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The Evolution of Medical Face Masks SPOTLIGHT Through Plagues and Pandemics: The Evolution of Medical Face Masks KELLY PAN, ANUVA GOEL, LILIANA R. AKIN, SUTCHIN R. PATEL, MD, FACS 72 75 EN KEYWORDS: face masks, pandemic, conversation could disseminate COVID-19 respiratory droplets with bacte- ria. This led Mickulicz-Radecki to create and wear a face mask PLAGUES AND PANDEMICS in 1897, which he described as The first face masks were created to a “piece of gauze tied by two combat the earliest plagues. The Bubon- strings to the cap, and sweeping ic Plague, otherwise known as the Black across the face so as to cover the Death, spread throughout the Roman nose, mouth and beard.”6 Empire in the 6th Century AD.1 When Gregory I became Pope in 590 AD, an out- The Manchurian Plague, break was reaching Rome. To combat the 1910–1911 disease he ordered unending prayer. At The Manchurian Plague of 1910– the time, sneezing was thought to be an 1911 started along the Russian early symptom of the plague, thus stat- border of Manchuria, an area ing “God bless you” became a common of Northeast Asia, and quickly Paul Fürst, engraving, c. 1721, of a plague doctor of phrase spoken to help halt the disease.2 spread south along the railways. Marseilles (introduced as ‘Dr. Beaky of Rome’). His nose- The plague ravaged Europe and Asia The pneumonic form of plague case is filled with herbal material to keep off the plague. from the 14th to the 17th Centuries and killed every person it infected. [CC-PD] is estimated to have killed 200 million Most believed it was spread by people in the 14th Century alone.2 Plague rodents so the idea that it was airborne by the population to wear masks in order doctors wore the iconic bird-beak masks caused fear. The masks during the Man- to curb the epidemic led to a shift from in which the beaks were filled with a churian Plague consisted of a 4x6 inch the belief in superstitions and the super- mixture of herbs such as garlic and rue cotton rectangle secured over the mouth natural towards an acceptance of science to block the odors of the dead and dying by a long piece of gauze. The gauze was to help combat the plague.4 that were ever-present.1,4 This form of folded so that the rectangle was con- protection was thought to neutralize the tained within the gauze lengthwise. The The Spanish Influenza of 1918–1919 “miasma” in the air which was thought ends of the gauze were then cut so that The Spanish Influenza of 1918–1919 to be the cause of the illness.3 one end had two flaps and the other had brought worldwide hardship and halted In 1867, the British surgeon JOSEPH an opening for the flaps to tie into behind the normalcy of everyday life. The Span- LISTER (1827–1912) brought about the the head. The flaps and opening were ish Flu did not originate in Spain, but age of antisepsis, championing the use placed around the ears, similar to modern because Spain was a neutral country in of carbolic acid to sterilize surgical in- face masks, to secure the mask in place. World War I with a free media; the out- struments and clean wounds. At the The ends were then tied together to finish break was covered from the start, with time, LOUIS PASTEUR (1822–1895), the contraption.4 The final product was it being first reported in May of 1918. the French microbiologist and chemist, similar in appearance to a modern day During this time, there was a shortage had recently described the presence of cotton face mask, but the covering over of healthcare workers because those car- germs as the microscopic source of infec- the mouth and nose area were thicker ing for the sick were themselves ill with tion. Lister suggested eliminating germs than they are now. The mask was made the virus. The First World War added to through the use of antiseptic substances.6 for the entire population; however, the the severity of the pandemic as soldiers’ JOHANN MIKULICZ-RADECKI (1850 harsh winter conditions may have ad- immune systems, already weakened by –1905), Chair of the Department of Sur- versely affected the efficacy of the mask.4 the stress and ravages of war, allowed the gery at the University of Breslau, worked This plague and the widespread usage of virus to spread throughout the trench- with local bacteriologist, CARL FLÜGGE masks had a cultural effect on the Man- es. Increased travel due to the war effort (1847–1923), who showed that ordinary churian population. The collective effort further contributed to the spread of the RIMJ ARCHIVES | DECEMBER ISSUE WEBPAGE | RIMS DECEMBER 2020 RHODE ISLAND MEDICAL JOURNAL 72 SPOTLIGHT virus.2 Deaths worldwide were estimated rubber bands. The introduction of anti- The Hawk’s Nest Tunnel disaster to be 50 million, with 675,000 