Civil War Medicine
by Janet King, RN, BSN, CCRN.
Part II. The Microscopic War: Diseases and Medical Treatments
By the fall of 1861 at least 5 Vermont regiments were in Virginia. Many were encamped near Washington D.C. as part of the Army of the Potomac. The war's first "big" battle had been fought and lost, and now the Union soldiers reorganized, drilled incessantly, and fought a devious, unseen and in many cases, unbeatable enemy disease.
Letters from various encampments and statistical reports of diseases from regimental and brigade surgeons began to accumulate. They did not paint a bright picture. Captain Charles Dudley, writing to his home in Manchester, Vermont, stated "The weather is cold here. We have had a strong wind all the past day and night and the men are now suffering for want of better sleeping blankets...to look on and see others needing comforts, necessaries that cannot be had, makes me sick at heart...many of my company have been sick, some 10 of them very sick...I am sick at heart at times when I go into the hospital and see the suffering ones....Brigade Surgeon Haven of General Hancock's Brigade, reported: "This brigade is composed of Vermont troops who are the most thoroughly provincial of any in service, and who, accustomed to their native mountains, feel acutely the depressing influence of nostalgia and malaria when absent from them...and on this account, probably are more liable to disease than those from other localities". In November 1861 Governor Holbrook sent Dr. Edward Phelps of Brattleboro, Vermont to investigate Camp Griffin near Washington D.C. where many of his Vermont Regiments were encamped.
Dr. Phelps found that "4,939 Vermonters were in camp...all these troops were in the same brigade - encamped side by side". He felt these troops had been in the same location too long. The grounds of Camp Griffin had become "saturated with noxious elements". In reviewing the brigade surgeon's report he noted that in November of 1861 the army as a whole had a mean ratio of 6.5% sick. 12 regiments of Massachusetts troops averaged 50 sick each, 35 Pennsylvania regiments averaged 61 sick each, yet the 5 Vermont regiments encamped in the same area averaged 144 sick each! He could not explain, given the same locality and the same conditions, why the Vermonters had more sickness.
Of 4 Vermont regiments in January 1862 he noted: 2nd VT (1,021 men) - 87 sick; 3rd VT (900 men) - 84 sick; 4th VT (1,047 men) - 244 sick; 5th VT: (1,000 men) - 271 sick. Why the difference in the 4th and 5th VT compared to the other VT regiments? Neither Dr. Phelps nor the Army Medical Department had a firm answer. Surgeon General Tripler, in a report dated 1-28-1862 stated "...the food of our men is now good and they are gradually improving in their cooking. The clothing of the men is generally good. I do not think any deficiency in this respect has anything to do with fevers that scourge our Vermont troops. I believe there is a nostalgic element in those regiments affecting them unfavorably". [Nostalgia was a term meaning homesickness, and may be depression or some other mental health disorder] In later years historians and physicians would analyze this data further. Vermont soldiers, for whatever reasons, did seem to be more susceptible to disease and this fact would prevail for them throughout the Civil War.
Disease killed more soldiers than did any other cause. This fact was not only true for Vermont soldiers but for any soldier during the Civil War years. In the Union Army 4 men died from sickness for every 1 man killed in battle, and deaths from disease were twice those resulting from all other causes. On the whole, the heaviest incidence of disease occurred early in the war. This may be attributed to poor sanitation practices and increased susceptibility of the troops - especially those from rural areas such as Vermont where exposure to "childhood" diseases such as mumps and measles were limited. The men did not have the opportunity to build up a resistance (immunity) against them as children and vaccines for these diseases were a long way off. Ignorance or limited knowledge of causes of diseases and their treatments were large factors in the epidemics that occurred and the deaths that ensued because of them.
Physicians of the time did not have an understanding of the role bacteria (germs) or viruses and other microbes played in the cause of disease. The entire science of bacteriology did not exist at the time. The thinking was that when a person became ill the body was full of "ill humors".
Understanding of the importance of diet to ill health was somewhat understood, but this was hard to put into practice for the troops. One doctor advised new recruits in "The Military Handbook and Soldier's Manual to Eat sparingly of salt and smoked meats and make it up by more vegetables as squash, potatoes, peas and rice..." The manual also advised staying away from fatty foods and eating at a regular time each day. Sadly, most soldier's diets consisted heavily of fatty, salted meat, few vegetables and irregular meal preparation and times.
