For decades, surgeons have performed elaborate rituals to minimize risk of infection to patients. We wash our hands. Don gloves and gowns. Cover our hair. Avoid reaching over our heads or below our waist (except to adjust the light – yes, I know, the rituals are imperfect). It’s a familiar exercise. And it works.
Surgical infections are uncommon. Operating suites are not clean rooms. Patients are still exposed to bacteria. We try to lower the potential inoculum to an amount most patients can handle with a functioning immune system.
I cannot recall a single surgeon ever making a libertarian argument it’s his choice whether to adhere to these rituals.
That was not always so.
Ever heard of Dr. Ignaz Semmelweis? He was a Hungarian physician. His key innovation – cutting the incidence of puerperal fever (“childbed fever”) in obstetrical clinics by using hand disinfectants. Puerperal fever was common and often fatal. Semmelweis’ radical proposal in 1847 was washing hands with chlorinated lime solutions. At the time, the doctors’ wards had three times the mortality of midwives’ wards. When implemented, hand washing crushed the mortality rate. It worked.
During 1848, Semmelweis widened the scope of his washing protocol, to include all instruments coming in contact with patients in labor, and used mortality rates time series to document his success in virtually eliminating puerperal fever from the hospital ward.
How did the medical community react?
Semmelweis was treated as a pariah.
He could offer no acceptable scientific explanation for his findings, and some doctors were offended at the suggestion that they should wash their hands and mocked him for it. In 1865, the increasingly outspoken Semmelweis supposedly suffered a nervous breakdown and was committed to an asylum by his colleagues. He died 14 days later after being beaten by the guards, from a gangrenous wound on his right hand which might have been caused by the beating. Semmelweis’ practice earned widespread acceptance only years after his death, when Louis Pasteur confirmed the germ theory, and Joseph Lister, acting on the French microbiologist’s research, practiced and operated using hygienic methods, with great success.
Certainly, harsher than having to present at a peer review committee meeting.
Semmelweis paved the way toward wide acceptance of infection control.
I trained at Baylor College of Medicine. There, urban legend had it a visiting professor from another country was watching a famous cardiac surgeon operate. The professor stood next to the anesthesiologist, peering over the drape. His glasses supposedly fell into the wound. The surgeon removed the polluting object and returned it to the visiting professor. (Was it first washed? I have no idea. This is an urban legend.) Although the cardiac surgeon had a famous temper, he kept his cool. The same hour, the visiting professor’s glasses fell into the wound again. The surgeon merely looked up and said, “Why don’t you take your pants down and defecate in the wound?” Urban legend has it he used a synonym for defecate.
Onward to masks. In May, Lancet published an article on the history of the surgical mask.
Covering the nose and mouth had been part of traditional sanitary practices against contagious diseases in early modern Europe. This protection was primarily about neutralising so-called miasma in the air through perfumes and spices held under a mask, such as the plague doctors’ bird-like masks. Such practices, however, had become marginal by the 18th century.
Following a hiatus of several centuries,
Johann Mikulicz, head of the surgery department of the University of Breslau (now Wroclaw, Poland) started working with the local bacteriologist Carl Flügge, who had shown experimentally that respiratory droplets carried culturable bacteria. In response to these findings, Mikulicz started to wear a face mask in 1897, which he described as “a piece of gauze tied by two strings to the cap, and sweeping across the face so as to cover the nose and mouth and beard”. In Paris, the surgeon Paul Berger also began wearing a mask in the operating room the same year…
However, masks became increasingly widespread. A study of more than 1000 photographs of surgeons in operating rooms in US and European hospitals between 1863 and 1969 indicated that by 1923 over two-thirds of them wore masks and by 1935 most of them were using masks.
It was mainly the use of the mask to cover the mouth and nose (and beard) during the Manchurian plague of 1910–11 and the influenza pandemic of 1918–19 that turned the face mask into a means of protecting medical workers and patients from infectious diseases outside of the operating room. During the 1918–19 influenza pandemic, wearing a mask became mandatory for police forces, medical workers, and even residents in some US cities, although its use was often controversial. Yet in cities like San Francisco, the decline in deaths from influenza was partly attributed to the mandatory mask-wearing policies. At this point, the rationale for wearing masks moved beyond their original use in the operating theatre: they now also protected the wearer against infection.