deaths in biotics in the 1940s briefly decreased in- Respirator-type masks that protect the the United States.7 During the 1918–1919 terest in surgical masks, but it was soon wearer from inhaling pathogens have be- influenza pandemic, masks were manda- discovered that antibiotics were not a come heavily associated with the medical tory for medical workers, police officers, substitute for good aseptic technique.8 field today during the COVID-19 pandem- and in certain American cities (citizens in The standardization and testing of sur- ic. These respirators were originally de- San Francisco were fined $5 if they were gical face masks began in earnest in the veloped in the mining industry. In 1919, caught in public without a mask), but the 1950s, establishing the basis for our pres- the U.S. Bureau of Mines (USBM) began mandate of face masks was not without ent-day practices. Numerous tests were working to address the high fatality rate protest.5 By this time, most masks were conducted to assess the effectiveness of of mineworkers by establishing the first made of layers of cotton gauze with oc- masks in preventing the dissemination respirator certification program.10 From casionally another layer of a less porous of germs from the wearer. Some tests in- the beginning, inequalities existed in material surrounded by a metal frame. volved placing petri dishes or glass slides workers’ access to respiratory protection, Furthermore, these masks were reusable at varied intervals from an individual as exemplified by one of the deadliest and could be sterilized.5 The 1918–1919 to pick up exhaled germs. Other more disasters in American industrial history, influenza pandemic ended approximately tech-savvy tests visualized droplets and the Hawk’s Nest Tunnel disaster of the 18 months after its outbreak. The wearing aerosols using high-speed cameras and 1930s. From 1930–1935, three thousand of face masks was thought to have played strobe lights. Many of the principles es- men, the majority of whom were Black an important role in helping stop the tablished by these tests remain important migrant workers from the South, worked spread of the disease during its course.2 to keep in mind today. For instance, it on the construction of a tunnel near was discovered that the closeness of fit of Gauley Bridge, West Virginia. In the con- THE DEVELOPMENT AND the mask to the face is just as important struction process, they found the mineral EVOLUTION OF FACE MASKS as the material, that semi-porous filtering silica and were forced to mine it without As discussed earlier, one of the first sur- masks are more effective than nonporous any respiratory protection. As a result, an gical masks, composed of a single layer deflector masks, and that masks quickly estimated one-third of the workers died of gauze, was described by Johann Mi- lose their filtration capability once wet.9 from acute silicosis and related condi- kulicz-Radecki in 1897. In 1899, Flug- In the modern era, there has been a tions. Notably, the dangers of silica dust ge, who was working with tuberculosis, scarcity of experimental evidence to sup- were well-known to the company, as demonstrated that ordinary conversation port the effectiveness of face masks in their engineers wore respirators inside could disseminate bacteria-filled droplets the prevention of surgical site infections.6 the tunnel.11 The disaster accelerated the from the nose and mouth. The droplet What literature there is on the subject adoption of standards for dust, fume, and theory of infection substantiated the is dated and has had poorly explained mist respirators, but it was not until the need for an effective face mask. In 1905, methodology. Furthermore, it is uncer- passage of the Occupational Safety and ALICE HAMILTON (1869–1970), a Chica- tain that the results of these studies can Health Act of 1970 that the federal gov- go physician, proposed that scarlet fever be extrapolated to today given the usage ernment began requiring employers to was transmitted through droplet infection of new antiseptic techniques since their provide adequate respiratory protection and recommended doctors wear masks completion. Face masks have also been to all workers. at the time of surgery because of heavy thought to have utility in that they act In 1972, the USBM approved the first droplet transmission from the mouth and as a physical barrier against blood and single-use N95 respirator, which is the nose while talking and teaching. This bodily fluid splashes during surgery. De- respirator-type mask that many of us are may have been the first recommendation spite clear evidence that face masks act familiar with today. The designation of that surgeons wear masks.
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