The influence of insects as disease carriers was not known. Swampy land, which we now know hosts malaria carrying mosquitoes, was known as "miasmatic swamps" and the fevers people developed near them were termed "miasmatic fevers". The thinking was that the air itself was the source of the disease.
The role of sanitation in preventing disease onset or spread of disease was little known and it's implementation amongst the troops extremely variable. An entire civilian based group would be formed during the war to spread information about proper hygiene and sanitation. Known as the Sanitary Commission, it too was limited in its understanding of a cause and effect in regards to disease, as its secretary's statement testifies: "It is well known that when a considerable body of men have been living together in a camp a few weeks a peculiar subtle poison is generated, the effect of which is exhibited in stiffness of muscles; sickness of the stomach in the morning; sudden and unusual looseness of the bowels; and subsequent by dysentery, and other endemic and epidemic diseases of a still more fatal character, such as camp fevers and cholera...These dangers can be averted by strict cleanliness and proper preparation of good food eaten at regular times."
He also stressed that officers were responsible for the sanitary hygiene of their men. With a lack of knowledge regarding contamination of water and food sources by bacteria, medical men and Sanitary Commission agents assumed men crowded together or camped close to privies, unburied garbage or in unclean camps were exposed to "mephitic effluvia" (bad air). Thus, they felt clean camps, exposure to fresh air, dry ground and sunlight would prevent disease. (In this they were partially correct.)
Prevention of small pox by vaccination was known but not consistently practiced during the war. Thorough examination of the troops, as was noted earlier, left much to be desired, and those with chronic and communicable diseases were mustered in along side those troops who had little to no exposure to disease. So it was that some 414,000 soldiers - both Union and Confederate - died from diseases acquired during the Civil War.
The following lists common camp diseases, their symptoms (modern knowledge is in italics), and their treatments then and what they would be today. Specific treatments and medications used will be looked at in more detail after this.
MEASLES: Noted to be increased in occurrence when regiments consisted of a high percentage of "country" troops. It was one of the first diseases to strike the soldiers in epidemic proportions. Most frequently occurred within a few months of a unit's organization and reoccurred after each large addition of recruits. Sometimes the disease was mild but undue exposure and poor diet could lead to complications such as pneumonia. If the case was mild the soldier generally returned to duty in 3-4 weeks. Complications were a leading cause of death from this disease.
Symptoms: cough, sneezing,runny nose,watery eyes, fever - followed by an eruption (blotchy red rash) in 4 days.
Treatment:Isolation of the soldier or regiment from others until the disease ran its course. For mild cases "nutritious" diet and rest. For more severe cases complicated with pneumonia: cupping, counter-irritants to thorax, turpentine by mouth and small doses of opium.
Modern Knowledge: Rubeola or "hard measles" is now known to be caused by a virus that is spread by droplets - i.e. secretions from coughing, sneezing. It can be passed on via tissues, handkerchiefs, inanimate objects that have been in recent contact of an infected person. A vaccine given as an infant prevents this disease today. If a person were to contract the illness supportive treatment (rest,good diet) would be prescribed and if complications occurred they would be treated specifically i.e. antibiotics for pneumonia.
MUMPS: Swelling of the parotid gland (salivary gland(s) located on either side of the face and in front of the ears).
Symptons: pain, tenderness, fever - disappearing by the 6-7th day.
Treatment: Poultice of arnica leaves and flax seeds. If pus present - cut over affected part and allow to drain. Opium for pain.
Modern Knowledge: Mumps is a viral disease and known to be spread in much the same way as measles - by droplets. Unlike measles, it cannot be spread by inanimate objects. In adult men mumps can lead to infection of the testes and infertility. A vaccine is now given to infants which can prevent this disease. If an adult male were to be exposed to this disease a special serum could be given to prevent the actual disease or prevent it from causing infertility. Treatment for mumps would be supportive and specific as with measles.
PNEUMONIA: Acute inflammation or infection of the lungs. Can occur in one lung or both.
Symptons: Cough, hot skin, pain in shoulder blade or breast, headache, coughing up bloody mucus, difficult breathing.
Treatment: Various methods including: cupping, hot compresses, morphine or other opiates, camphor, quinine, various cathartics - with goal being to prevent spread of the inflammation and relieve pain.
