The Carmichael Papers: A Collection of the University of Virginia Library

By Laura Shepherd, MD

(Shepherd, as a third year resident, wrote this paper for the Twentieth Annual Department of Internal Medicine Research Day, University of Virginia Health System, April 9, 2001. Papers presented for this forum are the culmination of research projects accomplished during the previous years.)

The Carmichael collection, purchased by the University of Virginia Library on January 30, 1998, consists of approximately seven hundred notes, receipts, and letters written to James Carmichael and his sons from 1819 to1830 and a daybook dated 1816-17. These documents, written by wives, husbands, children, siblings, parents, overseers, owners, and the patients themselves, pertain primarily to patients’ symptoms and complaints including requests for urgent visits, advice, or additional medications. A number of the notes were written to accompany family members or slaves as they visited the physician at the office in town. Additional letters regarding shipments and receipts or invoices for purchases allow a glimpse into everyday nineteenth-century life and the role of the physician in the community.

James Carmichael was born in Glasgow, Scotland, on November 30, 1771. At an early age, he moved to Fredericksburg, Virgina, where he lived with an uncle, Dr. George French. He attended medical school in Edinburgh, Scotland, and moved back to America at the age of twenty. He married Elizabeth Hackley on June 12, 1794, and together they had six children who survived until adulthood: Edward, Richard, George, Janet, Ellen, and Ann. In 1815 Dr. Carmichael bought a house on Hanover Street in Fredericksburg that had been built by Charles Yates between 1771 and 1790. Dr. Carmichael practiced medicine from a small brick office on the property. Later, his sons Edward and George joined his practice, followed by George’s son, Dr. Spotswood Carmichael, and then George’s grandson, Dr. Randolph Carmichael. James Carmichael died June 14, 1831, and was buried at the Masonic Burial Ground in Fredericksburg (Gordon 2). His obituary read, “Few men of the Faculty have had a wider range or been more successful as a practitioner of the healing art—He was justly regarded as very skillful and had the highest confidence of the community in which he lived and died” (Virginia Herald).

When Carmichael arrived in Virginia, Fredericksburg was a well-established community that had been founded in 1728 on the banks of the Rappahannock River and incorporated as an independent town in 1782. According to Wyndham Blanton in Medicine in Virginia in the Eighteenth Century, the population of Fredericksburg was approximately two thousand (Blanton 313). Blanton also writes,

Other physicians of Fredericksburg during this period were Ewen Carter, a partner of Hugh Mercer; Thomas Powell, who moved up from Yorktown in 1776 and occupied Dr. Mercer’s old shop; Dr. Hand, 1785; Dr. Gills; and Dr. James Carmichael, who was the first of a long line of Carmichael physicians and a vestryman of St. George’s Church. He is found treating yellow fever in 1800 (Blanton 360).

The patients served by the Carmichaels during the period of this correspondence included not only townspeople but also farm families and slaves from Spotsylvania and the surrounding counties.

The nineteenth century was a period of transition for the medical profession. Scientific discoveries would change the understanding of diseases and methods of treatment. William Cullen, who lived from 1710 to 1790 and was the most famous medical teacher at the Edinburgh medical school, probably influenced James Carmichael. Cullen advocated three institutions of medicine: physiology, pathology, and therapeutics. He classified diseases based upon their symptoms and believed that disease affected the body as a whole rather than one body part or organ. Although there was less adherence to the Hippocratic teaching of the four humors—blood, yellow bile, black bile, and phlegm—there remained dedication to the concept of balance. Areas garnering research interest at the turn of the century included anatomy, blood, and the nervous system. Unifying theories applicable to all diseases were promoted, and descriptions of various diseases were published. The idea of balance can be seen in the dominant therapies of the day including bleeding, purging, and cathartics. In William Buchan’s introduction to Domestic Medicine, initially published prior to 1800, this idea is expounded upon for lay practitioners:

The principle evacuations from the human body are those of stool, urine, and insensible perspirations. None of these can be long obstructed without impairing the health. When that which ought to be thrown out of the body is too long retained, it not only occasions a plethora, or too great fullness of the vessels, but acquires qualities which are hurtful to the health (Buchan 151).

The concepts of cells and germ theory remained on the horizon.

In early nineteenth-century Virginia the practice of medicine was not limited to those educated in medical schools or serving as apprentices to physicians. Due to financial concerns and difficulties with transportation, the dispensing of therapy often fell to family members, slave owners, and the wives of landowners.  The collection includes a series of letters to the Drs. Carmichael from William Herndon from January to March of 1820 regarding the illnesses of slaves. Herndon writes of a young man suspected of having mumps, “Isabella has given him a Cathartick. I shall blead him today… Isabella our Doctriss has believed flaxceed tea proper, however your advice & what medisin you may think proper will be greatfully received.” [see letter] Several weeks later Herndon discusses another slave, “We have a little boy two years old that is & have been very sick principally with worms.—Isabella the family doctris, has given him worm sead oil… she has also given him two doses of calomel & a dose of salts.” [see letter]  Public records indicate that William Herndon’s wife was named Isabella, and these letters may refer to her in the role of the “doctriss.” Numerous additional letters cite the administration of medical treatment by women to patients, although it would be years later in 1849 that the first woman to receive medical training, Elizabeth Blackwell, earned her degree (Lyon 569). In a note of March 13, 1827, Elizabeth Withers requests care from the physicians for a boy with a toothache, “I have given salts, had him bled, and applied blisters, which has no good affect. The pain still continues violent - and I am apprehensive.” [see letter]

In order to assist lay persons in dispensing medical care, several texts were available and popular in the early nineteenth century. Buchan encouraged self help in Domestic Medicine:

By attending the sick, and carefully observing the various occurrences in diseases, a great degree of accuracy may be acquired, both in distinguishing their symptoms, and in the application of medicine. Hence sensible nurses and other persons who wait upon the sick often know disease better than those who have been bred to physic (Buchan 166).

