The Intriguing History of Gloves and Their Application to Surgery

ABSTRACT

Many millennia ago, gloves were devised for protection, first from the cold and then to protect the hands from injury. In time, they became associated with social class, wealth and as a sign of privilege. With status and prestige followed the glamour and commercialism of fashion. Surgeons had little interest in gloves until relatively recently unless they were dealing with foul and putrid wounds. The first serious use of gloves in surgery was to protect hands from the irritating effects of antiseptics such as mercuric chloride—until Joseph Bloodgood noticed that they also markedly reduced surgical infection rates. Soon glove‐wearing became routine in surgery and the drive, promoted by glove manufacturers, moved to expansion of their use. An example of this is the increased use of double‐gloving for elective soft tissue surgery. The obsession to reduce infection at all costs (based on theoretical grounds from observing glove micro‐perforations after surgery) without any evidence of actual benefit to patient or surgeon (no RCT has shown reduction in SSIs or blood‐borne transmission of infection from double‐gloving) has led to actual harm, particularly if the environmental damage and huge costs to healthcare services are taken into account. Review of the history of surgical gloves suggests that some accepted dogma should be challenged and that guidelines for glove wearing would be better aligned to the available evidence if they are to minimize harm.

Gloves were first worn to protect against cold and injury. In surgery, their purpose now is to reduce surgical site infection and blood‐borne transmission of disease. Surprisingly, their adoption in surgery as a routine has been remarkably recent and had a bizarre origin. Current use in routine surgery appears to be excessive and not always evidence‐based. For example, routine double‐gloving for elective surgery has substantial but unintended adverse environmental effects and huge financial consequences for health services in the absence of direct evidence of benefit. Yet established dogma is hard to change!

1. Early Uses of Gloves

Humans have used gloves since the Ice Age for their own protection, initially against the cold, but subsequently, mostly for protection against injury whether it be from hard labour or war. Primitive gloves were bag‐like. Mittens with a separate extension for the thumb appeared later. This increased their utility, as it allowed thumb apposition for grip and to improve dexterity. The oldest surviving gloves are the more than 20 pairs found in Tutankhamun's tomb. By now, their complexity had increased enormously, and there were separate sheaths for the fingers. In Egypt, Athens and Rome, they became a sign of status and nobility. For lower classes, they were used simply to protect the hand from injury, yet not always, as depictions of the time show that not all charioteers in Egypt were afforded the privilege and protection of wearing gloves, dangerous though that occupation was.

Although gloves have always been primarily protective, and remain so even now, they have also been intimately connected to social class, wealth and importance. Thus, gloves feature prominently in portrait art to such a degree that social history can be followed by studying gloves in art. As an example, Charles 1 ushered in an era of understated style with his highest quality fur‐lined, softest Cordoba leather gloves (Figure 1). Gloves have reflected the imperatives and whims of the age. And with status and prestige, closely follows fashion with its amalgam of glamour, aesthetics and commercialism. In Europe, this took off in the 13th century, and remains active worldwide today. The unpredictability and vagaries of fashion have meant that as fashions evolve, the functionality of gloves sometimes suffers. Meanwhile, manual workers still rely heavily on protective gloves; and unlike in fashion, their design and functionality have been refined to best suit their intended purpose. The same applies to sport.

FIGURE 1.

Detail of Daniel Mytens' (1590–1647) portrait of King Charles I (1600–1649) wearing his trend‐setting highest quality fur‐lined, softest Cordoba leather gloves.

Gloves have become part of rituals in several religions. Even with the coronation of English sovereigns there is a particular ritual that has persisted for over 1000 years from when King Edgar the Peaceful in AD973 allowed his right‐hand glove to be removed to enable a coronation ring to be placed. It is noteworthy that King Charles III, who in a commitment to sustainability—itself a sign of the times—chose to use the same white kid leather glove as King George 6th had used before him in 1937.

The phrase “throw down the gauntlet” has its origin in the medieval armoured gloves worn by knights, at a time when chivalry and honour were paramount. To throw your glove before the feet of the person who had insulted you was an invitation to a duel to restore your honour. If the challenge was accepted, the gauntlet was picked up. And if a duel ensued (perhaps at dawn the next morning), might not a surgeon be needed, and if their assistance was sought, would they have worn gloves? No.