Modern Knowledge: Pneumonia can be caused by numerous organisms such as bacteria, viruses etc. Today, an x-ray of the lungs would be done, as well as analysis of what the patient coughs up (expectorates) to determine specific cause. Once this is done the doctor would prescribe a specific drug(s) to combat the specific cause. Care would also consist of nutritious diet, and rest. This disease can still be deadly especially in those with little resistance to disease such as the very ill (i.e.cancer or AIDS patient) and in the very young or very old.
CONSUMPTION [Tuberculosis] [TB] An infectious, inflammatory, communicable disease that usually attacks the lungs, but may occur in almost any other body part. Many people were most likely exposed to TB in the 1860's but not all developed symptoms. Resistance to this disease is now known to go down when the person is subjected to poor health, fatigue, crowded or poor living conditions and poor nutrition and exposure to the disease causing organism in such great numbers or so often that even a healthy person in the best living conditions would get the disease.
Symptons: chronic cough, weight loss, bleeding from lungs, "consumptive look".
Treatment: cod liver oil, tonics i.e. cinchona, tincture of iron; stimulants i.e. whiskey, or brandy; opiates i.e. Dover's Powders; external applications i.e. poultices. In severe cases ammonia carbonate and free use of alcohol.
Modern Knowledge: The causative organism for TB is the tubercle bacillus. It can enter the lungs in various ways - usually by droplets from an infected person to a non-infected person.This bacteria can live for months in the dried droplets (mucus). It can also be introduced via the gastrointestinal system if a person were to drink milk infected from tuberculosis infected cows. (pasteurized milk prevents this) Tests are available now to determine if one has been exposed. If a person was exposed and TB was confirmed by x-ray, several specific antibiotics could be used to treat this.
MALARIA [ague, the shakes; simple intermittent fever] This disease accounted for about 1 out of 4 illnesses suffered by the troops.
Symptons: Intermittent fever, shakes.
Treatment: Whiskey and quinine in variable dosages as a preventative and as a treatment. Mercury compounds for bowel complaints; opium for pain; external therapy i.e. sinapisms (blisters).
Modern Knowledge: Malaria is caused by a protozoan parasite which is carried by a specific mosquitoes - the Anopheles. It was very prevalent in the Southern states as late as the 1930's. The drainage of swampy areas and use of insecticides has greatly reduced the numbers of Anopheles mosquitoes and decreased numbers of cases in the US substantially. Antimalarial drugs may be given prophylactically to persons traveling in high risk areas and specific drugs can be given to control symptoms if the disease is contacted. Quinine was the standard of care into the 1940's, now newer, synthetic drugs are used.The hallmark of malaria is its cycles of chills and fever, feelings of exhaustion,and headache - lasting 4-6 hours and recurring at regular intervals.
TYPHOID [camp fever, continued fever] Typhoid caused approximately one-fourth of all deaths that occurred because of disease in the Civil War.
Symptons: chills, sweating, prostration, pain in limbs, rapid pulse, head ache, high fever, diarrhea common, constipation occurring at times, intestinal ulcers and internal bleeding at times leading to death.
Treatment: Diarrhea treated with opiates i.e. opium pills; abdominal pain treated with hot poultices, blistering, cupping. Fever treated with spraying body with cold water or applying cold applications to the head. Turpentine by mouth given for ulcers; stimulants given if patient collapsed - including external friction. Calomel and quinine also used.
Modern Knowledge: Typhoid is a bacterial illness transmitted via contaminated water/milk/shellfish and other foods. The disease can be asymptomatic and the person infected be in a "carrier" state where he/she can spread the disease to others. The causative organism enters the body via the intestinal tract and is found in an infected person's excrement. This disease has been virtually eliminated in the US due to advanced sanitation practices - however, during disasters i.e. floods , where water can become contaminated - the disease can occur. Specific antibiotics are now given to those who develop this disease, and the primary goal remains to prevent it by vigilant sanitation practices.
DYSENTERY [the flux] This disease was one of the three most common diseases acquired in the Union Army, causing some 233,812 cases of illness and 4,084 deaths.
Symptons: Fever; passage of mucus or blood in the stool; swelling or tenderness of the bowels; painful straining during a bowel movement with little or no result.