Medicine moved from reusable to single use protective equipment.
Medical masks started to be replaced by disposable paper masks during the 1930s and were increasingly made of synthetic materials for single use in the 1960s. By the early 1960s, there were advertisements for new kinds of filtering masks made of non-woven synthetic fibres in nursing and surgery journals. These filtering masks were all disposable.
Industry-sponsored studies found the new synthetic masks to be superior to traditional reusable cotton masks. More frequently, however, reusable masks were omitted from comparative studies. In 1975, in one of the last studies to include an industrially manufactured cotton mask, the author concluded that the reusable mask, made of four-ply cotton muslin, was superior to the popular disposable paper masks and the new synthetic respirators. He noted that “cotton fabrics may be as effective as synthetic fabrics when incorporated in a good mask design.” Some studies have suggested that washing reusable masks might increase their bacterial filtering efficiency, perhaps by tightening their fibres. In the absence of commercial cotton masks, more recent studies have only compared artisanal or homemade masks with industrially produced disposable masks, finding the latter to be superior. These results to some extent reinforced the idea that reusable masks were potentially unsafe, partly discouraging further research into well designed and industrially manufactured reusable masks.
The Lancet article concludes:
Perhaps one day it might again be possible to say about protective face masks what medical researchers wrote in 1918: “A mask may be repeatedly washed and used indefinitely.”
My take on the mask wearing debate conforms to what most physicians are advising as we reopen our economy during the COVID-19 pandemic. Just wear a mask.
If I were king, I would mandate this until we have better therapeutics or vaccines: (a) No super-large gatherings. (eg professional football games, rock concerts, Mardi Gras); (b) face masks; and (c) hand washing (ubiquitous alcohol-based goop). That’s mostly it, although as king I’d probably have to fill in some details. We can still have a functioning economy.
My measures as king require some sacrifice. But, let’s admit it, are they really that big a deal? People should just do that stuff anyway. Sorry to be crude – I wash my hands after I have a bowel movement. No law needed. I don’t go on TV crying about freedom to not wash my hands after I wipe my bottom. It’s just good sense. And I’m sure people around me are glad I take THAT minor act seriously. I don’t consider the choice to wipe or not wipe my bottom an act of libertarian deliberation. Of course, once I buy the Toto I’ve had my eye on, I WILL have a choice. That’s a story for another day.
There are analogous public health measures we already accept; for example, related to driving under the influence. The vast majority of times a person has a blood alcohol over 0.08%, he is able to make it home without crashing into a tree or killing riders in other cars. That statistic does not inform our laws. We agree that because we don’t know when some drunk driver will be lethal, we just ban all driving while under the influence. Because we don’t know when some asymptomatic or pre-symptomatic COVID-19 petri dish may infect a vulnerable person, we consider mandating measures (such as wearing a mask) to prevent a bad outcome.
The effort required to wear a mask is minimal. The inconvenience slight. The potential benefit great. It’s always a balancing act. We know more now. We still have much to learn. Not everyone will agree with me. What do you think? Comment below.
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Dr. Jeffrey Segal, Chief Executive Officer and Founder of Medical Justice, is a board-certified neurosurgeon. Dr. Segal is a Fellow of the American College of Surgeons; the American College of Legal Medicine; and the American Association of Neurological Surgeons. He is also a member of the North American Spine Society. In the process of conceiving, funding, developing, and growing Medical Justice, Dr. Segal has established himself as one of the country’s leading authorities on medical malpractice issues, counterclaims, and internet-based assaults on reputation.
Dr. Segal was a practicing neurosurgeon for approximately ten years, during which time he also played an active role as a participant on various state-sanctioned medical review panels designed to decrease the incidence of meritless medical malpractice cases.
Dr. Segal holds a M.D. from Baylor College of Medicine, where he also completed a neurosurgical residency. Dr. Segal served as a Spinal Surgery Fellow at The University of South Florida Medical School. He is a member of Phi Beta Kappa as well as the AOA Medical Honor Society. Dr. Segal received his B.A. from the University of Texas and graduated with a J.D. from Concord Law School with highest honors.
