In order to advocate the validity of an intervention in medicine, it must satisfy three levels of evidence: efficacy, effectiveness and cost-effectiveness.4 In the context of facemask, efficacy is whether masks prevent the propagation of droplets derived from the mouth and nose of the operating staff. Effectiveness is whether efficacy translates into a significant reduction in surgical site infection morbidity and mortality. And finally, cost-effectiveness determines whether the cost-to-benefit ratio of this effect would be desirable compared to an alternative course of action.
In the modern era, there has also been a scarcity of experimental evidence to support the effectiveness of facemasks in the prevention of surgical site infections. The earliest retrospective studies7 failed to demonstrate any statistically significant improvement in surgical site infection rates following the use of masks. Indeed, the latest National Institute for Health and Care Excellence guidelines on the matter do not require operating staff to wear a mask in theatre.8 This decision was based primarily upon the findings of a Cochrane systematic review.9 This review was guided by the findings of two particular randomised/quasi-randomised control trials.10,11 The latest update of this review,12 which was amended after the publication of current National Institute for Health and Care Excellence guidelines, included one further study.13
Use Of Masks In Contemporary Theatre
The Cochrane review12 searched through six established databases (Appendix 1) looking for randomised control trials and quasi-randomised control trials investigating surgical outcomes comparing the use of disposable surgical masks with the use of no masks. The authors limited the scope of their analysis only to patients undergoing clean procedures (whereby the operating procedure does not enter a body cavity or viscus normally colonised by bacteria). The review chose not to investigate the role of mask in clean-contaminated, contaminated or dirty wounds as one would expect that masks would contribute less towards the prevention of surgical site infections under such circumstances. Primary outcomes of postoperative surgical wound infection and secondary outcomes of costs, length of hospital stay and mortality rates were ascertained.
Unfortunately, publically available information regarding the financial costs of facemask usage on the National Health Service is lacking. However, as part of the Freedom of Information Publication Scheme, the data are available for the West Hertfordshire Hospitals NHS Trust which purchased 44,482 single-use facemasks in 2012.14 During this year, the West Hertfordshire Hospitals NHS Trust performed a total of 63,250 operative procedures or interventions.15 Extrapolation to the 10,594,814 total operative procedures and interventions carried out across NHS England during the same period15 would equate to an annual procurement of almost 7.5 million single-use masks across hospitals in England. The NHS Atlas of Procurement lists the per unit expenditure of surgical facemasks to be between 0.34 to 1.22, depending on trust and supplier.16 This suggests that annual NHS England expenditure on facemasks lies somewhere in the region of 2.5 to 9.1 million.
Despite clear evidence that facemasks act to protect the theatre staff from macroscopic facial contamination, there are studies to suggest that they fail to protect surgeons from potentially hazardous sub-micrometre contaminants.21 This corresponds roughly to the size range of infectious bacteria while viruses are even smaller. Therefore, the protection that masks confer in the form of macroscopic facial contamination may not necessarily extend towards any microscopic infectious agents present within that contamination.
What literature that is available on the subject tends to be dated with poorly explained methodology. There is also uncertainty over whether the results of such studies can be extrapolated to current surgical practice given the advent of new antiseptic techniques since they were completed. The evidence base investigating the effects of facemask usage on patient-based outcomes is, in general, more extensive than that of surgeon-centred outcomes. Facemasks do have a clear role in maintaining the social cleanliness of surgical staff, but evidence is lacking to suggest that they confer protection from infection either to patients or to the surgeons that wear them.
It is clear that more studies are required before any absolute conclusions can be drawn regarding the effectiveness or, indeed, ineffectiveness of surgical masks. The published literature does suggest that it may be reasonable to further examine the need for masks in contemporary surgical practice given the interests of comfort, budget constraints and potential ease of communication, although any such study would undoubtedly have to be large and well controlled to prove causality given the low event frequency of surgical site infections. It is possible, if not probable, that if surgical facemasks were to be introduced today, without the historical impetus currently associated with their use, the experimental evidence would not be sufficiently compelling to incorporate facemasks into surgical practice.