Treatment: Opium; whiskey; castor oil in the morning and opium at night; calomel (blue mass); turpentine; ipecac; strychnine in chronic cases; fresh foods.
Modern Knowledge: Dysentery can be caused by bacteria, by protozoa or by virus. Bacteria(bacillary) dysentery is the most common form and is spread through the fecal material of persons who have the bacteria in their intestines, and can be passed on by eating or drinking from anything contaminated with the bacteria from the feces of those who have the disease or who are "carriers". It is more prevalent in areas of crowding and poor sanitation. Specific antibiotics or other agents are now given based on the type of causative agent. Care is taken to prevent and treat dehydration that can rapidly occur with diarrhea.
DIARRHEA [acute or chronic, the flux, the quickstep] Acute and chronic diarrhea were the two leading causes of disease for Union soldiers - with chronic diarrhea causing some 27,558 deaths. It is estimated that almost everyone suffered from diarrhea at some point in his army career.
Symptons: Frequent bowel movements, loss of body fluids through dehydration. Had tendency to become chronic and very debilitating.
Treatment: (See dysentery - the treatments were essentially the same); flannel body bandages were advertised as preventatives as well as treatments.
Modern Knowledge: Diarrhea is more a symptom than a specific disease. Treatment is based on determining the cause of the diarrhea. Prevention and treatment of dehydration (loss of body water and electrolytes) is vigorous. Lab tests to determine potential causes and treatment with specific medications i.e. antidiarrheal like immodium or kaopectate, treatment of infection with specific antibiotic etc. are often done. Avoidance of rough or fatty foods and good nutrition is important in treatment as well. It may be that the diet of the soldiers contributed a great deal to their distress - since it consisted of a lot of fat, grease, and rough food (hard tack) and food that was poorly prepared and perhaps contaminated as well.
Symptons: Slight chill, fever, severe back pain; delirium; flushed face; whites of eyes and skin yellow; great thirst; tongue coated white; pain in limbs and in pit of stomach; bleeding from intestines or in vomit.
Treatment: Supportive therapy; quinine; calomel; cathartics, blisters; ipecac; lead acetate; opium.
pModern Knowledge: Yellow Fever is an acute viral illness transmitted by a certain type of female mosquito. It affects the liver -producing the yellow skin and eyes (jaundice) and internal bleeding. Vaccines are available to prevent this. The disease is more common in tropical countries, not in the USA. If the disease is contracted supportive measures are instituted and specific medicines given as needed.
SCURVY: [vit. c deficiency]:
Symptons: debility; sponginess/bleeding gums; loose teeth; heart palpitations; skin easy to bruise.
Treatment: Diet with vegetables i.e. potatoes, onions; cabbage and with fruit: strawberries; lemons; oranges.
Modern Knowledge: Treatment basically the same with emphasis on good diet, high in Vit. C; Vit. C supplements. This is rare in the US today.
VENEREAL DISEASES [ SYPHILIS/GONORRHEA ] Venereal disease was more common at the beginning and at the end of the Civil War. It is estimated that some 73,382 cases of syphilis and 109,397 cases of gonorrhea occurred among white Union troops during the Civil War, with African-American troops having a slightly lower incidence.
Symptons: (Syphilis: painless sore in the early stage, which disappears fairly soon - in later stages: rash; widespread sores; joint pain ; insanity or other nervous system disorders, and death. Gonorrhea: painful burning upon urination, discharge from penis).
Treatment: Injections (into penis) of silver nitrate; zinc chloride; chlorate of potash; also - saline cathartics; mercury compounds; cauterization of sores. Attempts to license "women of the town" (prostitutes), who were examined and certified to be "free of disease" - to limit outbreaks of these diseases.
Modern Knowledge: None of the treatments of the 1860's would have eradicated these diseases, so the men who became infected during their stints as soldiers could infect their wives or sweet-hearts upon returning home. Syphilis is caused by a spiral shaped bacteria. The initial symptoms may be minimal and the disease lay dormant for many years until appearing again as "late" stages - eventually killing the patient if untreated. Gonorrhea is caused by the gonococcus bacteria. This disease, untreated in men, can lead to further infections of the sexual organs leading to sterility and to narrowing of the urine passageway, causing great difficulty passing urine. The infected female may also have chronic pelvic infections and become infertile. If a child is born and the mother is infected, the bacteria can lead to blindness in the newborn. Syphilis, also, can be passed on to the newborn via the mother, leading to stillbirth or a weak, sickly child or to birth deformities. These are definitely diseases that had more consequences than the soldiers ever dreamed of. Fortunately today, these diseases can be prevented (use of condoms) and treated with specific drugs that cure the disease, and prevent the dire consequences listed above.