In 2000, he co-founded and served as CEO of DarPharma, Inc, a biotechnology company in Chapel Hill, NC, focused on the discovery and development of first-of-class pharmaceuticals for neuropsychiatric disorders.
Dr. Segal is also a partner at Byrd Adatto, a national business and health care law firm. With over 50 combined years of experience in serving doctors, dentists, and other providers, Byrd Adatto has a national pedigree to address most legal issues that arise in the business and practice of medicine.
right on
what is the sacrifice of wearing a mask compared to dying from the virus
What’s the sacrifice? The price is the freedom to make my own decisions. I’m not willing to make that sacrifice. As far as I can tell, my judgment and opinions are at least as good as the ones coming out of Washington. Feel free to give up your freedom, but please don’t try to bully or shame me into surrendering mine.
I base my opinion on the simple fact that we need to have herd immunity. We aren’t going to get it by avoiding the virus. That phobia/cause has been stoked by the media,* not by rational medical thought. Is there a mortality rate if you get infected? Sure. Same for any infection. Is this mine higher than others? Yes. Is it what I consider to be dangerously high. No. Not even close.
* And not to save lives, but to sell ads. The more people can be gulled into believing that they’re in deadly peril is the degree to which they can be controlled. I’m more skeptical than you seem to be.
I refer you to a quote from the 1981 Michael Crichton movie, Looker. The quote is from a speech the heavy, well played by James viburnum, gives to the board of directors of Looker Labs:
John Reston: Television can control public opinion more effectively than armies of secret police, because television is entirely voluntary. The American government forces our children to attend school, but nobody forces them to watch T.V. Americans of all ages *submit* to television. Television is the American ideal. Persuasion without coercion. Nobody makes us watch. Who could have predicted that a *free* people would voluntarily spend one fifth of their lives sitting in front of a *box* with pictures? Fifteen years sitting in prison is punishment. But 15 years sitting in front of a television set is entertainment. And the average American now spends more than one and a half years of his life just watching television commercials. Fifty minutes, every day of his life, watching commercials. Now, that’s power
Almost all articles on this topic conflate wearing masks for other-protection vs. wearing masks for self-protection. The requirement for the public to wear masks in public places where interpersonal distancing cannot be assured … is for OTHER-protection, NOT self-protection. That is why wearing masks in public places must be enforced. Please … can we keep these issues separate? I have friends who don’t wear masks because they say, “I am not worried about being infected.” I ask, what if your daughter were employed at a grocery checkout? They say, “well, they should know I am not infected.” What? This is not for self-protection like being required to wear a helmet when riding a motorcycle. Refusing there is Libertarian, or “rugged individualism,” to some. Not wearing a mask when requested is simply rude and endangers others … “rugged idiocy.” Please … let’s keep these issues separate in our articles as not to add to the confusion.
All masks work for others-protection and self-protection since they stop the flow of viral particles – droplet or aerosol depending on their efficacy of filtration – in both directions through the mask. For the greatest protection from others, others should wear a mask and you should wear a mask. You will then have two mask filtration systems to remove the viral particles.
I totally agree. The masks protect the wearer as well as the others. if some one thinks they don”t need protection- for whatever their reason may be- they should wear it to protect others.
Right on, as always, Jeff. And James, I assume your pleas for precision are directed at others; I see no confusion evinced in the present article. Ironically, I have recently escaped from a country that still believes it is 1347 and that Covid is carried by miasmas. They kept us seniors on house arrest for 164 hrs/wk and we were only allowed out to buy food or drugs (at the exact same hour as all other seniors—so perhaps it was rather an attempt at geriatricide). Even now, while allowing for exercise, they are not allowing anyone outside their immediate yard without a mask. And this is a country with wide open exquisite nature, seldom do you encounter anyone else while out in an exercising capacity. So it can definitely be taken too far. But I entirely agree with King Jeff. One should always wash ones hands after (quite a few actually) “intimate” activities, and whenever else you pass by a source of clean water and soap, these days…perfectly effective for Covid, and not as likely to dry your skin or suppress your testosterone as alcohol based sanitizers. And you should wear a mask, whenever you might get within range of another human. You never know whether YOU might be the asymptomatic petri dish, or when the other is immune compromised. It is not just rudeness. It is decency. We need a LOT more of that these days.
