This April the CDC issued at statement that encouraged all Americans, regardless of their Covid-19 status, to wear a cloth face mask when out in public. One hundred and two years ago, Americans were doing the same thing—they were sporting a “new, simple, cheap and successful device” to protect themselves from the Spanish Flu: the cloth face mask.1
While the idea of using masks to ward off disease wasn’t exactly new, in 1918, face masks had only recently been proven to prevent disease.
Just eight years earlier in 1910, a new strain of bubonic plague originating in marmots broke out across Northern China. Highly infectious and extremely deadly, it killed within a day or two of producing symptoms. Desperate to try to locate the source of the infections and stop its spread, the Chinese Imperial Court called in doctors from all over the world. One of them was Lien-teh Wu, a young doctor fresh from medical school, who was eventually put in charge of public health for the epidemic.
After discovering via autopsy that the new plague was spread through the air rather than fleas as had other iterations, Wu created a new mask to use around his sick patients. Loosely based off Western surgical masks of the 1870s, Wu’s mask was a “hardier” mass of cotton and gauze tied securely to the face with some extra layers of cloth on top for extra filtration. They were cheap, easy to produce, and effective. Unlike surgical masks, which are still primarily used today to prevent a surgeon from coughing or spitting into open wounds as they work, Wu’s masks were worn to reduce the spread between the sick and the healthy—something they did remarkably well, especially in combination with his new quarantine techniques.
Not everyone was receptive to Wu’s ideas, however. Thanks to the open racism of the time, many non-Asian doctors questioned its effectiveness. This often led to needless death, as this famous story sum up from historian Christos Lynteris about an interaction between Dr. Wu and a French doctor demonstrates:
“He’s confronted by a famous old hand in the region, a French doctor [Gérald Mesny] . . . and Wu explains to the French doctor his theory that plague is pneumonic and airborne,” Lynteris says. “And the French guy humiliates him . . . and in very racist terms says, ‘What can we expect from a Chinaman?’ And to prove this point, [Mesny] goes and attends the sick in a plague hospital without wearing Wu’s mask, and he dies in two days with plague.”
Despite these doubts, Wu’s mask proved itself time and again in the field, and by 1911 they were being handed out to both healthcare workers and the general public alike across Manchuria, helping to stop the spread of the new plague.
When the Spanish Flu hit the world eight years later, healthcare professionals around the world turned to Wu’s face masks for inspiration in creating their own designs.
Initially, cloth face masks were only deemed necessary for healthcare workers and the sick. Only nurses, those nursing the sick, and the sick people themselves were encouraged to wear them. “The sick person and [their] attendants should wear face masks,” instructed Dr. W. A. Evans on one of his many articles on how to treat the Spanish Flu.2 “The nurse should wear a face mask when waiting on the patient” and “the mask should be sterilized by boiling daily.”3 “The wearing of face masks by nurses and other hospital attendants should be made compulsory in hospitals and by all who are directly exposed to the disease,” recommended the American Public Health Association of Chicago, including barbers and dentists and any others “whose work compels them to bring their faces close to the faces of others.”4
Eventually, the use of masks was recommended for the public as well. Across the country, it became illegal not to wear one, and people could be denied service, arrested, or fined if they did not comply.
Their usefulness regarding the general public, however, was debatable even back in 1918. Some doctors thought they helped significantly, while others were more doubtful. One of their biggest proponents in Chicago was the city’s former health commissioner, Dr. A. R. Reynolds. He trumpeted the usefulness of masks in the Tribune, declaring that they would allow an immediate return to normalcy:
“…if the general public can be made to use [masks], there will be no need to restrict public assemblages or impede in any way the usual habits of the public…prudence demands that everybody should wear the mask in crowded rooms, on windy days, or when engaged in dusty occupations.”5
Instilling that kind false confidence, however, is a dangerous thing to do, and the doctors of 1918 took pains to point that out as well. Dr. W. A. Evans, the Chicago Tribune’s health contributor from 1913 to 1933, was less enthusiastic about the public using masks:
“The wearing of face masks as a means of preventing influenza is on trial. It seems to offer something as a means of prevention for nurses and hospital attendants. The proof that it is effective as a measure employed by men on the street is poor at best. Nevertheless, any trial given the method should be a fair one. The wearing of improperly made masks that are wet and soiled or masks that are improperly placed does not constitute a fair trial.”6
A face mask, Dr. Evans noted further, was only worth it if used it correctly—and not many people were doing that. In one article, he described meeting a man on the street from Fort Wayne, Indiana who was not using his mask correctly:
“A while ago I met a man who had just come from Fort Wayne…he stopped and showed me the face mask he had worn while in Fort Wayne. It was soiled and wadded. He said he had carried it in his pocket and that whenever he went into a building he held it in front of his face. That illustrates how not to wear a face mask.”7
