100 Years of Modern Nasal Surgery

Part 2: The Great Age of Medicine in Berlin

by H. Behrbohm, W. Briedigkeit and G. Reintanz

Jakob Lewin (Jacques) Joseph was born on 6 September 1865 in Königsberg as the third child of the Rabbi Israel Joseph and his wife Sara. From 1885 to 1889 he studied medicine at the Friedrich-Wilhelm University in Berlin. He completed his studies in 1889 and obtained his doctorate in 1890 in Leipzig.

Professor Jacques Joseph (1865-1934) systematised corrective, reconstructive and aesthetic rhinosurgery and defined it anew with regard to its aims and techniques. He is considered the founder of modern nasal surgery and was an important pioneer of plastic facial surgery generally. The 12 February 2004 was the 70th anniversary of his death.

A Break in His Clinical Career - Unauthorised Otoplasty

Following his medical licensing and medical practical training period,  Joseph became a general practitioner in 1892 in the district of Berlin-Mitte. Despite the fact that his practice was soon doing well, he wanted to specialise. In 1892 he successfully applied to the University Polyclinic for Orthopaedic Surgery, headed by Professor Julius Wolff (1836-1902) – a recognised surgeon, called ‘Knochenwolff’ (Bonewolff) by the Berlin populace –, who is considered one of the founders of modern orthopaedics. Joseph became a respected fellow worker at the clinic and also displayed scientific interest, much to Wolff’s joy. The good relationship came, however, to a sudden end when Joseph undertook to surgically correct the earlobes of a ten-year-old boy, which were too large and stuck out much too far (‘donkey’s ears’), but without informin Wolff and without obtaining his prior permissions. The patient suffered severely until then from the mockery of his surroundings. This first plastic operation by Joseph was successful.  Nevertheless, Professor Wolff fired Jacques Joseph, giving as the reason that Joseph had undertaken an untried and, in addition ‘cosmetic’ operation without permission. Joseph’s four years of work at Wolff’s famous clinic – which could have been the start of a university career – were finished with this in 1896. He returned to private practice. It is not known whether Wolff and Joseph ever buried the hatchet or ever became close in any way again. Wolff’s well-known honourable character certainly would not have stood in the way; Joseph’s East Prussian stubbornness probably more so. Wolff died in 1902. Both are buried in the same cemetery – about a kilometer apart.

100 Years Ago: The First Intranasal Septorhinoplasty

In 1898 Joseph carried out the first nasal reduction operation using external access in his own practice. In 1904, just 100 years ago, he reported for the first time on a simultaneous intranasal correction of a protuberant nose with a correction of the anterior septum. This route of access was systematically improved by Joseph in the following years for further indications. Intranasal operating techniques were considered then to be unclear, bad surgically, and carrying a high risk of infection.
At the start of the First World War, Jacques Joseph had the well-earned reputation of being the most prominent German facial surgeon, both with his colleagues and with the public at large.

First World War:
The Number of Operations
Becomes Astronomical

The war brought Jacques Joseph, the staff physician in the reserve, new challenges. Modern methods of warfare to injuries of a frequency and severity unknown until then. Joseph – obeying necessity and his patriotic feeling of duty – had to increase the number and extent of his operations to the most extreme degree. Since he worked with extraordinary success in the field of reconstructive surgery as well, attaining quite spectacular successes, the ‘Supreme Commander’ Wilhelm II himself came to notice him, or at least Joseph was brought to his attention.

Figures 2a-c (from left to right):
a: Young soldier with a total nasal defect.
b: Line of incision on the forehead in nasal substitutive surgery (frontal method according to Joseph)
c: From the ‘chirurgischen Modellierung und Knocheneinführung’ (‘surgical modelling and bone implantation’) in: J. Joseph: Nasenplastik und sonstige Gesichtsplastik, C. Kabitzsch, Leipzig 1931.

In 1915 the Emperor personally offered Joseph, who had no habilitation to be a professor, the Chair for Plastic Surgery at the Charité hospital – but only under the condition that he, Joseph, convert to Christianity. Joseph refused. Did the Supreme Commander want to quiet his conscience by offering the soldiers, some of whom were horribly disfigured, the ‘best facial surgeon in the world’ in such an exposed position? Wilhelm II, however, was probably free of such scruples and sentimentality.
Joseph continued to work, but soon recognised that the continuation of war meant that the frequency of patients with the most severe facial disfigurement, even those only from Berlin, far exceeded the capacities of his practice.

Head of the Department for Facial Plastic Surgery

Others saw this too, and thus, on 2 June 1916 at the Ear and Nose Clinic of the Charité, headed by Adolf Passow (1859-1926), a Department of Facial Plastic Surgery was opened. The Prussian Ministry for Ecclesiastical and Educational Matters (Ministerium für geistliche und Unterrichtsangelegenheiten) gave J. Joseph the task of heading this. He was, however, not to expect any ‘remuneration’! In 1919 he was named professor – but this time not by the Emperor, and without any impossible conditions being attached. He received the Iron Cross in addition.
With the aid of regional or forehead and upper arm flap plastic surgery on the one hand, and free cartilage and bone transplants on the other, he succeeded in reconstructing faces even in cases of extensive injury.