As can be seen, a wide variety of treatments were utilized in the war on disease. Let us take a closer look at the therapeutics of the 1860's. Remember - the doctors of this era were at a cross roads between older, more "old fashioned" practices such as blood letting (bleeding) and purging, and the newer, more specific methods of treatment i.e. quinine for malaria. Some emphasized a more "watchful" approach that was aimed at supporting the body with tonics and nutritious food. Reading a case history, one finds many different approaches. The US Army Medical Department had on their supply list (pannier) some 52 different medicines. The following are the more common medicines and therapeutic techniques utilized.
[CAUTION: THESE ARE THE 1860 USES!
NOT FOR TODAY'S PROBLEMS!!!!!!!]
STIMULANTS: Thought to have a "stimulating" effect in appropriate doses. Would be given to soldiers to prevent problems as well as in cases of collapse i.e. gunshot wounds.
Whiskey; brandy; strychnine (to stimulate the nervous system and circulatory system).
DRUGS THAT EFFECTED THE STOMACH OR BOWELS: Used to purge the body of disease or to correct diarrhea or constipation.
Cathartic [stimulate bowel movement; "purge"]: **mercury compounds (these would be taken off the US Medical Depts supply list by Surgeon General Hammond - a very controversial act, that cost him his job. Hammond was correct in doing so, as these compounds are very deadly and is considered a deadly poison - not to be taken internally!)i.e. blue mass; blue pills; calomel; "also used:" castor oil; Epsom salts; aloe.
Anti-diarrhea [decrease frequency or stop diarrhea]: "opiates": powdered opium; Dover's powders; laudanum; morphine; opium pills; others: blue vitriol (copper sulfate); lead acetate; belladonna; paregoric.
Upset stomach or to promote digestion: "ammonia water" - used to decrease "gas" and settle stomach; "bitters": (composed of liquor, bitter herbs, roots, bark) - used to increase appetite and promote digestion - as a "tonic" also: red peppers - to promote gastric stimulation; magnesia; potassium bicarbonate and sodium bicarbonate - to decrease gas and settle stomach.
Emetic [To Cause Vomiting - thus purging disease from upper gastrointestinal system] : alum; calomel, colocyth pills; ipecac; tartar emetic. ** the calomel - being a mercury compound would have caused burning of the esophagus and other side effects - another reason Dr. Hammond wanted it banned!
For Nutritional Support: beef extract; coffee; condensed milk; black tea; panada (paste or gruel of bread crumbs or toast or flour combined with milk, stock or tea); ferrous (iron) compounds: "green vitriol" - used to fight anemia "low blood.
For Venereal Disease: "calomel" (internal - by mouth) or as an ointment applied to sores. Other: injections into penis of silver nitrate; zinc chloride; chlorate of potash.
For Malaria: **Quinine (considered to be a "miracle drug" of the era and a specific treatment for this disease) other: spirits of nitre; potassium iodine.
For Skin Problems: "simple cerate" (compound of fat/lard mixed together with wax): for soothing agent; "Bromine": used as corrosive agent for wounds or ulcers with gangrene. (This was another "miracle" drug of the era. Given under influence of ether or chloroform to rid wound of gangrene); Iron chloride - placed in wounds to help them heal.; camphor - used for itching, also as a "stimulant or an irritant".
For Kidney Problems: (To produce more urine - diuretic): aromatic spirit of ammonia; spanish flies; bicarbonate of potassium.
PAIN CONTROL/ANESTHESIA: (opiates): opium pills; powdered opium - sprinkled into wounds; Dover's Powders: mixed in water and drunk; laudanum ; also morphine(was beginning to be injected but not a common mode of giving this.) (anesthesia) ether: Inhaled by soldier to produce pain free/anesthesia state; chloroform: most common anesthetic agent utilized in the Civil War. Dropped on a cloth thru a funnel. Could be very toxic causing depressed heart function and kidney or bladder problems in larger doses.Sometimes these two agents were mixed together.