2. The Surgical Context Emerging

For barber surgeons, speed mattered, as duration of surgery correlated directly with mortality. There was no understanding of contamination: such that wiping hands on grubby aprons was encouraged so that your instruments did not slip out of your bloodied hand as easily. By 1700, increasingly complex procedures were being performed (e.g., amputations), and the amount of blood on the surgeon's coat and apron became a measure of their experience. Gloves were sometimes worn but only for the most foul, putrid and offensive wounds.

As the 19th century quickly approached, there was still no sign of any use of gloves in surgery. For example, when Rear Admiral Nelson led an assault on Tenerife in 1797 he was hit in the right arm by a musket ball as he climbed ashore. As he still had three functional limbs he refused assistance, but instead ordered the surgeons to prepare for his surgery. The amputation clearly was done carefully, as it took 15 min. No gloves were used. He sat there calmly, complaining only that the instruments were cold and in future, surgeons should always warm their instruments before using them. His wound healed, and apart from a ligature which may have been applied to his median nerve that caused him excruciating and unrelenting pain until it fell off and was extruded much later, he was fine. The rest is history.

Would Nelson have fared any better a generation later? Likely not. For surgeons, speed remained critical as it was perceived to reduce pain and improve survival. Prior to anaesthesia, Robert Liston (1794–1847), famous as being the fastest surgeon of his time, would say to his students prior to starting: “Now gentlemen, time me”. He got some amputations down to well under 30 s. He commonly held the bloody knife in his teeth to free his cutting hand. Admittedly, on one occasion, he inadvertently amputated the patient's testis as well as the leg. He was also famous for a case with a 300% mortality: a spectator's coat was slashed with a knife and the shock of that killed the man watching. An assistant died of infection from part of his hand being cut off, and the poor patient succumbed to gangrene. The surgeon survived. No gloves were worn, but perhaps in retrospect, a gauntlet may have been helpful for the assistant.

The advent of ether anaesthesia from 1846 enabled more complex operations, but longer procedures increased the risk of sepsis. Joseph Lister (1827–1912) started using carbolic acid sprays and emphasized cleaning instruments (and wounds), but even he saw no need to advocate gloves. In 1847, Ignaz Semmerweis (1818–1865) introduced mandatory handwashing with chlorinated lime to dramatically reduce deaths from postpartum puerperal fever—from 18% to 2% but without the added protection of gloves. For the rest of the 19th century, the inconsistent use of surgical gloves was to protect the skin from the corrosive and irritating effects of antiseptics and not to protect against the transmission of infection. The gloves used then were heavy rubber or linen and nothing like what we are used to now.

Remarkably, glove‐wearing in surgery occurred remarkably late in surgical history, and initially not even for antisepsis.

3. The Advent of Modern Surgical Gloves

Probably the first person to advise surgeons to wear gloves during a surgical procedure was the Persian military surgeon Hakim Mohammad (1571–1629) who advocated the use of a sheath of skin from a sheep's testis (presumeably meaning scrotum) for their fingers when examining wounds caused by infection, smallpox, leprosy and anthrax, clearly to prevent transmission of disease to the physician. In Europe, a century later, credit is often given to Johann Walbaum (1724–1799), a famous ichthyologist and physician who used a sheep's caecum pulled over three fingers (middle, ring and little fingers) on one hand for obstetric deliveries, but their exact purpose and advantage are elusive which might explain why his influence at the time was, at best, modest.

The big advance was not until 1890, and for a bizarre reason. William Stewart Halsted (1852–1922) at Johns Hopkins Hospital engaged the Goodyear Rubber Company to make some custom thin rubber gloves to provide relief for his most efficient and favourite nurse to protect her sore and inflamed hands. He was aware that Charles Goodyear had refined the process of vulcanization of rubber, so he provided him with a cast of his nurse's hands to make a prototype. This nurse, Caroline Hampton, had suffered such severe dermatitis from contact with mercuric chloride that her attendance at operations was being compromised [1]. He was concerned not to lose her. Back came the new gloves. They were an immediate success. The improvement to the condition of her skin was so quick and remarkable, and clearly so well received that within months, they were married. But there was a downside to this happy ending—despite this gallant endeavour, it came at a cost—because she was forced to resign as it was seen as being unfit and inappropriate for a married woman to continue as his scrub nurse.

The story could quite easily have ended there had it not been for the astute observations of his former Chief Resident, Joseph Colt Bloodgood (1867–1935) (Figure 2) 10 years later, by which time quite a few surgical staff were wearing these new‐fangled Goodyear reusable gloves. He noticed their dramatically lower infection rates, from 17% to 2%, and it was this observation that made him demand the routine use of gloves in surgery at his own hospital. This stimulated the gradual adoption of gloves for surgery elsewhere as it became increasingly obvious that glove wearing could markedly reduce perioperative infection. What was initially motivated to protect staff skin, and perhaps enhance certain other prospects, was to have an even more profound and enduring effect in protecting patients from sepsis.