A similar text by John C. Gunn, Domestic Medicine or Poor Man’s Friend in the Hours of Affliction, Pain, and Sickness, describes common diseases and therapies. He writes in detail how to perform bleeding with venesection or leeching and blistering (Gunn 738). Both authors explain medication preparation with dosing information and conservative interventions referred to as a “regimen” including dietary changes, clothing recommendations, and hygiene. In the Carmichael collection many notes refer to some type of home therapy instituted prior to seeking a professional opinion. While this certainly decreased the number of trivial calls, the acuity and severity of the cases were probably higher once the physicians were finally sought. Several of the urgent letters request that the Drs. Carmichael send another physician if they were unavailable themselves. In February 1824 W.O. Brown concluded with, “If you can not Come please Send Some Surgical Gentl in Whom you have Confidence Please do not delay.” [see letter]  Samuel Alsop wrote in September 1824, “If you can not possibly go yourself send any physician you think best as The nature of the case will not admit of any further delay.” [see letter]  Due to the paucity of effective therapy for the majority of the prevalent diseases, the physician may not have had further treatment to offer at the conclusion of his evaluation.

A significant proportion of the illnesses that plagued nineteenth-century Americans consisted of infectious diseases. An 1818 account from Portsmouth, New Hampshire, indicated that of 118 deaths, 22 were due to consumption; 27 of fever including typhus, puerperal, inflammatory, and pulmonic; 4 of pneumonia; 3 of cholera; 2 of croup; and 2 of diarrhea and inflammation of the bowels (Pfeiffer 102). An array of infectious diseases is presented in the Carmichael collection, suggesting that this patient population is a representative sample of early nineteenth-century Americans and their illnesses. Antibiotics would not be available until almost a century later, but the ideas of the contagious nature of some illnesses and disease prevention with inoculation and vaccination had been incorporated into medical science. 

One of the most frequent complaints appearing in the Carmichael collection is fever. In October 1821 Robert Taylor writes, “My wife has been afflicted for nine day, with an ague & fever every other day. & during the fever a disposition to puke… The ague or rather chill is followed with high fever.” [see letter]  In the same month Charles Battaile penned, “My father this morning has had a return of the ague and fever, and desires that either of you would see him as early as convenient to-morrow-morning. It is accompanied with bad cold and very high fever.” [see letter]  Similarly Cary Selden noted in September 1822:

Louisa Brooks is very unwell with the Ague & Fever, or Billious fever, which does not yield to the Medicine she has taken; being rather delicate I am at a loss what medicine to give her, I wish you would ride over this forenoon and see her -- We are very sickly here. [see letter]

Many nineteenth-century Americans, including some physicians, considered fever a disease rather than a sign of underlying disease. Although the etiology of fevers remained elusive, fever patterns had been described. Interestingly, clinical thermometers were not in general use until around 1870 (Blanton 136). Buchan devotes a chapter in Domestic Medicine to a discussion of pyrexia:

A fever is the most general disease incident to mankind. It attacks every age, sex, and constitution, and affects every part of the body; nor is the mind itself free from its influence. A fever is known by a quick pulse, and increased heat, a general debility, and a difficulty in performing some of the vital or animal functions, as breathing, walking, etc (Buchan 174).

Fevers could be divided into continual, remitting—in which the temperature would increase and decrease but not return to normal, and intermittent—characterized by asymptomatic periods of euthermia. Intermittent fevers and associated chills were also referred to as agues and could be further divided into tertian—with fever and symptoms occurring every third day, or quartan—every fourth day (Buchan 182). Later this would be understood as malaria with tertian fevers due to Plasmodium malariae and quartan fevers due to P falciparum, P vivax, and P ovale, all transmitted through the bite of the female Anopheles mosquito.

Cinchona bark, also known as Peruvian bark, was an effective treatment for intermittent fever and had been known for several years.  In 1819 the active ingredient in the bark, quinine, was isolated in France (Rothstein 29). The Drs. Carmichael frequently used bark and quinine as evidenced by patient requests for additional supplies and receipts for such purchases. Invoices in the collection from George H. and J.S. Keerl, Druggists, no. 233 Market Street, Baltimore, cite the purchase of ½ oz Sulph Quinine in October 1823 [see letter], 2 oz Sulphate Quinine in May 1824 [see letter], 2 oz Sulphate of Quinine in September 1824 [see letter], and 2 oz Sulph. Quinine in April 1825. [see letter] In September of 1823 John Lomax wrote:

My wife is very Sick with an intermittent, Today is her sick day. The paroxysm came on about 3 o.Clock this morning, attended by violent head & Slight delirium. I will thank you to Send Some bark. And if you think there is any thing in her Situation which requires any particular course of treatment, please prescribe also. [see letter]

Francis Brooke wrote in September of 1824 regarding a patient named Helen, “about one OCloch She again had a return of Slight chill and has now a fever – we propose to give her again Quinine when her fever goes off if you approve of it, there are only two doses of what you left.” [see letter]

Other common complaints of the patients, particularly diarrhea and costiveness or constipation, involved the gastrointestinal system. James Maury wrote in June 1823 regarding a three-month-old child:

My little child’s bowels are very much disordered, they have been so for several days, his discharges are frequent & copious and very green, he has taken Rhubarb & paregorick and castor oil & chalk, he appears to be in great pain when he has an evacuation I will thank you to send me something to relieve him. [see letter]

In December 1820 Lucy Alexander, author of numerous documents, wrote about bowel-related afflictions:

The medicine I have been taking from you has relieved my head and bowels which are and have been for more than a fortnight in a costive state I am much afflicted with an uneasiness in my stomach… a heaviness at the pit of my stomach attended with a noisure which sometimes prevents my rest and I have a great deal of acid on my stomach… almost every thing I eat appears to disagree with me though I attend particularly to your directions with regard to regemin it appears to me that I have the cholic continually I had a very violent fit of it likely the obstruction I named to you still continues. [see letter]

James S. Cole wrote on behalf of Mr. Sutton in 1821, “his whole complaint appears to be in his bowels, with a Discharge upwards of something Black Similar to Sut in its appearance.” [see letter]  A letter from James Holliday reads:

Since my bowels is no better than when you saw me I have some days 15 or 20 pases during the day… I Cannot eat any thing pertickler of an evening when I go so often to the pot… I wish you Could send me some thing that will check it… what Comes is of a motlee tuff nater [tough nature] somewhat like snot with some little blood. [see letter]

Other patients wrote requesting treatment for “bloody passages.” The treatment of these various maladies included some combination of emetics, purgatives, laxatives, tonics, and anodynes or analgesics. In hindsight these symptoms were probably due to infections with bacteria, such as shigella and salmonella; parasites, such as amoeba and giardia; or viruses.  Other possible etiologies include malabsorption syndromes and inflammatory bowel disease.

