The doctor’s bag in 1906: lessons for the modern doctor
David J Unwin, FRCGP
As part of a new exhibition on research in general practice, a fully stocked doctor’s bag from 1906 is on display in the entrance of the RCGP building at 30 Euston Square.
The exhibition, which opened on 19 September to coincide with the College’s involvement in London Open House, serves as a reminder that the medical world is constantly undergoing innovation and change.
The bag’s contents give a fascinating insight into the daily work of the original owner and the drugs that were in common use at the time. They include fifty nearly full glass tablet bottles labelled with contents, dosage and indication, and a silver hypodermic syringe and tablets to be made up with water.
Possible lessons for 2015?
The doctor who first bought this bag would have believed himself to be thoroughly modern as we do today. It would not have occurred to him that future doctors would been appalled by his treatments. After all they had the basis of many scientific experiments backed up by numerous learned journals! Each generation of doctors believes themselves to be modern. Is it likely that in 50 years all our treatments will still be appropriate?
Confidence in our modern judgement may be boosted by twenty years of ‘evidence based medicine’ but worrying storm clouds are gathering around the complexity of patient needs and current evidence and advice.1
A recent example of possible problems would be the surprise news in the BMJ that we must treat women with low bone density using bisphosphonates for three years for primary prevention of each hip fracture.2 Who knew?
Truth in medicine would seem to be something of a holy grail, we strive for it, but at any time in history it is represented by a ‘best guess’ that evolves constantly.
Let’s see what the up to date Edwardian practitioner was using:
A fever? Try Mercurous chloride: ‘Ten to thirty tablets a day’
Mercurous chloride (HgCl) is also known as calomel, a popular drug from the 1800s. It was prescribed for a number of infections – most notably syphilis. However, as mercury is highly toxic it tended to act as a slow poison rather than a cure. Calomel was used as an antiseptic and laxative during the First World War, but its main function was to combat sexually transmitted infections.
Tired all the time? Try arsenic: ‘One or two tablets three times daily’
Fowler's Solution is a potassium arsenic solution that was prescribed as a general tonic from about 1786 to 1936. The carcinogenic nature of arsenic compounds caused numerous disastrous side effects including cancer and cirrhosis. Some say Charles Darwin used it often.
Tickly cough or joint pain? Try Heroin: ‘One tablet every three hours’
The drug that Bayer launched under the trademark Heroin in 1898 was not an original discovery. Diacetylmorphine, a white, odourless, bitter, crystalline powder deriving from morphine, had been invented in 1874 by an English chemist, C R Wright.3
Scientists had been looking for some time for a non-addictive substitute for morphine, then widely used as a painkiller and in the treatment of respiratory diseases. If diacetylmorphine could be shown to be such a product, Bayer would make a lot of money.
It was tested on some of Bayer's workers and they loved it, some saying it made them feel "heroic" (heroisch). So the brand name was easy. Bayer presented the drug to the Congress of German Naturalists and Physicians, claiming it was 10 times more effective as a cough medicine than codeine, but had only a tenth of its toxic effects.
Mailshots and free samples were sent out by the thousand to physicians in Europe and the USA. Between 1899 and 1905, at least 180 clinical works on heroin were published around the world, and most were favourable, if cautious. In 1906, the American Medical Association approved heroin for medical use, though with strong reservations about a "habit" that was "readily formed".
Final thought: Crisis in evidence based medicine?1
Reflecting on the contents of the bag, I couldn't help but reflect on the future of today's primary care and the issues we face:
- The evidence based “quality mark” has been misappropriated by vested interests
- The volume of evidence, especially clinical guidelines, has become unmanageable
- Statistically significant benefits may be marginal in clinical practice
- Inflexible rules and technology driven prompts may produce care that is management driven rather than patient centred
- Evidence based guidelines often map poorly to complex multimorbidity
The exhibition, located in the café and ground floor of the RCGP headquarters Opens on 19 September 2015 and will run until September 2016. For further information about the exhibition contact email@example.com
The doctor’s bag is on loan to the College’s museum collection due to the generosity of the widow of the late Professor Alan Percival of Liverpool University.
1Greenhalgh T, Howick J, Maskrey N. Evidence based medicine: a movement in crisis? BMJ (Clinical research ed). 2014;348:g3725
2Jarvinen TL, Michaelsson K, Jokihaara J, Collins GS, Perry TL, Mintzes B, et al. Overdiagnosis of bone fragility in the quest to prevent hip fracture. BMJ (Clinical research ed). 2015;350:h2088
3Askwith R. How aspirin turned hero. Sunday Times. 1998