Reading the history of surgery before retiring for the evening is ill advised, particularly the history of surgery prior to the mid-nineteenth century, which is to say, prior to the advent of anesthesia. The accounts are truly the stuff of nightmares and might best be left unimagined. Even today, behind the quiet hospital hallways and the faint, regular beeps of machines measuring heart beats, surgery remains a grisly business.

This is the lasting impression of the first few times I scrubbed in to observe a surgery: the necessary thrust with which an endotracheal tube is inserted, the sharp, reclined angle of the child’s head that made the insertion and subsequent flow of oxygen possible, the tactile nature of dissection and the tugging of tissue prior to stitching, the pull at the suture and rejoining of tissue with force that would yank a string straight through a garment in need of mending. The physicality of surgery unfolded in such sharp contrast to the images that are conjured up by the phrase healing arts.

Beyond the lurid nature of what was unfolding on the operating table, the atmosphere of the room was calm. A capable care team moved about, a surgeon explained his movements to those in a position of learning, the child laid peacefully. Even still, I couldn’t help but think that the act of surgery bordered on brutal.

How much more so it must’ve been in 1825. Before anesthesia preceded every surgical procedure, the need for speed was the driving imperative in care. Reducing the length of a surgery was the only real method available for reducing pain, as well as shock and blood loss. (Alcohol and opium, among other things, had been long been used to offset pain but their use in practice was not uniform or wholly effective.) Because of the risk of infection and because of the pain involved, major operations were infrequent. One of the only common major procedures of the day was amputation. With this procedure, surgeons measured their success by the number of seconds the operation would take. In the early 1800s at the University College Hospital in London, Robert Liston was known for his ability to perform an amputation at the thigh and dress the wound in a mere three and a half minutes. His movements were quick to the point of blurred motion. Describing this, one onlooker noted that “the gleam of his knife was followed so instantaneously by the sound of sawing as to make the two actions appear simultaneous.”

All of this changed dramatically in the 1840s with the advent of anesthesia. First, a couple of teeth were extracted under ether. Then, a surgeon used ether while removing a neck tumor. By the 1840s, anesthesia had been ‘systematically introduced into surgical practice.’ Interestingly, despite the game changing invention of anesthesia, corollary changes in practice were not immediate or universal. On December 21st, 1846 Dr. Liston walked into a crowded surgical amphitheater to perform an amputation on a 36 year old butler. “We are going to try a Yankee dodge today, gentlemen, for making men insensible,” he said. Ether was administered and a signal was given that the patient was ready. Before beginning, Liston made a request: “Time me.”

The time clocked in somewhere between 25 and 28 seconds and within five minutes the patient was awake and asking when the operation would begin. There has been a great deal of conjecture as to why Liston only took a few seconds on the procedure. With anesthesia limiting pain, operating as quickly as possible was no longer necessary. Were the words “time me” uttered out of force of habit? Did he mistrust the ether? It’s unclear. But what we know for sure is that on that day in December 1846, Dr. Liston was operating in a world that no longer existed.

Reflecting on Liston’s unnecessarily expeditious procedure makes me wonder how often we continue to play by the same rules we were taught, even when they are no longer relevant. The world evolves and markers of success shift, yet changes in our behaviors lag behind. We can’t quite see things the way they are — at least not in real time. We are, perhaps, a bit under the ether ourselves. How often are we guided by the aspirations of a world that is no longer? As you look across your professional endeavors, how are the markers of success shifting? How are you defining success as a result?