Although cholera, with its profuse diarrhea of “rice water stools” and accompanying dehydration, caused epidemics in the United States, including Virginia, during the era of James and Edward Carmichael’s practice, it is not mentioned as such by the authors in the collection. This is probably due to the employment of inappropriate terminology by the patients rather than an absence of the infection. Certainly, if the Drs. Carmichael had not treated cholera in their patient population, they were aware of the presence and impact of the disease. A published letter to Dr. Carmichael of Fredericksburg, Virginia, written in September 1832 by Professor Granville S. Pattison of the Jefferson Medical School in Philadelphia is a response to Dr. Carmichael’s queries, “Is cholera asphyxia contagious, what causes operate in its production, and what system of treatment has been found the most successful?” (Bell 3). This letter was probably addressed to Edward or George Carmichael as James Carmichael died in 1831. In his fourteen-page response Dr. Pattison advocated that cholera is not contagious, has “the effect of operating specially on this system of nerves producing… mere diminished functional power,” and may benefit from treatment with mercury or calomel, cupping, and bleeding (Bell 11).

Numerous other infectious diseases afflicted early nineteenth-century Virginians.   Laurence Battaile wrote in February 1823, “his cough continued, & it seemed pretty well ascertained that it actually was the wooping cough.” [see letter]  In May 1824 Battaile also wrote, “My overseer, George Jones, requests me to inform you that his wife is extremely ill, having miscarried today, & also has the Measles.” [see letter]  Larkin Stanard, writing on behalf of his granddaughter in October 1824, stated, “The Youngest is very hoarse and I am afraid, she may have The Croup.” [see letter]  M. Jones explained in April 1821, “The bearer Judy takes her Child over to You… I believe it has the Hooping Cough as all our Black Children have it.” [see letter]  William Herndon noted in January 1820, “We have a boy about 18 or 20 years old, Who have the mumps,—he has been confind two or three days.” [see letter]  A.F. Rose wrote in May 1820, “My Daughter Maria was taken this morning about day light with violent symptoms of Croup pray send out Dr. Carmichael to me immediately—as I consider her to be in great danger delay not a moment for her life and my happiness depend on it.” [see letter]

The Carmichaels’ patients also experienced skin infections. In February 1823 Laurence Battaile wrote about an individual named Charles, “He had had an eruption of the Erysepelas on his breast & body for several days.” [see letter]  William Herndon noted in August 1821 of a slave, “she has some bad boils and sometimes a fever.” [see letter]  Other frequently mentioned lesions were ulcers. In March 1823 Jane Mitchell wrote:

my servant girl that you visited 4 or 5 years since, is very ill indeed… you recollect it was an ulcer of some description on her thigh near the joint, the sore discharges a considerable quantity of matter, and she complains of a most excrutiating pain, from her thigh down to her ankle, I have been disposed to think it was something of the Rheumatism, but I am doubtful about it. [see letter]

A series of letters from Charles Urquhart, Jr. to Dr. Edward Carmichael in the spring and summer of 1823 address his brother James’s leg ulcer.

I should be glad that you would Come up immediately on the receipt of this that we may have your counsel on the state of my Brother James- I find, that the ulcer is nearly as it was when I saw him last, except that the matter has acquired greater consistence & is increased in quantity since the introduction of the Seton—The issue below has not been such as I expected, but continues very small, & the greatest part of the pus comes out from the old track—This, I am confident, is owing to the small aperture that was made in the fascia of the thigh, which fascia, no doubt, had become morbidly thickened by Inflammation.

Urquhart continued in this same letter dated May 15, 1823, by explaining the effect of “the application of emollient poultices” and concluded:

My view of the case at present is this. viz. that an enlargement of the incision though the Fascia, should be made, so that the matter may have room to escape, without detention in the Sinus. - this operation, I suppose might be performed by a guarded Bistoury, or… Perhaps a knife concealed in a canula, might be introduced though the old Sinus. & the incision enlarged in that way… I have no probe longer that 6 inches & it would be well for you to provide yourself with one that would pass intirely through Say 8 or 9 Inches in Length. [see letter]

The instrumentation discussed in this letter, including the placement of a seton—a piece of thread or other foreign body placed in the skin or a wound to incite an inflammatory reaction, probably only served to expand or re-infect the wound. In a following letter dated May 28, 1823, Urquhart wrote that they:

pass the bougie twice a day thro the limb, but no matter at all comes out below, nor do we think the first abscess yields any; tho there is a considerable quantity from a cavity lower down the upper part of the thigh, which, comes thro’ the upper aperture & an incident exfoliation has taken place in the bone. a very small piece of which came away with the matter to day – James’s general health is not as good as when you were here, he has fever every night & sleeps but little…his appetite fails him, & debelity is the consequence. [see letter]

Subsequent letters, written in the summer of 1823, document the progression of James’ affliction. His abscess worsens, he suffers persistent sweats, and there is bloody drainage.

It is worth noting that in 1823, the procedures proposed by Urquhart were not performed under sterile conditions or with the benefit of anesthesia. Joseph Lister was the first to routinely use antiseptics to decrease the incidence of post-surgical sepsis in surgical procedures in 1867. Surgical anesthesia was not employed until 1842 when Crawford Long first used ether.

Unhygienic living conditions prevailed during the early nineteenth century and made the early Americans susceptible to not just bacterial and viral infections, but also to parasitic infections. Most rural people used the woods or emptied chamber pots into a nearby stream, yard, or garden. The rakings accumulated from around homes, yards, and slave quarters often became fertilizer for fields and gardens. As a result, farmers and slaves who worked the land and children who spent a great deal of time playing outside served as hosts for worms. The true prevalence of parasitic infections is not known, but literature supports the presence of Ascaris, the long roundworm, Trichuris, the whipworm, Taenia, the pork and beef tapeworm, and Diphyllobothrium, the fish tapeworm (Savitt 64). Necator americanus, the hookworm, also infected Virginians by penetrating the skin particularly of the feet and legs causing a cutaneous lesion, “ground itch” or “dew itch” (Savitt 68-72). In a previously cited letter William Herndon wrote, “We have a little boy two years old that is & have been very sick. principally with worms…he has past about thirty worms.” [see letter]  M. Jones explained in April of 1821, “I send you by the bearer Patty another sick Child… We thought he had Worms, & have given Calomel & Jalap together, twice in the course of the Winter.” [see letter]  Larkin Stanard wrote in June 1823, “Another negro boy of Rob. Stanards is now sick & was taken in the same way the other was with a pain in his head & high fevers… there has a good many worms come from him, the boy is about six years old… P.S. The other boy that was sick is dead.” [see letter]