One can assume that theatre artists of ancient Greece had as much, if not more, knowledge of the sophisticated expressive form of the theater mask as we do today. Masks throughout time and across cultures have been connected to religious, spiritual and ritual practice. This was no different concerning their use in Greek theatre given the performances were part of the ritual celebrations of the time. The artists who both performed and created them would have engaged in a profound exploration of practice much the same as we do today.
The mask is a tool that reveals. The actor uses it to share the discoveries being made, the thoughts being had and the emotions being felt with the audience. In turn because of the archetypal forms inherent in the theatre masks the audience experiences themselves and their life struggles through the sharing of the mask.
One can assume that the use of Greek theater masks in ancient Greece was in many ways no different than they are being used today in the heightened environment of classical theatre. When the theater mask is considered to be more than just a costume element it becomes the driving force of the theatrical event. Our ancient cultures and societies are often assumed to have had a much greater connection to the natural world. The mask is one such extension of that knowledge and daily practice.
One of the challenges in anthropology is finding the precise derivation of human culture and early activities, the invention and use of the mask is only one area of unsolved inquiry. The use of masks dates back several millennia. It is conjectured that the first masks may have been used by primitive people to associate the wearer with some kind of unimpeachable authority, such as a deity, or to otherwise lend credence to the person's claim on a given social role.
In the Greek bacchanalia and the Dionysus cult, which involved the use of masks, the ordinary controls on behaviour were temporarily suspended, and people cavorted in merry revelry outside their ordinary rank or status. René Guénon claims that in the Roman saturnalia festivals, the ordinary roles were often inverted. Sometimes a slave or a criminal was temporarily granted the insignia and status of royalty, only to be killed after the festival ended.[11] The Carnival of Venice, in which all are equal behind their masks, dates back to 1268 AD.[12] The use of carnivalesque masks in the Jewish Purim festivities probably originated in the late 15th century, although some Jewish authors claim it has always been part of Judaic tradition.[13]
The North American Iroquois tribes used masks for healing purposes (see False Face Society). In the Himalayas, masks functioned above all as mediators of supernatural forces.[14][15][16] Yup'ik masks could be small 3-inch (7.6 cm) finger masks, but also 10-kilogram (22 lb) masks hung from the ceiling or carried by several people.[17][18] Masks have been created with plastic surgery for mutilated soldiers.[19]
In many dramatic traditions including the theatre of ancient Greece, the classical Noh drama of Japan (14th century to present), the traditional Lhamo drama of Tibet, Talchum in Korea, and the Topeng dance of Indonesia, masks were or are typically worn by all the performers, with several different types of mask used for different types of character.
In Ancient Rome, the word persona meant 'a mask'; it also referred to an individual who had full Roman citizenship. A citizen could demonstrate his or her lineage through imagines, death masks of the ancestors. These were wax casts kept in a lararium, the family shrine. Rites of passage, such as initiation of young members of the family, or funerals, were carried out at the shrine under the watch of the ancestral masks. At funerals, professional actors would wear these masks to perform deeds of the lives of the ancestors,[23] thus linking the role of mask as a ritual object and in theatre.
Ritual masks occur throughout the world, and although they tend to share many characteristics, highly distinctive forms have developed. The function of the masks may be magical or religious; they may appear in rites of passage or as a make-up for a form of theatre. Equally masks may disguise a penitent or preside over important ceremonies; they may help mediate with spirits, or offer a protective role to the members of a society who use their powers.[24] Biologist Jeremy Griffith has suggested that ritual masks, as representations of the human face, are extremely revealing of the two fundamental aspects of the human psychological condition: firstly, the repression of a cooperative, instinctive self or soul; and secondly, the extremely angry state of the unjustly condemned conscious thinking egocentric intellect.[25] 2ff7e9595c
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