FIGURE 2.

Joseph Colt Bloodgood (1867–1935) must be credited with his careful observation that those surgeons who wore reusable Goodyear gloves had a lower surgical infection rate.

Over the next 30 years there were multiple observational studies showing a reduction in infection rates; incrementally, gloves became more widely used until they became the standard in clean surgery. It was refinements in rubber manufacturing, better sterilization methods and an increasing understanding of microbiology that facilitated their routine use (Table 1). In the 1960s single‐use latex gloves were introduced by the Ansell Rubber company, whereas previously, gloves were re‐used and sterilized between cases.

TABLE 1.

Factors leading to the widespread use and acceptance of gloves for surgery.

Multiple studies showing reduction in the rates of peri‐operative surgical infection

Refinements in manufacture:

Better fit

More comfortable

More consistent in quality

Better sterilization methods for reusable gloves

Greater understanding of microbiology and how infection occurs

4. Focus on Reducing Surgical Infection

By the end of World War 2, gloving had become routine in surgery, and the focus turned to further reducing surgical infection. Multiple innovations were introduced, some with a sound scientific basis, others less so. The drive was now on the protection of the patient, and the surgical philosophy of the time was: “if it may help and does no harm, then do it”. Then appeared two disruptors: first, with the scourge of HIV and Hepatitis B and C, there was a paradigm shift to mutual protection (surgeon and patient). Secondly, as problems with latex were becoming more apparent, alternative materials were sought: hence the emergence of nitrile and neoprene gloves. Further refinements to protect both the patient and surgical staff were introduced. These included double‐gloving (or treble gloving), glove indicator systems to detect leaks, and frequent and regular glove changes for longer operations. These innovations coincided with a number of other initiatives such as protective clothing for high‐risk procedures (e.g., joint replacements), positive pressure operating theatres, laminar flow ventilation in theatres, prophylactic perioperative antibiotics, and in some circumstances pre‐operative shaving and bowel preparation. It has proved difficult to reliably tease out exactly the true effect of each initiative, as demonstrated in the example below.

5. Double‐Gloving

Double‐gloving as a routine for surgical procedures has been around for about 40 years in the belief it might reduce surgical site infection and risk to theatre staff from blood‐borne infection. As early as 1980, double‐gloving was beginning to be introduced for some orthopaedic procedures and for trauma. The impetus for this change came from glove manufacturers and distributors. And for good reason: the glove market is massive and growing. The surgical maxim that was promoted became: “we want to reduce infection: double gloves may help—so use them”. The glove industry, convinced of the merits of double‐gloving, has worked hard to change surgical culture and has engaged actively in many educational programmes for nurses and surgeons [2, 3]. Their promotion of double‐gloving was predicated on the demonstration of micro‐perforations of gloves following surgery and this was taken as a proxy for risk of surgical site infection or risk to blood‐borne infection to surgical staff. The justification was potential benefit in the absence of harm. There was no consideration of its potential to cause unintended harm outside surgery, including to the environmental damage from the extra sterile gloves used, the increased cost to the health system, and the ethical ramifications.

5.1. Micro‐Perforations as a Proxy for Benefit

There are about 106 studies, many supported by glove manufacturers, that show the micro‐perforations in surgical gloves occur frequently during surgery. Moreover, the factors that contribute to glove perforations are now well established, and there is remarkably good concordance between the various studies. The factors that are associated with higher percentages of micro‐perforations of surgical gloves include the type and duration of surgery, and the observation that when double‐gloving is used, there are fewer perforations in the inner glove than in the outer glove. Jagged bone edges and some surgical instrumentation also increase the likelihood of glove perforations (Table 2).

TABLE 2.

Factors that are associated with an increased rate of micro‐perforations in gloves during surgery.

Longer duration of surgery

Single glove compared with perforation rate of the inner glove with double‐gloving

Surgery around jagged bone edges

In 2019, the Covid epidemic embedded the practice of double‐gloving in many Western countries, again without any evidence of additional benefit to patient or surgeon. This epidemic dramatically increased the use of gloves generally in health care facilities, including for surgical procedures. For example, during the Covid‐19 epidemic gloves were being used at a rate of 65 billion per month. In March 2022, in the United Kingdom alone, over 12 billion gloves were used. In Australia, 1.1 billion gloves were used in 2024 [4].