Venereal diseases or sexually transmitted diseases were known to infect nineteenth-century Americans. In October 1820 F.S. Stoel wrote, “I send my boy Israel down for you to examine him, I have examined him, and find he has got the Pox.” [see letter]  Gunn described the pox as a venereal disease with “small inflamed pimples, which show themselves on the head of the penis or yard, or on the side of the penis near the end” (Gunn 425). The Carmichael collection includes a referral from another physician to Dr. Carmichael for therapy of a sexually transmitted disease. In June 1823 Robert Richardson wrote:

Mr. Sandy Chapman the bearer of this, has been for some time past a patient of mine—& in consequence of a fear of his disease being known by his fathers family he has prefered to remain in Fredbg under the care of some physician until he is cured. I have Sir, recommended him to you—When I first saw him, there was phymosis, & one large ulcer on the penum, discharging large quantities purulent matter, & also a good deal was discharged from the inside of t[he] prepuce—since that I have only seen him twice, he now has ulcers on the outside of the prepuce, which altho, cannot be called true chancres, I intended to treat as such, by the use of the blue pill, & extend (local) merc. applications—it is no doubt a case of pseudosyphilis. [see letter]

To update Dr. Carmichael, Mr. Chapman wrote on July 11, 1823:

I have since I saw you continued to take the pills (according to your prescription) until Tuesday last when my mouth became a little sore… The ointment I have likewise applyed in the [manner] you directed, on the sores, on the end of the penis which look I think a [little]. The skin I have not been able to get back yet;… The sores on the outside matter very freely; and so has the other until about two days ago when it stopped and has since that time looked very dry. [see letter]

It is unclear from the above information whether Mr. Chapman’s illness was syphilis, chancroid, or herpes. The primary treatment available to Dr. Carmichael for treatment of syphilis was a mercury preparation such as “the blue pill” (Gunn 777). Side effects of mercury therapy included excessive salivation, tongue swelling, a metallic taste in the mouth, and painful inflammation of the tongue, salivary glands, and gums as this patient noted. In his text Rothstein described the devastating effects of this treatment:

The mouth feels unusually hot, and is sometimes sensible of a coppery or metallic taste; the gums are swollen, red, and tender; ulcers make their appearance and spread in all directions; the saliva is thick and stringy, and has that peculiar, offensive odor characteristic of mercurial disease; the tongue is swollen and stiff, and there is some fever, with derangement of the secretions. The disease progressing, it destroys every part that it touches, until the lips, the cheeks, and even the bones have been eaten away before death comes to the sufferer’s relief (Rothstein 51).

Several references in the collection concern patients suffering from “ruptures.” Ruptures refer to hernias and were often managed by having the patient wear a truss, a brace designed to prevent prolapse through the defect. In January 1820 John Pratt sent his slave Scipio to see the doctor with the following note, “The bearer Scipio says he has a Rupture & stands in need of a Truss will you examine him & have a Truss put on him if necessary.” [see letter]  Pratt wrote again in February 1824, “I have sent a man to you who is much diseased with a Rupture, or a Watury testicle… [w]ish you to examine him & see if you can do any thing for him. if an oppe[r]ation is necessary, perhaps it might be best for him to return and have it done at home.” [see letter]  William Jones wrote in June 1824, “Doctr Carmichal will pleas to send by the Bearer a trus for a Negroe man who has got a Rupture.” [see letter]

Several letters describe dysfunction of the kidneys and urinary tract. In an undated letter A. Peck stated to Mrs. Mary Carter,

you will be so kind as to explain my case to Doctor Carmical & get his advice about this torturing malady [unclear] which I am so often afflicted:. Every attack is more and more violent and my constitution less able to bear them.: I suffered last week till I became apprehensive that convulsive fits would be produced. - Tell him I generally pass two peices of round gravel which are attended with pain that exceeds all I ever felt besides with a short interval between passing the first and [last] gravel. [see letter]

J. Herron wrote in January 1827, “Doctor Carmichael will please render what assistance he can to Hamilton Harding who complains of something like the Gravel.” [see letter]  Another letter addressed to Mr. Robert Taylor in October 1821 declared:

Sir I have a complaint. That is called the gravel, but I think it is nothing more than a Palsey of the neck of the urether, There is no gravel comes from me, & the urine is perfectly clear & no sediments in the pot, please to show this letter to Mr. Carmichal, & if he can Send me Some Medicine to Relieve me will greatly Oblidge. [see letter]

A letter from Brodie S. Hull in September 1821 noted, “A few days since I was taken with the same complaint which plagued me in January 1820, that of passing blood with the urine.” [see letter]  The aforementioned letters do not allude to the treatment employed, but a receipt from George H. and J.S. Keerl in Baltimore dated October 22, 1824, included notation of the purchase of “Weiss Forceps as made for Sir A. Cooper, for extracting very small Stones from the bladder.” [see letter]

Another condition that affected the Carmichaels’ patients was “piles” or hemorrhoids. In July 1823, George Banks wrote:

Mrs. B. has the Piles very bad, she was not, incommoded until last night abought 8. Oclock cince which the Payne has been unceasing and frequently most excrutiating – She has taken Cream Tartar, and applyed a poultice, to the part, this seems to have had no good effect, the Payne increases and the part enlarges. [see letter]

J. Smock wrote in March 1825, “Have bin troubled with the pils. But thay are Better. I am afeard of the ointment this weather. is it not dangeris please my friend answar these questens.” [see letter]

Other authors and historians have noted the prevalence of consumption during the nineteenth century. In the previously cited data from Portsmouth, New Hampshire, consumption was named as the primary cause of death in 22 of the 118 persons (Pfeiffer 102). Consumption is thought to be an infection with tuberculosis although certainly some of the cases of wasting syndrome may be due to other chronic medical problems. No letters or notes in the collection refer specifically to consumption, but there are several references to persistent coughs and fevers. Two letters mention another, now common, pulmonary complaint: asthma. In April 1820 Sam Skinker penned, “Mrs. Julian has laboured under a most severe attack of the astma for the last fortnight she has taken during the time anti bilious Pills, Magneasia, Peppermint, Ether, and Laudanum and still continues to have it.” [see letter]  W. H. Hooe wrote in September 1825, “The bearer Caroline is & has been for some time much afflicted with astma, & perhaps combined with some other malady… she is about 34 yr’s old, & has been troubled with astma about a year.” [see letter]

