Snotty Hand-Washing

Hand-washing is one of the mainstays of public health and of good clinical practice. Images of surgeons with their hands raised in the air, as they enter the OR to have a nurse help them don sterile latex gloves after having meticulously washing their hands, have been immortalized by pop-culture representations of medicine. Indeed, learning the “surgical hand-wash” is one of the glorified coming-of-age rituals for med students. It quite literally initiates aspiring physicians into being legally and morally allowed to cut people open for their own benefit.

Proper hand-washing is crucial for non-surgical clinical practice as well. At my hospital, clinicians are supposed to wash or sanitize their hands as soon as they enter a patient’s room, and after they have made any contact with a patient. And although the procedure for “clinical hand-washing” is much less thorough than its surgical counterpart, there’s still an evidence-based, 11 step process that WHO officially recommends in its annual “SAVE LIVES: Clean Your Hands Campaign.

The rationale for all this rigor in medical practice is pretty obvious, and any hospital-based physician who doesn’t have overly dry skin without moisturizing is probably shirking an important responsibility. However, the clinical obsession over asepticism has spilled over to mainstream culture, but not without some controversy.

Relax: I’m not going to get into the debate over the hygiene hypothesis. I’m also not even going get back on the bacterial-resistance soapbox (except for one quick point–although asepticism in clinical settings certainly does help prevent resistance, it might be counterproductive beyond the clinical setting as wiping out benign bacteria might simply open more ecological space for nastier bugs).

I just want to point out that simple repugnance is probably a better explanation  for the hygiene-neurosis of current times than any legitimate public health concern. Normal people today would probably have seemed like obsessed germophobes fifty years ago. What’s interesting is there’s lots of neat evidence that even the most visceral types of disgust are socially constructed. For example, Norbert Elias’ treatise on snot in “The History of Manners” (1982) describes dinner-table behavior that was deemed perfectly polite by in the most sophisticated European social circles of previous centuries, but which would probably make even the coarsest sailor of today vomit in disgust. I’ll leave you with some highlights, taken from pages 143-148 of this wonderful (yet long, two volume) work by Elias.

Thirteenth century
From Bonvesinde la Riva (Bonvicino da Riva), De La zinquanra
cortexie da tavoLa (Fifty table courtesies):
(a) Precept for gentlemen:
When you blow your nose or cough, tun round so that nothing falls on the table.

From A. Cabanes ,Moeurs intimes du temps passe (Paris, 1910),1st
series, p.101:
In the fifteenth century people blew their noses into their fingers, and the
sculptors of the age were not afraid to reproduce the gesture, in a passably
realistic form, in their monuments.

Among the knights, the plourans, at the grave of Philip the Bold at
Dijon, one is seen blowing his nose into his coat, another into his fingers.

Sixteenth century
From De civilitate morum puerilium, by Erasmus,ch. 1:
To blow your nose on your hat or clothing is rustic, and to do so with the
arm or elbow befits a tradesman; nor is it much more polite to use the hand,
if you immediately smear the snot on your garment. It is proper to wipe the
nostrils with a handkerchief, and to do this while turning away..

If any thing falls to the ground when blowing the nose with two fingers, it
should immediately be trodden away.

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