On the evening of September 27, 1886, Justus Ohage, MD, presented an unusual surgical specimen to the Ramsey County Medical Society in Saint Paul, Minnesota.
The specimen was a gallbladder he had removed 3 days earlier.¹ Described in the meeting minutes as “very interesting,” it was only the ninth gallbladder removed in the world at that time and the first outside Germany or France.
The following month, Dr. Ohage presented a well-received paper to the society titled “The Surgical Treatment of Diseases of the Gall-Bladder.”² In it, he observed that surgeons were now performing “operations [that were] but a few years ago considered absurd.” His operation and accompanying paper provide a window into the state of surgery in the 1880s, a decade widely regarded as transformative for the profession.
From Soldier to Surgeon
By his own account, Dr. Ohage (1849–1935) led a colorful early life.³ The son of a German surgeon, he immigrated to the US in 1864 at age 14. He joined a New Jersey regiment during the American Civil War, where he was wounded in action. While recovering in a military hospital, he met President Abraham Lincoln, who was visiting wounded soldiers. Dr. Ohage returned to Germany from 1865 to 1870, then spent time in the American west with Buffalo Bill Cody before graduating from the University of Missouri Medical School in 1880. After a year of additional study in Europe, he settled permanently in Saint Paul in 1881.
He quickly established himself as a prominent physician and surgeon. Although his education lacked the structure of later surgical training, by the standards of the day he was a well-trained clinician. As a native German speaker, he also had direct access to the leading surgical literature of the era, including Carl Johann August Langenbuch’s pioneering cholecystectomy in 1882.⁴
For abdominal operations to no longer be considered “absurd,” four prerequisites had to be met: evidence that the organ—in this case, the gallbladder—was not essential to life; the availability of anesthesia; antisepsis and asepsis; and an understanding that internal diseases originated in specific organs rather than reflecting a systemic imbalance of “humors” or “fibers.” By the 1880s, all four conditions had been met.
The technical aspects of these operations also required refinement. Dr. Langenbuch practiced on cadavers, while Dr. Ohage, closely following developments in Europe, rehearsed the procedure on canine specimens at his hospital. As historians have noted, every abdominal operation performed during this period was, in many respects, experimental. It is little wonder that most surgeons approached these procedures cautiously.
Preparation Meets Opportunity
Because of his background, education, and experimentation, Dr. Ohage was well prepared when 35-year-old “Mrs. Lena A., Swede” presented to his office on September 23, 1886, with a 3-month history of pain, intermittent jaundice, and a palpable right upper quadrant mass.
He admitted the patient and operated the following day using strict antiseptic technique, although without carbolic acid spray. Notably, he maintained the operating room at 90°F. Assisted by the house surgeon and four prominent practitioners, he ensured the presence of respected professional witnesses, a recommended safeguard for surgeons undertaking major operations at the time.
Dr. Ohage used a 6-inch (15.2-cm) incision parallel to the lateral border of the rectus muscle. By comparison, Dr. Langenbuch used a T-shaped incision consisting of a 10–15 cm horizontal limb along the liver edge intersected by a 10–15 cm vertical incision along the rectus border.
After mobilizing the gallbladder, Dr. Ohage milked a large, impacted stone from the cystic duct. He ligated the cystic duct with carbolized silk, removed the gallbladder, irrigated the operative field with antiseptics, and closed the incision in layers with silk sutures. Remarkably, the gallbladder contained 135 stones. The patient was allowed to sit up on postoperative day 11 and was discharged on postoperative day 13.
Eight months earlier, when confronted with a thickened, friable, edematous gallbladder, Dr. Ohage had instead performed a delayed cholecystostomy. He brought the gallbladder fundus to the wound, secured it with iodoform packing, and opened it at the bedside on postoperative day 8. Aside from an intermittent fistula, the patient recovered well.
Dr. Ohage’s Recommendations for Gallbladder Surgery
Dr. Ohage published his case report and literature review in Medical News.² Including his two patients, only 50 cholecystotomies and 9 cholecystectomies had been reported worldwide. At that time, cholecystotomy carried a mortality rate of 22%, compared with 11% for cholecystectomy.
He described three operative approaches to gallbladder disease:
- Suturing the gallbladder to the abdominal wall with delayed opening (“natural cholecystotomy”)
- Emptying and closing the gallbladder (“ideal cholecystotomy”)
- Cholecystectomy (“Langenbuch’s operation”)
Reflecting the evolving understanding of gallbladder disease, Dr. Ohage directly addressed and affirmatively answered the question many physicians of the day were asking: “Is life compatible without the existence of a gallbladder [sic]?”
Drawing on his limited personal experience and the existing literature, Dr. Ohage offered several recommendations. He considered surgery indicated for (1) repeated attacks of pain; (2) obstruction of the cystic or hepatic ducts; and (3) perforation of the gallbladder, even in the presence of shock.
For elderly (those older than 50 years) or debilitated patients or for patients with extensive inflammation or uncertain duct patency, Dr. Ohage recommended cholecystotomy. For younger, healthier patients, he considered cholecystectomy the preferred operation. He emphasized meticulous antiseptic technique and cleanliness, and forcefully asserted that “the diseases of the gallbladder belong to the surgeon.”
Dr. Ohage’s experience illustrates how many internal diseases became the domain of surgery during the late 19th century. This transformation reflected an evolving understanding of disease, growing confidence that organs could be safely modified or removed, and the availability of anesthesia and antisepsis. Dr. Ohage also recognized that physicians and the public needed convincing that these new operations were effective rather than absurd.
The age of radical surgery, and of the surgeon as an intrepid pioneer, had begun.⁵
Dr. Peter Kernahan is chair of the ACS History and Archives Committee and an adjunct faculty member in the Department of Surgery at the University of Minnesota in Minneapolis.
References
- Report of the societies. Northwest Lancet. 1886;6:54-55, 113.
- Ohage J. The surgical treatment of diseases of the gallbladder. Med News. 1887;50:202-206, 233-236.
- Deziel DJ. The journey of the surgeon-hero. Surg Endosc. 2008;22(1):1-7.
- Traverso LW. Carl Langenbuch and the first cholecystectomy. Am J Surg. 1976;132(1):81-82.
- Brieger GH. From conservative to radical surgery in late nineteenth-century America. In: Lawrence C, ed. Medical Theory, Surgical Practice: Studies in the History of Surgery. Routledge; 1992:216-229.