Clearly, the patients presenting to the Drs. Carmichael suffered a wide array of diseases, many of them infectious.  However, some of the most common diseases of today—namely cardiovascular disease, diabetes, and cancer—are noticeably absent or at least very infrequently mentioned. The following letters are notable because they do indicate cardiovascular disease.  William Herndon wrote in December 1825:

My wife still complains of a voilent palpatation of the heart & short ness of breath at times sometimes her feet are very Hot & then very cold with a dead numness & pain over her whole sistem. She cant bear fatagues even the getting into bed causes palpatation & shortness of breath. [see letter]

This description may refer to a patient with congestive heart failure, arrhythmias, or rheumatic heart disease. “Dropsy” was the term used to apply to swelling in the limbs. In 1785 William Withering identified the active ingredient, digitalis, in the foxglove plant. During his examination of the new agent he noted that it worked for some types of dropsy but not others and that it could have toxic side effects (Lyons 489). These observations are now understood because digitalis is an effective treatment for congestive heart failure but of no utility in treating edema or swelling from other nephrotic syndromes, malnutrition, myxedema, or other diseases. In April 1823 Laurence Battaile wrote, “Charles has a fellow lately taken with a Dropsy—He wishes you to bring some medicine proper for him.” [see letter]  A month later Battaile stated, “The old Man has got well of the Dropsy & has gone out to work. But it may be necessary he should still take bitters, or something to prevent a relapse.” [see letter]  Another letter alludes to the deficits caused by a stroke. Fanny Spindle wrote in June 1826:

his speach is very bad it is with dificulty at times that we can understand him he complains of the right side of his head and neck frequently feeling tired and in pain his mouth is very much drawn to the left side and it is with dificulty that he can stand up with assistance I go by your directions in his diet and everything else. [see letter]

Only one letter mentions cancer. William Richardson wrote, “Charles has a sore on his arm which is of several weeks standing - and I am afraid it is something like Cancer. He is of opinion that it proceeded from the Bite of a Tick: will you be so good as to examine it and direct what is to be done.” [see letter]  In the early nineteenth century diabetes was known as a disease of the kidneys resulting in frequent urination and sweet smelling and tasting urine, but no reference to diabetes is noted in the Carmichael collection.

In addition to the management of diseases, the Carmichaels treated various injuries. In an undated letter James Mitchell declared, “My son has got a fall from a horse & it appears that the Back of his hand is altogether out of place or Brok be So good as come with the Bearer with all Speed… P.S. The Boy is in great pain.” [see letter] W.O. Brown wrote in February 1824:

It is the request of Doctr Clayton that you would come up to Mr. William Skinkers immideatily—his Son John Skinker has by a fall from a horse received a Very Severe injoury on the head—the Doctr thinks a fracture of the Skull—he lies in a State of Stupufaction—perhaps Trepaning Will be Necessary—If you can not Come please Send Some Surgical Gentl in Whom you have Confidence Please do not delay. [see letter]

Brown suggested the need for trepaning which would have entailed the use of a specialized surgical instrument to remove a core of bone from Skinker’s skull. Polly Fox wrote in August 1821, “My overseer - is very much indisposed with a wound on his knee- recieved by falling on a rock—When running.” [see letter]  Samuel Alsop consulted the doctors in this letter of January 1822, “Will you be so good as to Examine the boy (Edmunds) Arm, and See what is the matter with it - I believe his elbow i[s] out of place.” [see letter]  John Clark wrote in February 1827, “Ned unfortuneately got his fingers frost bitten. The last freeze and I never have noticed them particular untill this morning. They appear to be in a dangerous situation—I wish therefore you would examine them and if they can be cur.d without cutting I shall be glad.” [see letter]  The collection also includes this urgent request from James Long in June 1823, “I should thank you to come to newpost quick as possible if you can not come I should thank you to send Doctor Wallace or the best Doctor you can. A little negroe boy has nearly cut out one of his privates.” [see letter]

Patients also consulted the Carmichael physicians to assist with childbirth. These letters suggest that the physicians were called in cases with protracted labors or other difficulties, while midwives, or other persons in the home or community, managed uncomplicated deliveries. In September 1824 Samuel Alsop wrote, “I have a woman who has been in labour ever since Monday and can not bring forth. Be so good as to go down and see her (this evening.)” [see letter]  Francis Brooke stated in January 1821, “Mrs. Brooke has been in Labour Mrs. Newton thinks the greater part of the night I fear by the time you can get here your assistance will be truly important and therefore request you will come with as much haste as you can.” [see letter]  Thomas Seddon wrote in April 1822, “I have a Negroe Woman on my Plantation in Labour She Requires your aid… I Just Recd a note from my overseer who says it is an Urgent Perhaps a Calcutta Case.” [see letter]  A letter from D. Gatewood in January 1825 reads:

I have a woman Very ill She has been in labour ever Since Monday Night 9.oclock, And Cant be delivered… She has the Cramp so bad that they Cant do nothing with her Says all her Misary in her thighs, they Say the child is right And nothing is rong as they can discover, She is of Middle age & Several years Since She had a child. [see letter]

During the early nineteenth century American physicians and apothecaries often served as dentists. The Carmichael collection includes several letters requesting tooth extractions. In February 1820 C. Jones penned, “I will thank you to have a Tooth Extracted for the Bearer Ned.” [see letter]  In March 1820 Laurence Battaile wrote to James Carmichael, “As it may not be convenient for you to come down, I should be glad if your Son would come today & bring with him such medicines as he may think necessary… & also his tooth drawers.” [see letter]  On the preceding day Battaile had written:

Mrs. Battaile has been much afflicted with the toothach lately, & is now pregnant, she wishes you to come down & extract it for her, remembering the safety with which you extracted one for her some years ago—She is very timid, & her situation, perhaps, renders her more so at this time. [see letter]

John Gunn’s Domestic Medicine includes a detailed description of the few classes of medications available to nineteenth-century Americans. He divided agents by function into the following classifications: emetics, purgatives, laxatives, antispasmotics, tonics or bitters, stimulants, anodynes or analgesics, and mercury preparations. The emetics included ipecacuanha, tartar emetic, and white vitriol, a zinc sulphate (Gunn 755). Laxatives, according to Gunn, were meant to “gently open the bowels” and included castor oil, sweet oil, charcoal powder, Magnesia, and Cream of Tartar (Gunn 761). Purgatives, less gentle and aimed to purge the patient freely, included calomel, a chloride of mercury; jalap; Epsom salts; rhubarb; Lee’s Antibilious Pills containing calomel, jalap, and tartar emetic; and Cook’s pills containing rhubarb, calomel, and aloes (Gunn 759). Antispasmotics included opium, laudanum, peppermint, and asafoetida.