Yes, Louise. You are exactly right that I should have clarified that my request for precision is directed toward OTHER articles and not this one. Jeff is a treasured colleague, and Medical Justice a valued service — and this particular article is a good one. Also directed at other articles would be a comment that balanced evidence should be, but is so often not, provided. Once one has made up one’s mind about an issue, it is easy to find supporting evidence on the internet for the position … but that is neither fair nor helpful. However, I think it is fairly well known that cloth masks do NOT offer much protection for the wearer from virus-laden droplets. On the other hand, there IS high speed camera and study evidence for a level of protection of OTHERS from the wearer … which is also unfairly ignored by most other articles and comments taking a sided position. Thanks for the article and all the good comments!
James, so true! We are all constantly being bombarded these days with “Motivated Reasoning” https://bit.ly/Motivatedreasoning.
And yes, agree that Jeff’s a treasure. If I were not a birthright Quaker, I might bow to him….
I think it is better to look at the actual data on efficacy of facemasks for prevention of viral transmissions. Evidence based research should be considered.
From Cowling 2020
Disposable medical masks (also known as surgical masks) are loose-fitting devices that were designed to be worn by medical personnel to protect accidental contamination of patient wounds, and to protect the wearer against splashes or sprays of bodily fluids (36). There is limited evidence for their effectiveness in preventing influenza virus transmission either when worn by the infected person for source control or when worn by uninfected persons to reduce exposure. Our systematic review found no significant effect of face masks on transmission of laboratory-confirmed influenza.
From Brosseau 2020
We do not recommend requiring the general public who do not have symptoms of COVID-
19-like illness to routinely wear cloth or surgical masks because:
There is no scientific evidence they are effective in reducing the risk of SARS-CoV-2
transmission
I have no problem with ‘guidance’ recommedations, but do have a problem with ‘tribal’ laws with penalties and face masks ‘Nazis’.
Medical Justice is aweome! AND, I appreciate the ability to submit comments.
Dr Segal’s Comments on the historical use of masks is very compelling if understood in the historical context that at the time they were shown to be effective against bacteria, long before we deduced the existence of viruses. Only the more recent development of nanofiber industrial masks that filter particles smaller than the smallest bacteria, approximately 400 microns, do we see protection against viruses in the 20 to 400 micron range. The average corona virus is in the 60 micron range. The ever popular cotton TShirt DIY mask even if fabricated from your expensive 600 thread count sheets filters less than 40 % of larger viruses. Still “better than nothing” as the study purports? So, fashion statement or effective protection?
Are there data supporting wearing masks (such as plain vanilla surgical masks) other than N95 respirators? Yes.
(a) Animal model looking at surgical masks in SARS-CoV-2 model in hamsters. academic.oup.com/cid/article/doi/10.1093/cid/ciaa644/5848814 Transmission reduced and, of those who became sick, they had fewer clinical findings and lower viral nucleocapsid antigen expression.The hamsters were not actually wearing surgical masks 🙂 There was a surgical mask barrier between adjacent cages.
(b) “Two hair stylists who tested positive for SARS-CoV-2 and apparently had mild COVID-19 (they were symptomatic) wore masks as did all of their clients. Not one of their 140 clients ended up with COVID-19. Forty-six of them pursued testing and all tested negative, while the rest were quarantined for a 14-day period, according to the health department (no symptoms). Additionally, there were no cases of coronavirus out of the more than 400 other people who were in the Great Clips location during the shifts by the two affected stylists.” http://www.today.com/health/missouri-great-clips-hairstylists-coronavirus-did-not-infect-140-clients-t183982
How is it that a virus that is smaller than the barrier in a surgical mask can still prevent infection? Hard to say. Perhaps much of the time the coughing sends the virus to a recipient on an airborne particle which can be blocked.
