Cold bath treatment for typhoid fever

It’s mid-summer Brisbane in early 1887. You’ve got headaches, diarrhoea, a high fever, dry mouth and red spots on your chest. You’re chilled but sweating. You feel exhausted, your neck aches and you can’t concentrate. Nothing helps, so you go to the Brisbane Hospital where you’re placed in the fever ward and diagnosed with typhoid fever. Under the care of Dr Frances Hare, you receive the controversial cold bath treatment. Of the 464 patients admitted for typhoid the previous year, 64 died. Do you survive?

Typhoid in the 1880s

Typhoid fever is a bacterial infection affecting the intestinal tract. It is mainly transmitted by ingesting food or water contaminated with infected faecal matter, but also by flies spreading bacteria to food products. Although typhoid fever was common in the 1800s, few understood what caused it. It was, however, commonly accepted that it was a ‘filth’ disease associated with poor sanitation.

Queensland experienced significant outbreaks of typhoid fever in the 1870s and 1880s, but the worst was experienced in Brisbane, described in the 1884 Queensland Times as that “city of sin, smells and sorrow”. The city had no proper sewerage or drainage systems, with the 1873 Brisbane Courier deeming it “…an abode of filth, abominable smells and foul and fatal effluvia of all kinds”. When Dr Hare was appointed Resident Medical Officer of the Brisbane Hospital in August 1885, Queensland was in a typhoid epidemic. It had the highest proportion of death from typhoid of any Australian colony. There was no known cure.

Dr Hare introduced the cold bath treatment at the Brisbane Hospital on 1 January 1887. He followed the treatment developed by Dr Brand in Germany in the 1860s; whenever a patient’s internal temperature exceeded 102.2^°F (39^°C) they would be placed in a bath filled with water chilled to 68^°F (20^°C) for 10–15 minutes, repeated every three hours until their temperature was below 101^°F (38.3^°C).

"On no single occasion that I can discover has its introduction failed to be followed by a very considerably reduced death rate." (Hare, FE, 1889)

The treatment

Upon your arrival at the hospital your temperature is taken. It’s above 104°F (40°C). You are taken to a bed in the fever ward, your clothes are removed and a sheet is placed over you. All other beds are full and the only other people in the ward are a couple of nurses and two male attendants. Visitors are not allowed in the ward. The breeze through the open windows provides no relief, nor does the iced water you can drink at any time. The headache is unbearable, your limbs ache and you’re breathing rapidly.

Two staff wheel a timber bath to the foot of your bed. They slide you onto a canvas stretcher, placing a cushion beneath your head. They then lower you into the bath. The shock of the iced water makes your groan as you gasp for air. Then the shivering starts, lasting for a few minutes. As your body adjusts to the cold the shivering stops, and you notice your headache has gone. But soon the shivering returns, worse than before. This is when the staff appear. They lift you out of the bath, dry you off, and return you to your bed, still shivering but feeling drowsy. Thirty minutes later the shivers have stopped and your temperature is taken: down to 102°F (38.8°C). You have your first good sleep in ages but are awakened three hours later. The bath is at the foot of your bed.

Cold bath treatment at the Brisbane Hospital was used for 1,902 cases from January 1887 until December 1896, a period known as the ‘bath decade’.

"…at the Brisbane Hospital, where the two typhoid wards for acute cases contain forty-eight beds, the four baths during the great fever seasons were almost constantly in use; and it was often found possible at the height of the season to administer without great difficulty 150 [baths] and upwards in the course of 24 hours." (Hare, FE, 1889)

In the first year, ice was used to chill the water to 68°F (20°C). The ice was the most expensive part of the treatment and after the first year it was only used in the most severe cases. To compensate for the slightly higher temperature the duration of the bath was extended, as the temperature of the tap water was rarely below 70°F (21.1°C). In extreme cases, where the treatment failed to reduce the patient’s temperature to the desired level, ice was added and bath duration increased.

"The most noticeable instance that occurred in Brisbane was that of a hospital nurse who contracted typhoid in the ward… The case did not finally convalesce until the thirty-seventh day of the fever, and needed in all 134 baths, varying in duration from 20 to 60 minutes each." (Hare, FE, 1889)

Cold bathing sceptics

Hippocrates, regarded as the ‘father of medicine’, wrote about the use of baths to treat fevers and the word hydrotherapy is derived from the Greek words ‘hydro’ (water) and ‘therapia’ (healing). Hippocrates was clear that the water should not be too hot or too cold.

Hydrotherapy, including cold bathing, was being used by many professional medical practitioners by the 19th century. The Bavarian priest and hydrotherapist, Sebastian Kneipp, used cold bathing to try to heal Pope Leo XIII. Kneipp was dismissed in disgrace after the Pope reacted badly to his first chilly bath.

John Kellogg, co-founder of the Kellogg’s food company, ran the Battle Creek Sanitarium in Michigan from 1876 to 1902. On his appointment he introduced ‘rational hydrotherapy’ and attempted to provide a scientific rationale for natural treatments. Although Kellogg praised hydrotherapy for its many uses, he criticised those who overestimated hydrotherapy in treating disease, particularly ‘cold-water’ doctors:

"… very cold general applications, especially if prolonged, are rarely needed, and that far better effects can be obtained by the use of temperatures which do not occasion the patient so much discomfort nor give rise to such apprehension as to constitute a nervous shock either to him or to his friends…" (Kellogg, JH, 1902)

During the ‘bath decade’ in Brisbane, Dr Lucas was the most vocal critic of the cold bath treatment at the Brisbane Hospital saying in 1889 “In the name of humanity, in the interests of medical science and skill, I protest against the violent treatment by ice-baths.” In his pamphlet titled Shall they die?, he compared the treatment to torture:

"Scorchings, burnings, bleedings and a host of other outrages of humanity are things of the past. Yet, in the nineteenth century, we see in the Brisbane Hospital an exhibition as terrible, perhaps, as any of the past. Fifteen to thirty minutes in a cold water and ice bath, every two or four hours, is no remedy for severe cases of typhoid fever, it is neither scientific nor humane." (Lucas, TP, 1889)

Dr Hare was fully aware of these comments, noting that critics described the treatment as a harsh and unpleasant experience, barbarous and brutal.