Other agents were bitters, used to treat fevers as previously discussed, and tonics administered in hopes of giving “tone and strength to an irritable weak stomach” (Gunn 768). This group included Peruvian bark of which there were three kinds—red, yellow, and pale—as well as dogwood bark, gentian root, Virginia snake root, chamomile, and Spirits of Nitre. Stimulants included sulphuric ether, opium, oil of turpentine, and spirit of lavender. Anodynes, prescribed to ease pain and induce sleep, included opium, laudanum, and paregoric containing opium, laudanum, flowers of benzoic, and camphor (Gunn 767).

Elizabeth Withers wrote in January 1826, “I give from six to eight doses of bark in camomile tea daily.” [see letter]  St. Leger Landon Carter wrote in October 1823:

she gave Mr. Brent the camphorated julap as you directed with good effect…he began to complain of a griping occasioned by the dose of sulphur which increased to so great a degree that he insisted on taking laudanum—& she gave him 30 drops & soon afterwards 40 more which relieved the pain in a great measure—Six doses of bark have been administered. [see letter]

In October 1821 Charles Battaile wrote from his farm, Prospect Hill, “he would be glad to have some parigoric, extract of bark, sweet Spirits of Nitre, & also ingredients for bitters and such other medicines as you may think proper.” [see letter]  Invoices from the Keerl brothers record the purchase of 20 pounds of best pale bark, 9 pounds of Spirit of Nitir, 1 pound of opium, and 1 dozen bottles of castor oil in August 1823. [see letter] An April 1825 invoice notes that “3 bottles of Sweet Oil and 2 oz raw Seneka” were sent by way of the schooner Laura Jane from Baltimore. [see letter]  A receipt of October 1823 notes the purchase of two dozen Lee’s Pills and lemon caustic among other items. [see letter]

Patients often used a combination of remedies for the gastrointestinal system (Gunn 767). In October 1821 Robert Taylor stated that his wife took “a dose to tartar & one of Calomel & Julup.” [see letter]  Y. Johnson wrote in June 1821, “I deemed it prudent to take a small dose of Colomel at night, & in the morning a dose of Epsom salts… I have been compe[lled] occasionally to take a little Rheubarb.” [see letter]  William Richardson wrote in May 1824, “I gave him a Large dose of Calomel & Jalap Which operated very well.” [see letter]  In September 1820 Beverly Stanard explained, “On thursday evening last I took 20 grains of Calomel and on friday aided the operation by 2 table spoon full of Caster Oil which in the course of the day brought off a considerable quantity of bile.” [see letter]

In studying these letters and notes, recurrent themes or theories of treatment become evident. Many of the treatments are based upon maintaining balance with the body’s fluids and excretions. At the time these letters were written, the therapies known to be effective and disease specific included foxglove or digitalis for dropsy, mercury for syphilis, and quinine for intermittent fever. While other remedies produced responses including vomiting and bowel movements, they probably did not impact the course or outcome of the disease. From the patterns of use described in these letters, many of these medications were used much more broadly than the indications noted above.  Bark, Peruvian, pale, or otherwise, or bitters were used for all febrile illnesses and even illnesses without fever, and mercury was administered in all venereal disease.

The use of these various medications also induced some unwanted side effects. As previously mentioned, mercury and calomel, used primarily for treatment of venereal disease, had cumulative toxicity involving the salivary glands, tongue, gums, and teeth. The collection includes an unsigned letter of March 1822 that reads, “She is at present evidently under the influence of mercury altho’ not much salivated.” [see letter]  Another difficulty with these medications was its poor palatability. In September 1820 William Bernard wrote, “I think you had better send only one paper of the mixed bark, as I do not expect I shall be able to get the girls to take it wel.l” [see letter]  The addictive and sedative properties of the commonly used anodynes, opium and laudanum, were known. Beverly Stanard penned in January 1821, “Be so good as send me a box of anodyne pills which I will take care to use with great caution.” [see letter]  As noted in the following letter, the most dramatic effects were related to the overzealous use of emetics and purgatives and the severe or prolonged effects of these agents. Francis Brooke wrote in March 1821:

The Emetic operated So violently that Mrs Brooke had nearly expired under it She was So convulsed that it was Some time before She was restored by hot Bricks to the feet, and flannels diped in Spirits applied to the Breast &c She was better however the next Day though So weak as to Decline taking the powders untill yesterday. [see letter]

Mrs. Brooke demonstrated great fortitude to resume taking the powders at all after the severe reaction she suffered. The patients’ willingness to submit to the harsh treatments available at the time attests to the prevalence of high mortality rates and the belief that all disease without intervention caused death.

In addition to medications, another commonly used treatment was bleeding. In Domestic Medicine, William Buchan outlines the appropriate indications for bleeding:

Bleeding is proper at the beginning of all inflammatory fevers, as pleurisies, peripneumonies, etc. It is likewise proper in all topical inflammations, as those of the intestines, womb, bladder, stomach, kidneys, throat, eyes, etc; and also in the asthma, sciatic pains, coughs, head-achs, rheumatisms, apoplexy, epilepsy and bloody flux. After falls, blows, bruises, or any violent hurt received either externally or internally, bleeding is necessary. It is likewise necessary for persons who have had the misfortune to be strangled, drowned, suffocated with foul air, the fumes of metals, or the like (Buchan 696).

If a physician regularly employed these indications, it would be a rare patient who would not undergo bleeding. Several methods of bloodletting were commonly used. According to Savitt, in venesection:

the operator took a small, sharp knife known as a lancet and incised the vein, taking care not to sever it and nick the pulsating artery beneath it. Blood flowed from the wound into a strategically placed bowl. Pressure applied to the incision stopped the bleeding when an appropriate amount had been removed (Savitt 39).