Should one wear a mask in the ocean while swimming? Easy. No. Just stay reasonably far away from other people.
Masks are a tool to be used indoors>outdoors in areas where you cannot easily separate yourself from others.
Oh No, not Mardi Gras! We can throw beads without crowds (LOL). Most of the revelers are to wasted to catch them anyway.
Dr. Glaser:
Thank you for bringing up evidence based medicine. For the past 20+ years we have been harped on about the use of evidence based medicine. Thank you for presenting these studies. My objection to the wearing of masks is several fold:
1) There is no good evidence that anything other than an N95 mask stops viral transmission.
2) The surgical and cloth masks that we use are not viral filters. Based on some anecdotal evidence the masks change cough or sneeze droplet propagation but not viral transmission.
This brings up the primary advice, if you are sick, stay home, and quarantine.
3) Because mask costs have gone up tremendously in cost disposable masks are being reused. For a period of time they were unaffordable. Cloth masks also get reused in most cases outside of healthcare and therefore are contaminated by whatever they come in contact with, acting as additional focal points of infection if not for Covid 19 then for other infectious agents.
4) Mask wearing gives patients false hope that they are protected and therefore they ignore social distancing.
Beyond this, who is kidding whom. The CDC this week announced that as many as 10 times the number of known cases (now close to 3 million in the US). That translates to 30 million people that have been infected, but testing has not reached them because many were asymptomatic.
So how are you going to prevent spread of an already widespread virus.
Locking down a nation seems more like anti science and superstition. Protect the vulnerable ones that are over age 75. Have them wear masks.
Having people swimming at the beach with masks on is ludicrous to the point of being dangerous if they go swimming, the mask gets wet, and gets inhaled.
If one is sick they should not go out. Trying to prevent the spread of the virus when 80% of the victims are asymptomatic, is impossible. Are we going to go into lockdown for cold of flu season?
If we were serious about providing protection to people, everyone should have been supplied an N95 mask by the government, and not closed down the country. Again, the elderly over age 75 should have been protected and told to isolate, but not the rest of the country.
We should not blindly wear masks out of “an abundance of caution”. We should follow evidence based medicine, which clearly shows anything but an N95 mask is useless in preventing Covid 19 spread.
While we are at it, the evidence strongly suggests limited virus survival on environmental surfaces, and if there is viral survival it is poorly infectious at that point. So all of the excessive cleaning going on is costing millions of dollars , and inconveniencing millions more (ie shutting down NYC subways at night), but with no real evidence that it has prevented any transmission.
One aspect of wearing a mask has NOT been discussed; and that is HOW OFTEN PEOPLE ACTUALLY TOUCH AND REARRANGE THEIR OWN FACEMASKS, which can effectively render their facemask useless as their nasal and respiratory fluids have now penetrated their mask and they are incessantly touching IT and EVERYTHING ELSE IN THEIR ARMS REACH; this only makes their surrounding 3foot sphere of influence MORE DANGEROUS because that area doesn’t get washed or disinfected so the next person inadvertently enters that sphere or picks up contaminants from that sphere so they are asymptomatically spreading their respiratory germs for everyone else to pick up. So what have we really accomplished? Well, we’ve made people aware that they should so SOMETHING; and is something better than nothing? I put forth that these 2 actions are actually the same thing so why bother?
I reminded a patient of mine about this fact; she had throughout her 30minute office visit readjusted her mask at least 100 times. Then she asked about the wisdom of hand-washing for 20 seconds. I made her aware that as a surgeon, the hand-washing ritual pre-surgical procedure was a 5-7minute ritual for the 1st case of the day and a 3-4minute ritual for subsequent cases; her eyes became as big as saucers, ‘I had no idea. Why would you do that if you are already gowned and gloved?’ When I told her it was in the case of an inadvertent glove breach that would expose the surgeon’s skin to the open wound of a vulnerable patient she nodded her understanding. ‘OHHHHHH. So I guess 20seconds doesn’t seem like that big a deal anymore’. It’s all about perspective.
So let’s put a little more thought into what we recommend as physicians and know that when recommend wearing a facemask in public in 90 and 100 degree weather and these patients are constantly rearranging a sweaty and respiratory-soiled mask at least 3-4times a minute that we are not accomplishing what we hope to accomplish!