Towards the end of the epidemic, healthcare professionals had backed off from encouraging the public to use masks, saying they were less effective than previously thought. The American Public Health Association of Chicago did not recommend them for general public:
“The general wearing of masks in the streets and elsewhere the committee did not advice. The principal reason lay in the certainty that most of the masks worn would be improperly made or improperly adjusted;” yet, they added, “There is no reason why any individual who wishes to wear a face mask as a means of self-protection should not do so.”8
When he looked back at the epidemic in 1920, Dr. Evans deemed them worthless, largely thanks to people not using them correctly:
“Some communities passed ordinances requiring that every person wear masks all the time. Other communities encouraged the use of masks but did not require it. At the end of the first wave there was a general agreement that the measure had proved ineffective. Unquestionably a part of the failure was due to bad faith on the part of the people. They wore masks when on the street or when under observation but took them off when they got inside the house. Some wore masks in a slipshod fashion. Some called any excuse a mask. Some wore masks after the masks had become dirty and wet. California communities gave the mask the best tryout,” he noted, but in the end if the mask didn’t fit right or was made out of the wrong materials, at best it reduced the number of bacteria by “one half,” and this was “not enough to warrant the compulsory use of masks by all the population.”9
The debate over public mask use is still going on today. While the CDC now officially recommends it, the World Health Organization sees them as only one step in a larger process, as this publication from April 6th, 2020 explains:
“Wearing a medical mask is one of the prevention measures that can limit the spread of certain respiratory viral diseases, including Covid-19. However, the use of a mask alone is insufficient to provide an adequate level of protection, and other measures should be adopted. Whether to not masks are used, maximum compliance with hand hygiene and other IPC measures is critical to prevent human-to-human transmission of Covid-19.”
Dr. Deborah Birx, the Coronavirus Response Coordinator for President Trump, cautions against looking at masks as some sort of cure-all as well. At a White House press briefing in April, she said:
“The most important thing is the social distancing and washing your hands. And we don’t want people to get an artificial sense of protection, because they’re behind a mask. Because if they’re touching things — remember, your eyes are not in the masks. So if you’re touching things and then touching your eyes, you’re exposing yourself in the same way….we don’t want people to feel like, ‘Oh, I’m wearing a mask. I’m protected and I’m protecting others.’ You may be protecting others, but don’t get a false sense of security that that mask is protecting you exclusively from getting infected, because there are other ways that you can get infected because of the number of asymptomatic and mild cases that are out there.”
So cloth face masks won’t protect you from Covid-19, just like they didn’t protect the public from Spanish Flu—but that doesn’t actually mean they’re useless. Besides providing at least some basic protection from large respiratory droplets, face masks can also increase the “psychological resiliency” of wearers in a stressful time, increasing feelings of safety and control, while also acting as signs of solidarity, as they’ve done in Asian countries which embraced them socially years ago.
It helps, too, to remember that we’re dealing with a different disease. Unlike the Spanish Flu of 1918, Covid-19 can present asymptomatically, so it’s possible to be sick without knowing it and spread it to others. Therefore, it behooves all of us, in the interest of protecting those who might die from it, to act as if we’re already infected. Ultimately, then, you’re not wearing a face mask to prevent YOU from getting sick—you’re wearing one to prevent OTHERS from getting sick. In that light, a homemade face mask is better than nothing when it comes to Covid-19, so we might as well all get on the bandwagon.
So, bring on the 1918 models! 🙂
HOW TO MAKE A FACE MASK FROM 1918:
Face masks in 1918 were a bit different than the ones that the CDC is suggesting we make now. Different materials, different styles, and different sizes were all possibilities. Here are a few of the more common models of 1918:
It’s your standard rectangle with fabric ties, more or less. Smaller and squarer than today’s CDC guidelines (it’s shorter by a few inches on both sides), it also calls for a marker to distinguish the outside-facing part of the mask from the inside one, so you don’t accidentally put the wrong side against your face. This particular page with mask directions comes from Epidemics: How to Meet Them by Louis A. Hansen, which was published for free in 1919 to help educate the general public about the spread of infectious diseases. One of the materials it asks for—“butter cloth”—is probably butter muslin, a finer grade of cheesecloth which is closer to a pillow case in terms of weave. However, another medical study on face masks at the time—Dr. George Weaver’s Droplet Infection And Its Prevention By The Face Mask (1919)—deemed butter cloth unsuitable, seeing as most of it was treated to be “nonabsorbent,” didn’t have “as fine a mesh as is desirable,” and was difficult to obtain in large quantities.