For Coughs/Colds: opiates; syrup of squill, turpentine; potassium iodide.
OTHER THERAPEUTIC TECHNIQUES USED TO TREAT DISEASES:
[Caution: these are 1860's techniques and are not recommended today!!]
Blistering/Cupping: The purpose of this technique was to introduce a "counter-irritant" to oppose pain caused by disease. It was most frequently used on patients who had pneumonia. A glass or metal cup was filled with alcohol. The alcohol was ignited and the cup pressed against the skin over the affected part. A blister would develop and then be drained. This was thought to decrease pain in the lung. An alternative method was to use a suction cup to raise the blister. Spanish flies (cantharoids) were also utilized as skin irritants causing blistering.
Plasters: These were medicinal preparations consisting of various agents i.e. mustard or belladonna. They would be formed into a sticky substance, harder than an ointment, then spread on muslin, linen or paper and then onto skin. They were used to allay pain and as a counter-irritant.
Poultices: These consisted of hot, moist masses of linseed, mustard or soap and oil between two pieces of muslin and applied to the skin to relieve congestion or pain. They were also thought to stimulate absorption of inflammatory products or to act as counter-irritants.
Hot Fomentations: Treatment of bodily pain or injury by the application of warm, moist liquid or compresses.
Bleeding: By the 1860's this technique was falling out of fashion. Its purpose was to eliminate "over abundant" or "tainted" blood from an affected part. Using a device called a fleam, the doctor would open up a vein and allow the blood to flow out until he felt the patient had been helped. He would, at times, repeat this procedure in subsequent days. Another device - a scarificator - made numerous scratches which then bled.
The following is a case history of a young Vermont soldier, who far away from his beloved Green Mountains, fought an invisible foe far more deadly than any Confederate soldier he could think of.
On October 15, 1861 23 year old Private C.A. Bartlette of Co. H, 5th Vermont Volunteer Infantry in the Army of the Potomac, encamped in Virginia, woke up with pain in his back and limbs. He had been troubled with diarrhea and had no appetite to speak of. He felt generally unwell. Reporting to his first sergeant, he was taken to the regimental surgeon at sick call. The surgeon examined him and the hospital steward listed his complaints in the regimental record. He was given medicine for his diarrhea, probably some type of opiate like Dover's Powders, and returned to duty. Private Bartlette found it hard to perform his duties. He was constantly troubled with diarrhea; feeling weak as the days went on. He still had no appetite and felt hot most of the time. His tent mates noticed that he could not sleep and seemed to suffer much from his diarrhea. By November 1 he had become so ill that he could not report to the regimental surgeon at sick call, and that officer checking him over in his tent saw just how much he had deteriorated. The private now had a deep cough, and expectorating yellow mucus from his lungs.. He immediately made plans to send Pvt. Bartlette to the Seminary Hospital in Georgetown (near Washington D.C.).
On Nov. 2 the examining surgeon of Seminary Hospital found that Pvt. Bartlette was wakeful, but that he had dull looking eyes, a congested appearing face, fast pulse, skin hot and dry and covered with a rash over his chest and abdomen. His tongue was dry, red at the tip and edges and coated yellow in the center. He was very hard of hearing and complained of constant buzzing in the ears. He complained of pain in his right lower intestinal region and still had frequent bouts with diarrhea. He still had the very bad cough which still produced yellow mucus. The doctor recognized these symptoms as typhoid fever with affliction of the lungs. He directed the steward to give the patient turpentine by mouth and the nurses to give him milk punch and beef essence. Mustard plasters were applied to his abdomen in the area he complained of pain. Still, he continued to suffer through the night. No family was there to care for him, and his mess mates seemed a long way off. When the doctor examined him the next day he found him delirious, confused and making frequent attempts to leave his bed. His pulse was imperceptible and his breathing laborious. By the time the doctor saw him again that day his condition had deteriorated further and death followed soon after. In his final report the surgeon listed Pvt Bartlette's death as occurring from typhoid fever with congestion of the lungs.
Neither the doctors nor this young soldier had the correct weapons to fight the enemies of typhoid and pneumonia. Private Bartlette's family would mourn the loss of one so young and full of promise. They would grieve knowing he died far away from his family without a loved one to care for him when he was suffering. For him the suffering was over - for them it had just begun. How many more of Vermont's young sons would die in such a way?
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