If it were possible to know what’s real in all this, it would be far easier to get people to act rationally. And there’s the rub: is the bug really as dangerous as the media and politicians make it out to be? What do masks really do? If you don’t also do a surgical scrub, do masks make much of a difference?
Solid data are hard to find. And the old saw is true: change imposed is change opposed.
There are many problems with what’s been passed off as data. Probably the most vexing are geographic disparities among death rates In infected people. New York and New Orleans are cases in point.
The Kings of New York, Cuomo and de Blasio, both have strong political reasons for wanting to be able to point to a high death rate. Demanding a quarter of a million ventilators and ridiculing Trump for finding a way to supply “only” something like 15,000 certainly created a strong political pressure to actually use them. Even with aggressive “early intubation,” I’m told they didn’t even use all the ones they already had. Paying hospitals large premiums for taking care of COVID patients also contributed to what looks like a scam. Localities with much less aggressive ventilator use had considerably lower mortality rates.
New Orleans? Unless things have changed drastically since I finished Tulane Med, residents and interns pretty much run the public hospitals with not that much oversight from attendings. “Hey, let’s get some intubation practice tonight. There’s one….”. Yes, really. Private hospitals don’t want COVID patients.
Me? I’m done with the shell game. With my coronaries (angioplasties and stents in ‘96, bypasses In ‘18) and being > 70 years old, I’m the one taking the risks. I wear a mask at CostCo and when flying commercial because they require it. Otherwise, no, thanks.
Great article. Thank you!
Some may consider me a “mask-hole” because of my relative reluctance to don one outside of the OR. There is nearly no covid in NY, and I believe you need to be close to a coughing / excreting person to get it. My take on masks is that they would have been a better alternative to quarantine of all society, sick and healthy together which is INSANE.
I believe during an epidemic masks decrease the likelihood of the asymptomatic carrier from spreading disease. This must be combined with the adage, if sick, stay home. Like anything else, with masks use common sense. If you’re going to the supermarket, wear out of respect to others, but wearing one in the park on a sunny day is not for me and largely unnecessary. Peace.
As Samuel Clements once said, “there are lies … damned lies … and statistics.” With the advent of the internet, I believe poor Sam has now completely rolled over in his grave. One can certainly find a multitude of credible evidences, both written and in video form, on the internet for any position one may wish to defend — that’s a given. One can also even find evidence to say that no contrary evidence exists, nor even the possibility of any contrary evidence (those are my favorite). Then when done swallowing all of that bull, I like to have a nice vomit and try to proceed more with the whole common sense kind of thing.
There is, I will assert, epidemiologic evidence that (non-N95) masks decrease spread. I will likewise assert that camera evidence also exists revealing that (non-N95) masks can decrease spread. It’s not very good. I can “disprove” all of it. I can say they took a bad sample. I can say the mask shouldn’t work because viruses are small and can scoot through the pores. I can say they were biased or influenced in their study, etc., etc. (And, of course, I can use similar arguments to disprove the other side as well.) It’s all very entertaining, and surely that battle can go on until Elon Musk lands on Mars. But I try also to be cognizant that there may be a problem with arguing the point until that time.
Problem is the actions we take are kinda now – not 20 years from now when we have our controlled studies (which evidence, too, will surely be debated — perhaps ON Mars). And if each of us decides fer his or her own self whether to wear a mask or whether it is instead an affront to our personal Southern freedoms — then the action we as a community take I think has kinda already been decided by default. (Some masks, I would argue, is pretty much the same as no masks.) Well, I then proceeds ta balance how gosh darn strenuous it is for me to lift that dern mask all the way up to my face and put it on, versus what might I be preventing if the evidence really is correct — and I somehow just barely muster the effort (after debating the issue for hours with my friends, of course — I’m surely always looking for a way out or at least a delay).
The other thing I also know for certain? If social distance is not possible, there is at least one parent or child out there who will probably be more afraid if I don’t wear a mask. So in a way, I just try not to be an @$$hole as well (when it suits me, that is, of course).
Cheers!