5.2. Evidence for Benefit From Double Gloving

The real question is whether glove perforation rates should be used to justify the practice of double‐gloving, rather than from any direct evidence that double‐gloving actually reduces the frequency of surgical site infection (SSI) or transmission of infection to surgical staff. There is no RCT that has shown that double‐gloving reduces SSIs. Perhaps surprisingly to many, the only two RCT that have looked at surgical site infection (SSI) have both failed to show any benefit, mainly because there were no infections in the single glove arms of the trials [5, 6]. The design of neither study was adequate to convincingly conclude whether the use of double‐gloving was important. While it could be argued that the power of the studies was not great enough to demonstrate a difference, it could be equally argued that any difference must be so miniscule that it probably has no clinical significance. Two Cochrane reviews were unable to make any confident comment on the basis of the limited information available [7, 8].

Against this, double gloving does adversely affect tactility, sensitivity, comfort and dexterity, although with familiarity by the surgeon, these shortcomings become largely accommodated with continued use.

5.3. Double‐Gloving Challenged

There are strong grounds for challenging routine double‐gloving because of its adverse consequences: environmental and financial. Billions of sterile gloves are produced monthly. They are the highest‐volume single‐use items in hospitals. The international surgical glove market is growing annually, even without the effects of Covid. Proportionally, their effects on the environment are also growing. The most damaging for the environment are sterile surgical gloves, sadly the ones used for double‐gloving, where their environmental impact is about 11.6X that of non‐sterile gloves, mainly because of the extra sterilization steps [9]. Their adverse environmental costs relate to the raw materials, production, sterilization, transport/distribution and disposal (Table 3). Vulcanization is energy intensive [10], and often the energy comes from fossil fuels. There are toxic emissions of volatile organic compounds, such as dichloromethane, carbon disulphide and styrene. Later disposal also has damaging effects from their durability, heavy metal release, incineration and microplastic release [11].

TABLE 3.

The adverse environmental effects of sterile glove production.

64% of the environmental impact of surgical gloves comes from their production

Latex gloves from rubber trees:

Some carbon sequestration but offset by deforestation

Use of fertilizers

Loss of biodiversity

Soil degradation from monoculture

Synthetic (nitrile) gloves:

Made from fossil fuels

Effects of extraction and refining

Vulcanization is energy intensive—typically the energy comes from fossil fuels

Toxic emissions of volatile organic compounds such as dichloromethane, carbon disulphide and styrene

Transport and distribution

Glove disposal: damaging effects from

Durability

Heavy metal release

Incineration

Microplastic release

The financial costs are substantial, at a time when health resources are constrained. Quite apart from the cost of the gloves themselves, the indirect cost is one of opportunity loss: money spent on excessive use of gloves is money that could have been spent more usefully elsewhere.

Ethically, it can be argued double gloving for most elective surgery is not justified. The dominant surgical driver to reduce perioperative infection has led to the maxim: “More gloves equals more safety” and assumes no harm. But double gloving does cause demonstrable harm, without evidence it reduces infection. Every extra glove used increases the carbon footprint, releases toxic materials, and has to be disposed of. Let alone the increased cost to hospitals. Absence of benefit becomes active harm. A more informed maxim might be: “they do cause harm, so without evidence of benefit, they should not be worn” [12].

5.4. The Place of Double‐Gloving

Current evidence, the culmination of over 30 years of reports, has shown no benefit to patient outcomes by double‐gloving, despite the entrenched belief it is the right thing to do. It is wasteful of resources, expensive to hospitals and bad for the environment at a time where we all have responsibility for sustainable health. On current evidence, routine double gloving is not indicated for soft tissue surgery. If one is very conservative and cautious, despite the lack of direct evidence of benefit, one might argue that double gloving could be optional for perceived high‐risk situations, such as trauma, some orthopaedics, long operations, and where it is deemed there is a particular risk to either patient or surgeon.

6. The Future

This critique of the use of surgical gloves over the 140 years shows that incremental advances in glove technology combined with advances in related areas of medicine have enabled safer and more complex surgery to be performed. Yet it also suggests the need for better risk–benefit analyses to inform better and more consistent practice. Consideration of evidence, especially with the move towards more sustainable health practices, implies that cost and unintended consequences, such as to our environment, also need to be included in any recommendations for their use. The result would be that we align our guidelines with actual evidence of both benefit and harm, and to do this, we must retain a healthy suspicion around accepting dogma.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.