"But the experience of the Brisbane Hospital is not in accordance with this description. The sensations connected with the first few baths, even in timid patients, do not amount to more than slight discomfort; while the almost immediate relief to malaise and febrile oppression which follows the bath renders the patient willing, at times even eager, for its repetition." (Hare, FE, 1898)

Unfortunately, the records reveal little about how patients actually felt about the treatment.

Did it work?

You survive. After three weeks of treatment, more than 100 baths, you can stand unassisted on day 21 and are discharged three days later. But did you dread the bath or welcome the relief it provided?

From the outset Dr Hare acknowledged that cold bathing was best used before the disease had progressed too far. In documenting its success he focused on the alleviation of symptoms, particularly headaches, diarrhoea, fever, weight and muscle loss, and the presence of sordes (crusty deposits that accumulate on the teeth and lips in patients experiencing fever).

"In Brisbane, at most seasons of the year, flies are extremely troublesome. They settled in swarms on patients with sordes who were in the typhoid state, and who usually slept with their mouths open, so that frequently the lips, teeth and tongue were coated with black masses and flies…After the bath treatment was introduced all this was changed; sordes were rare…and the fly nuisance became a thing of the past…" (Hare, FE, 1898)

He used statistics documenting the immediate, then progressive decline in deaths from typhoid fever to justify the treatment. Mortality rates from typhoid fever at the Brisbane Hospital during the ‘bath decade’ declined from 14.6% in 1886 to 11.3% in 1887, and down to 7% in 1896.

"Under the bath treatment, therefore, an improvement has taken place in the Hospital mortality amounting to practically 50 percent; in other words, seven out of every hundred cases admitted have been saved by the use of systematic cold bathing." (Hare, FE, 1898)

Interestingly, Dr Hare acknowledged that “…the influence of the treatment upon the actual duration of the disease is practically nil.” The duration from admission to convalescence and discharge was 24 days before the ‘bath decade’ and 23.3 days after.

"Systematic bathing, if it does nothing else, regularly breaks in upon the continuity of the temperature, and thereby gives…frequent periods of relief…" (Hare, FE, 1898)

A 1986 statistical analysis of deaths from typhoid fever reveals that the global mortality for typhoid fever dropped at the same rate as those recorded at Brisbane Hospital during the ‘bath decade’, confirming the view held by prominent Brisbane physician, Dr Thomas Bancroft: “Were the bath treatment at the Brisbane Hospital now abandoned, it is possible that a still lower mortality would be the result.”

Today, fewer than 150 cases of typhoid fever are reported in Australia each year, usually in people who have travelled to places with poor sanitation and environmental hygiene. Minor cases are treated with antibiotics, however if the symptoms are severe then hospitalisation may be needed. Typhoid vaccines are available, and typhoid fever is diagnosed with a blood test, since 1897. The cold bath treatment was last used in Brisbane in 1931.

The bath

The Queensland Museum collection holds one of the timber baths used by Dr Hare and his staff in the fever wards of the Brisbane Hospital.

Dr Hare’s monograph, The cold-bath treatment of typhoid fever, was described by Alfred Jefferis Turner, the first medical officer of the Brisbane Children’s Hospital, as one of the most important Australian works of the 19th century. In this, Dr Hare describes the bath in such detail we could make him an honorary staff member

Unfortunately no canvas stretcher, back-rest or cushion have survived.

Sources

• Australian Technical Advisory Group on Immunisation, 2024, ‘Typhoid fever’, Australian Immunisation Handbook
• Bancroft, T, 1897, ‘Cold bath treatment’, The Australasian Medical Gazette, Volume 16
• Bottalico, L et al, 2020, ‘From hydrotherapy to the discovery of the gut microbiota – The historical gastrointestinal health concept’, Pharmacophore, Issue 2
• Hare, FE, 1889, ‘The influence of the cold bath treatment on the hospital mortality of typhoid’, The Australasian Medical Gazette, Volume 8
• Hare, FE, 1898, The cold-bath treatment of typhoid fever
• Kellogg JH, 1902, Rational hydrotherapy: a manual of the physiological and therapeutic effects of hydriatic procedures, and the technique of their application in the treatment of disease
• Lucas, TP, 1889, Shall they die? Statistics of the Brisbane Hospital
• Lucas, TP, 1889, ‘Typhoid fever – cold bathing treatment’, Australasian Medical Gazette, Volume 8
• Queensland Parliament Legislative Council, 1885, Queensland Journals of the Legislative Council, Volume 35, Part 1
• Thearle, MJ, 1986, ‘Dr FEW Hare and the cold bath treatment of typhoid fever’, Reflections on medical history and health in Australia: third National Conference on Medical History and Health in Australia
• Turner, AJ, 1898, ‘Book Review: The cold-bath treatment of typhoid fever’, Intercolonial Medical Journal of Australasia