . . .

5. Mecholyl (ampules containing 25 mg. each). Mecholyl or some other strong vagal stimulant is useful in stopping an attack of acute paroxysmal auricular tachycardia that is endangering the patient's life. The author has personally known of three deaths occurring in individuals, each having a mitral stenosis, who developed a paroxysm of tachycardia that was treated too long by more conservative measures.

Mecholyl cannot be used indiscriminately. Safe administration may be realized by applying a blood pressure cuff on the arm, injecting the drug subcutaneously, distal to the cuff, with the physician having a syringe containing 1/75 of a grain of atropine at hand. If the patient should become anxious or experience a feeling of chest constriction, absorption of the drug can be quickly stopped by inflating the cuff. Generally the ectopic rhythm breaks at this point. When it does, or when the patient is experiencing uncomfortable or alarming symptoms, intravenous administration of the atropine immediately relieves the effect of Mecholyl.

6. Atropine Sulphate (hypodermic tablets grain 1/150). This drug may be used in combination with morphine or in instances as above described in neutralizing the effect of Mecholyl.

7. Quinidine Sulphate (tablets grain III). Quinidine sulphate may be administered in cases of paroxysmal arrhythmias that respond to quinidine therapy.

8. Mercurial Diuretics (2 cc. ampules). A preparation should be chosen that can be given intramuscularly without discomfort. Some of the newer products on the market can now be so administered, yet produce excellent diuresis.

9. Theophylline Ethylenediamine (Aminophylline). This is an excellent preparation, when slowly given intravenously, in doses of grain 3 3/4. It is especially useful for the treatment of acute asthma, acute pulmonary edema, Cheyne-Stokes respiration, and occasionally for the pain of coronary insufficiency. . . .

10. Epinephrine (ampule of 1:10,000 and/or adrenalin in oil). Epinephrine is a very useful preparation but is often misused in the treatment of peripheral vascular collapse and in the shock state associated with coronary disease where its administration can produce fatalities.

11. Ergotamine Tartrate. Ergotamine tartrate, DHE-45, or one of the newer preparations for the onset of severe migraines, should be included.

12. Hypodermic tablets of nitroglycerin (grain 1/200). Nitroglycerin may be administered beneath the tongue, not more often than three in one hour, in an attempt to relieve the pain of coronary insufficiency. . . .

13. Penicillin. One of the long-acting injectable penicillin products.

14. Sulfonamide preparation. An oral sulfa preparation.

15. Glucose. Ampules, 50 percent.

16. Aspirin.

17. Codeine and aspirin capsules.

Little need be said in this paper regarding the equipment carried in the bag, since it would be governed by the type of practice in which the different doctors are engaged. It is understood that all should have blood pressure apparatus, stethoscope, percussion hammer, flashlight, tongue depressors, and thermometers as well as sterile syringes and needles or equipment with which to sterilize them. Cotton, alcohol, and four tourniquets are essential. Some might carry blood counting equipment or culture media for throat swabs, otoscope, ophthalmoscope, catheters, sterile gloves, sutures, needles, scissors, and other such essentials. . . .

--William Hyatt Gordon, M.D.

Commentary

I felt pangs of nostalgia on reading Dr. William Hyatt Gordon's article "The Doctor's Bag--What Should Be in It," published in the April 1950 issue of GP. I entered rural family practice in 1964, in a small town in the Hudson Valley of New York. I arrived with my newly purchased black bag--the large "general practice" size, smelling of new leather. The first afternoon, my new FP partners sent me--with my new doctor's bag--on house calls, since, as the new doctor in the group, I had no patients of my own. Some early house calls I made are still seared in my memory, such as the irascible elderly man who threw me out of the house because I was not his usual doctor. In fact, he reconsidered on learning that his own doctor could not come for several days. In the end, I became his personal physician and attended him until he died a decade later.

Of course, as a new doctor, I gave a great deal of thought to what should be in my black bag. There would be no chance to run back to the office to get the right medicine. Dr. Gordon's list fairly well paralleled mine at that time, with a sedative, some antibiotics, analgesics, diuretic, epinephrine, nitroglycerine tablets, an ampule of 50 percent glucose, and so forth. Our list of instruments was also very similar. I never quite solved the problem of what to do with antibiotics requiring refrigeration.

My office was 18 miles from the hospital and from the nearest professional ambulance service. When there was a farm or auto accident in our area, I was expected to rush to the scene. Thus, I also carried a trauma bag with lots of sterile dressings and some Time magazines, which made handy splints, as well as a tank of oxygen.

How times have changed? Today, chiefly for economic reasons, there are many fewer house calls, although not because they would not be a valuable part of patient care. In a recent article in Medical Economics, the author describes family physician Thomas A. Cornwell, M.D., in DuPage, Ill., who has a "house-call only" practice. The article quotes Dr. Cornwell saying that house calls typically yield about $100 each in fees, and yet the practice loses money.¹

Today, from time to time, I make a visit to a patient's home. And I still own a black doctor's bag, although much smaller than before. In it I keep some basic equipment such as an extra stethoscope, flashlight and reflex hammer, but generally I stock the bag before departing with what I think will be needed for the specific house call I am making.

Will the black bag make a comeback? It might. Patients still love the house call. Sadly, we have largely abandoned home care to our colleagues in nursing. If we could find a way to make house calls cost-effective--as they seem to have done in England--we would each need to buy and stock a new black bag. The contents would be remarkably similar in categories to those described by Dr. Gordon. Of course his (mercurial) diuretic would probably now be furosemide and his ergotamine tartrate today might be sumatriptan. I would also probably add a portable computer with a modem to transmit EKG tracings and obtain consultation. What seems striking is how little has changed in the general types of supplies and equipment we would need, if only America could find a way, once again, to afford the doctor with the black bag.--Robert B. Taylor, M.D.

REFERENCE

1. Preston SH. The bottom-line case for making house calls. Med Econ 2000;77(4):114-22.

Dr. Robert B. Taylor is a 1961 graduate of the Temple University School of Medicine, Philadelphia, and trained at the U.S. Public Health Service Hospital, Norfolk, Va. He was in private practice for 14 years in New Paltz, N.Y., before joining the faculty of Bowman Grey School of Medicine in Winston-Salem, N.C. Dr. Taylor moved to Oregon Health Sciences University School of Medicine, Portland, in 1984, where he served as chair of the family medicine department until 1998. In addition to writing a number of medical textbooks, he has earned several distinguished awards, including the AAFP Thomas Johnson Award, in 1998.