A wound could also be made by a scarifier, a cube-shaped instrument with six to thirty-two tiny blades attached to a spring that when sprung could make multiple bleeding incisions. In some places leeches were available to be used for bleeding. The Carmichael collection includes a number of letters that refer to bleeding. At times the physicians performed this procedure while in other cases it was done by a family member. In May 1823 John Knox wrote, “Judy, the bearer wishes to be bled; if Doctors Carmichael think it necessary, they will please have her bled & charge the Estate of Maj Jones.” [see letter]  In March 1820 William Herndon wrote, “if letting of blood be necessary, please send me a lancet - mine is two dull for any purpose.” [see letter]

Cupping was performed with the placement of a cup on top of the wound. Flammable material was burned in the glass cup prior to placement to exhaust the cup of air and create a suction and seal when applied to the skin. In a procedure known as dry cupping a cup was applied to the skin without a prior incision but after burning to create an irritation that would proceed to wound formation. This was believed to draw blood, pus, or other impurity to the surface (Savitt 39-40). Based upon a principle similar to dry cupping, blistering was the application of a caustic agent to the skin to incite irritation and subsequent drainage.

Although all of the interventions noted above were designed for treatment purposes, one method of disease prevention was available to nineteenth-century physicians including the Carmichaels. Smallpox came to the New World with the earliest settlers. Inoculation had been used in Europe for many years, but in 1798 Edward Jenner’s work shifted the focus from inoculation to vaccination with cowpox as the primary means of smallpox prevention (Bordley 33). In the Fredericksburg newspaper, The Virginia Herald, on December 13, 1820, there is a citation that Dr. James Carmichael had been an auxiliary agent for vaccine administration by the National Vaccine Institution. Despite availability of the vaccine, new cases of smallpox continued to appear. In April 1828 Mary F. Skinker wrote to Edward Carmichael:

We are in a great state of alarm, having heard this morning that our neighbor Mr. Henry Somerville, has the small-pox…Mr. Skinker, & other persons were with him while his fever was high, & some appearance of the irruptions We wish you to come up, and vaccinate our Children & negroes, & pursue what course, you think best, to prevent this disorder from spreading through our family. I have had the small-pox. Mr. S-r has been vaccinated, but the children did not take the vaccination, administered by you, when you were last here. [see letter]

The Carmichael family is unusual as several physicians worked together in the same practice. Surely this was a great benefit for the patients and their physicians as they were able to confer regarding difficult cases to enhance patient care and their own medical knowledge. The Carmichael collection includes several letters written by other physicians. One previously mentioned letter describes a patient with venereal disease who was referred for continued mercurial therapy. Another letter, dated April 13, 1827, and written at the request of a Dr. Minor, asks Dr. Carmichael to visit and render an opinion on his illness:

Dr. Minor desires that you will come up and see him immediately, on Sunday next if possible…he is convinced that unless some plan of treatment be adopted, and rigidly followed, there is no hope. As he has more confidence in your skill and judgment than in that of any other Physicians in this part of the country, he is induced to apply to you for advice, and to follow closely whatever course you may think best, and although you have seen him before, and know the nature of his case, he thinks, that a more correct opinion may be formed from seeing him again, than can be from a letter… although it is not customary for Physicians to make any charge for services rendered to each other, he is determined to make you a liberal compensation. [see letter]

The collection contains an undated letter from Dr. John Moncure Daniels requesting the assistance of Dr. James Carmichael:

I am at present attending the eldest daughter of Mrs. Jane Mitchell in a dysentery - She is naturally delicate and the case is attended with some very troublesome symptoms - extreme irritability of stomach - violent pain in the bowels - occasional vomiting of dark bile - By blistering the abdomen I have been enabled to evacuate the bowels partially of fecal matter, but her stomach has become so exceedingly irritable that no cathartic can be retained - too much fever for anodynes - pulse will not bear bleeding - injections afford little relief tho’ freely used - I write at the earnest request of the young lady to request your particular attendance in person. [see letter]

One of the most interesting letters is from Dr. William S. Fife dated April 26, 1823. He described “a very extraordinary case which came under my notice a few days ago.” He proposed to make Dr. Carmichael aware of the case “as medical knowledge is the grand point in which we are all striving to obtain… and not knowing anyone whose reading has been so extinsive and who has had so good an oppertunity of obtaining medical knowledge as you have.” He described a seventy year-old lady whom he had treated for a cough. After initial improvement he was called again to find upon seeing her that, “she was about entering upon a nother woreld.” He continued:

I asked the servent the cause of the offencive smell that was in the room she told me the patient would not allow her to remove her and wished no person to touch her she likwis told me (to use her own woords) that she was half man half woman and she was afraid leest it should be discoverd.

He examined her on the day following her death and found:

to my very great astonishment… on the right Labia Pudendi a bag like a scrotum containing only one stone The clitores was very long nearly two inches and resembling very much the appearence of the male penis… Now Sir if you have ever meet with any case in all your extensive reading or practice resembling the above mentioned I shall look upon it as a great favour if you will let me know. I have mentioned the case to no one except yourself.

Fife concluded the letter by briefly summarizing his practice in the preceding year and then expressing gratitude to Dr. Carmichael:

I canot think of concluding this letter without returning my sincere thanks to your Father for it was him who first implanted in me the first principles of my profession and methinks he can say with Linnaeus when he is about to resign his profession “I have ranged” saies he “through the thick and shady forests of nature. I have in my rambles found many sharp and perplexing thorns. I have as much as possable avoided them. But I have learned at the same time that attention and foresight do not always conciliate perfect and entire safety. I have therefore quietly borne the derision of grinning satyrs and the jumps of monkeys on my back.” Such is the nature of our profession if I may be allowed the expression that even our Brethren are our greatest enemyes But I have been perhaps more than fortunate in falling among physicians who have don all that thay could do to get me into practice. [see letter]

This letter implies that most physicians practiced individually but might confer in extremely difficult cases with trusted associates.

Medical education remained a priority not only for young men interested in entering the profession, but also for those already practicing. James Carmichael received his degree from Scotland prior to his immigration. By 1810 five medical schools were in operation in the United States: The College of Philadelphia, King’s College in New York, Harvard Medical School, Dartmouth College, and the University of Maryland (Bordley 15). The University of Virginia conferred its first medical degrees in 1828, although medicine was included in the University’s curriculum from the first term in March 1825 forward. Other means of obtaining medical experience included working with practicing physicians either as an apprentice or after formal medical training. Letters in the collection suggest that the Drs. Carmichael assisted multiple young doctors and students. In an undated letter Elkanah Talley wrote regarding a small child with a foot lesion, “the riseing is the most singular one I ever saw or heard of therefore it will be worthy of your attention as well as your students to see come quick.” [see letter]  B. W. Bramham wrote on March 4, 1824, to Edward from Baltimore, “Knowing that you feel deeply interested in the welfare of you pupils - Permit me to have the pleasure of announcing to you, that Minor and myself were examined on yesterday and passed without a dissenting vote.” [see letter]  Bramham did not expand on the purpose of the “Board” mentioned in the letter, whether the examination was to award a degree or licensure. There were early attempts by physicians to regulate their profession with licensure, but strict criteria were not defined or properly enforced until later in the century (Rothstein 80).