THE DURAND HOSPITAL MASK
This particular style, which covers the entire lower half of the face, comes from Droplet Infection and its Prevention by the Face Mask by Dr. George H. Weaver. Full of lots of fun charts on expectorating disease particles, it also has face mask instructions. Dr. Weaver’s masks are different from the previous rectangle since they include diagonal corners on each end. This means the whole lower part of the face is covered while reducing “traction on the chin” and “not drawing on the nose and lips,” which was increased user comfort.
THE MASS-PRODUCED MASK
When the public were encouraged to wear masks by city officials in Chicago, they were either told to make them themselves or to obtain mass-produced ones. This description of a mass-produced mask comes from the Tribune:
“It is made of four thicknesses of plain unmedicated gauze, about four inches wide and six inches long, with a small tape or string sewed to each corner. It is just large enough to cover the mouth and nostrils, with allowance for shrinkage, and it is tied to the back of the head with the four strings. It freely admits the air in breathing and prevents the escape of droplets in expiration, cough, or sneezing.”10
A longer description of a proper face mask, which includes mass-produced “frames” to clip material on to, comes from a different Tribune article which calls for “butter cloth,” gauze, and mesh but cautions against using too many “non-absorbent” materials11:
THE BIAS SQUARE
This particular mask shape was attributed to Dr. C. St. Clair Drake, the Illinois state health director during the Spanish Flu. Unlike the other models, it’s a diagonally set square.
Surprisingly, this shape may be the most effective compared to the others. According to a study in the Journal of Exposure Science & Environmental Epidemiology, the shape of a cloth mask actually matters when it comes to protecting its user. In a study about air pollution, scientists tested three popular Indian cloth masks—the kind you can buy from street vendors to protect against air pollution, as well as a standard surgical mask—to see if they could block common air pollution particles like diesel fumes. While none of the cloth masks performed particularly well compared to modern plastic materials found in medical masks, only one of the cloth masks—the one which was formed to fit a user’s face—actually protected the user from air pollution. The worst ones, they noted, were “simple rectangles with loops to connect behind the ear.” The lack of “sufficient fit” from that shape allowed “the leakage of a significant fraction of particles”—something you don’t want when you’re trying to prevent those particles from leaving or getting near your mouth and nose.
…COTTON BALLS AND…MOUTHWASH?
The most ridiculous alternative to a cloth face mask that I found while researching this post was actually an advertisement. Here it is in all its glory, for maximum impact:
In case it isn’t immediately apparent, Kolynos Liquid is NOT a cleaning product like bleach—it’s a brand of mouthwash.
Established in 1908, Kolynos offered a range of oral care products that were quite popular throughout the 1930s and 1940s. While it disappeared from U.S. markets sometime in the early 1960s, it lived on in Latin America and Eastern Europe, where it was quite popular—until it became a subsidiary of Colgate in 1995, which subsequently killed their competition.
In a strange echo of Alex Jones’ Covid-19 toothpaste scandal, Kolynos advertisers were quick to claim their products prevented Spanish Flu. Since many doctors were promoting keeping mouths clean to combat influenza, many of Kolynos’ ads stressed using their product at least three times a day to “sanitize” one’s mouth and throat of disease: “Kolynos Dental Cream will give you clean teeth, a clean mouth, and a clean throat. This sanitary cleanliness endures for several hours and greatly diminishes the danger of infection.”12
Most ridiculous of all, though, these same ads also recommended applying “at the first sign of a cold…a small amount of dental cream—about half the size of a pea—in the entrance of each nostril, when retiring, and several times a day.”13 Cotton balls soaked in toothpaste or mouthwash were deemed particularly effective, thanks to the “filtering” action, as this Kloynos ad explains:
So did soaking cotton balls in toothpaste and shoving them up your nose really prevent the Spanish Flu? I’ll let you guys make the call on that one… 😉
So, Dear Readers, where to begin with creating your own mask?
While you could always try making one of the 1918 models, the internet is chock full of guides for more modern face masks, many of which are larger than the 1918 models and thus offer more coverage. Here are a few links to get you started if you’re looking for some ideas:
The official CDC guidelines, which include both sew and no-sew options.
This Smithsonian article showcases a few different videos on how to make masks and further explains the face mask debate.
This New York Times article offers some decent guidelines.
Good Housekeeping offers some different instructions and material recommendations.
Time magazine has three different methods for you to try.
CNN has a bunch of animated GIFs with coffee filters that are kind of fun.
While it’s hard to scientifically determine which fabrics are best to make masks from, the New York Times recommends quilting fabric, batik fabric, or other dense weaves. So doesSew Can She, which also offers different mask-making instructions depending on your skill level.
And of course, there’s always the official video guidelines from the CDC.
What about you, Dear Readers? Have you made a mask yet? If not, good luck on your mask-making adventure, and stay safe! 🙂