Physicians also attempted to regulate themselves as well as promote research and education through the creation of medical societies. The Medical Society of Virginia was established in 1820. Blanton noted in Medicine in Virginia in the Nineteenth Century that Edward H. Carmichael was a member of the society on January 1, 1824 (Blanton 76). The collection includes an undated letter addressed to Edward Carmichael regarding his membership:

At a meeting of the Medical Society of Virginia on Saturday the 15th just they came to the following resolution, ‘Resolved that the Corresponding Secretary be requested to address a letter to each of the non-resident members informing them of the month and day on which a Essay will be expected by the Society from them, in order of their admission.’… your essay will be expected on the third Saturday in August next. [see letter]

The collection contains receipts for the purchase of new medical texts. The works noted include Shutes’ Principles of Medical Science & Practice, Graham on the Stomach and Liver, Hewson on Venereal Ophthalmics (September 1824) [see letter], Woodvilles Medl. & Botany, Bigelow’s Botany (May 1820) [see letter], Dr. Burnett’s Official Report on the fever which appeared on board HM Ship Bann on the Coast of Africa & among the marines at the Island of Ascension in 1823, and Sir Astley Cooper’s lectures on Surgery. [see letter] By 1820 medical journals were being published in Massachusetts and Philadelphia, but the first medical journal of Virginia, The Stethoscope, was not published until 1851 (Blanton 78).

The size of the Carmichael collection and the large number of letters contained allow for an examination of a diverse patient population. As previous citations show, the doctors treated both white and black Virginians. The diseases afflicting the patient populations seem very similar. All age ranges are represented from newborns to the elderly in both men and women. The grammar and spelling used in the letters suggest varying levels of education. Unfortunately, no conclusion can be drawn about the cost of medication or home visits from this collection because fees for particular services are not given. Certainly some patients bartered for the physicians’ services. Elizabeth Withers wrote in January 1826, “I have no more turkies to send you, but in the course of a few weeks I shall have some very good pigs, let me know if you will take them pigs.” [see letter]  A letter dated December 11, 1825, by George Cooke requests the physicians’ assistance in decreasing one patient’s medical bills:

My Sisters have a Negro Man who it is said has a Fistula on his posterior and the knive will I apprehend be obliged to be resorted to - if so it will require the attention of the operator perhaps for some [time and thus] of so much expense as would attend visits to him at Home would be more than they could conveniently bare and have requested me to enquire of you if you would be so obliging as to take him in house and provide for him what might be necessary…He is a Brother of your woman Polly. [see letter]

This letter indicates that Dr. James Carmichael owned slaves, and his ownership of several male and female slaves is confirmed by a review of the property tax records from 1820 for Fredericksburg, Virginia. There is no reference in the collection regarding whether these slaves assisted him in his practice.

Although the collection primarily deals with medical matters, some documents pertain to everyday life in Fredericksburg, Virginia, in the early nineteenth century. An 1827 receipt reads, “To the Mutual Assurance Society against Fire on Buildings of the State of Virginia, To Quota of the year 1827 on buildings in Fredericksburg insured by Declaration No. 4201… $39.04.” [see letter]  Another receipt dated January 18, 1827 states, “To Bridge Company To Bridge Toll at Rappahannock Bridge 1825 - $5.00 [To] Bridge Toll at Chatham Bridge 1826—5.00 [Total] $10.00.” [see letter] On July 12, 1821 a bill to Dr. James Carmichael was written for repairs to a wagon including rimming of the wagon wheels for $5.00. [see letter]  The primary means of personal and family transportation were by foot, horseback, or carriage.  Personal property tax records for Fredericksburg in 1813 note that James Carmichael owned three horses, one coach, and one two-wheeled riding carriage. All the receipts in the collection for the purchase of books or instruments from Baltimore indicate the parcels were sent to Fredericksburg by ship. The first railroad was built in Baltimore in 1830 but did not connect with Fredericksburg until many years later.

Other notations for the purchase of foods and necessities give an idea of the cost of living. A note from November 1828 shows that the Carmichaels purchased 14 loads or 224 bushels of coal at 26 cents a bushel for a total of $58.24. [see letter] An undated receipt documents the purchase of one beef forequarter and one beef hindquarter for $253. [see letter] An invoice from Thomas Wright on March 7, 1819, records the price of a pair of boots at $9.00. [see letter] An extensive invoice from Elizabeth Withers in 1829 marks the Carmichaels’ purchase of turkeys, eggs for ten cents per dozen, pigs, geese, apples, Irish potatoes, barrels of cider for four dollars each, ducks, lamb, and pork. [see letter]

The Carmichael papers contain a wealth of information about the practice of medicine in the nineteenth century as well as the people themselves and their society. During the time that James Carmichael practiced, American medicine was on the verge of the modern era. The morbidity and mortality of diseases during his lifetime were extremely high.  Therefore patients and their physicians were willing to resort to the very harsh treatments available including bleeding, blistering, mercurial preparations, and surgical procedures without anesthesia or antiseptics. In light of the advances in medicine over the past one hundred and fifty years, these measures seem barbaric rather than heroic, as they were referred to at that time. One hundred years from now the interventions and treatments employed by physicians today will probably be judged to be just as inappropriate as those of the nineteenth century are to us. Many of the infectious diseases that ravaged early Americans have been subdued with the advent of improved hygiene, nutrition, and antibiotics while chronic conditions have taken their place as the leading causes of death. Medicine has changed so substantially that no fair comparison can be made between medical practice in the early nineteenth century and medical care at the turn of the twenty-first—the diseases, instruments, procedures, and treatments are different. The common thread over nearly two centuries is found with the patients. The voices and words that resonate from these letters are the same as those from the patients who fill clinics and hospitals today. While diseases differ, the symptoms such as cough, fever, weakness, and pain are the same, and the ways in which these symptoms impact patients’ lives are similar.  Just as they did with James and Edward Carmichael, patients will continue to seek advice, counsel, treatment, compassion, and understanding from their physicians. Similarly, physicians will bear the primary responsibilities of listening to their patients’ stories, whether written in letters or told in person, and then treating them with the best medical therapy available.