From 1922 in his own practice again:
Manifold activities in plastic surgery

After the Department for Facial Plastic surgery was no longer financed by the Army leadership from 1922, Joseph returned to his private practice and dedicated himself increasingly to corrective and aesthetic surgery. His major points now were corrective procedures for the nose and ‘hanging cheeks’, as well as breast operations. Assistants in his practice at this time included Gustave Aufricht, who later went to New York ging and contributed greatly to the spreading of the Joseph procedure in the USA, and the American Joseph Safian. The latter reported that up to six doctors from home and abroad were permitted to observe the operations from a platform at the foot of the operating table, for an appropriate payment. There were no explanations and comments on the operative procedure, and Joseph had forbidden all questions during operations (private patients under local anaesthetic were being operated upon!). The whole thing appears to have been discouraging rather than encouraging and informative.
Figure 3: Prof. Jacques Joseph demonstrating a rhinoplasty in 1921 in a group of interessted doctors (from: P. Natvig: Jacques Joseph – Surgical Sculptor. W. B. Saunders, Philadelphia 1982).

1 Dr. George Kelemen
2 A surgeon from Germany
3 A surgeon from Germany
4 Dr. Martin Bab
5 A surgeon from Brazil
6 A surgeon from Brazil
7 A surgeon from Brazil
8 Dr. Louis E. Wolfson
9 Dr. Boenninghaus from Breslau
10 Dr. Ernst Wodak
11 Professor Joseph
12 Nurse
13 Nurse
14 Patient

Jacques Joseph – thus J. Safian and Joseph’s biographer Paul Natvig – made a rather bad-tempered and uncordial impression on those who did not know him well. Those who did valued his warmth of heart and his humour. Behind a rough exterior there was hidden a deeply sensitive man, fascinated by a classical ideal of beauty, who, as a physician, was honestly fond of his unfortunately disfigured patients. Wounded veterans of the First World War, who had been operated on by Joseph, remained attached to him for the rest of their lives, for which there are moving testimonials from the families as late as the seventies and eighties. The last surviving surgical nurse from Joseph’s clinic, who was still alive in 1990, describes her extremely resolute boss as an attractive, particularly handsome man and thought the nurses in his clinic to be the best-paid nurses in Berlin at the time.
A legend in his own lifetime:
Nasen-Joseph (Nose-Joseph) or ‘Noseph’

Joseph was a legend in his own time, known as ‘Nasen-Joseph’ (Nose-Joseph) or ‘Noseph’. From the ‘racing reporter’ Egon Erwin Kisch we know something about daily life in Joseph’s practice in about 1922, from the waiting-room perspective: ‘... empfing Herr Professor Joseph in seinem Ordinationszimmer am Kurfürstendamm die an Eitelkeit kranken Menschen. Jeden fragte er, was er sei, ob er reich sei und aus welchem Valutabezirk er komme, und dann, erst dann, fragt er ihn nach seiner Wesensart... und er muß die Wesensart kennen, denn danach stellt er die Nase her. “Wünschen Sie eine kecke Nase, oder eine intelligente, ein kokkote oder eine energische?”.... der Herr Professor reicht ihm eine Album mit Hunderten von Photographien ehemaliger Patienten, vor der Operation und danach. Sie blättern im Album und wählen ein Näschen, das sie haben möchten. “Gut”, sagt der Herr Professor und packt sie an der Nase. Er verdreht sie mit der Hand und den Fingern und zeigt Ihnen, wie Sie später aussehen werden. “Kommen Sie morgen früh um zehn in meine Privatklinik, Bülowstraße 10” ’.

Abbildung 4a: Einige – heute noch erhaltene – Operationsinstrumente von Jacques Joseph. Sie wurden zum Teil nach genauen Vorgaben angefertigt und sind mit der Gravur „Prof. Joseph“ gekennzeichnet. (Sammlung von Prof. R. Stellmach)
(‘... Professor Joseph received the people ill with their vanity in his office at the Kurfürstendamm. He asked each one what he was, whether he were rich and from which valuta district he came, and only then, not until then, did he ask about their character... and he has to know the character, for he creates the noses accordingly. “Would you like a saucy nose, or an intelligent one, a flirty one or an energetic one?” ... the Professor gives him an album full of hundreds of photographs of former patients, before and after the operation. They turn the pages of the album and choose the nose that they would like to have. “Good”, says the Professor, and grabs their nose. He twists it with his hand and fingers and shows them what they will look like later. “Come to my private clinic in the Bülowstrasse 10 at ten o’clock tomorrow morning.” ’)

A talented surgeon with an artistic feeling for form

Joseph was a talented surgeon, who had not only excellent surgical know-how, but also that artistic feeling for form at his disposal, of which Erich Lexer (1867-1937) said that everyone who wishes to carry out cosmetic operations must have it. Joseph operated with a sure hand and very carefully, according to established procedures or also according to his own creative and perfected procedures. Every defect or disfigurement was thoroughly analysed prior to the operation, every step of which was painstakingly planned; he did not want to leave anything to intuition during the operation. He had mastered the most difficult form of nasal plastic surgery, nasal replacement, to such a degree that his methods, with regard to their external form, could hardly be bettered, as Hugo Ganzer –  himself extremely experience – emphasised in 1943.
Figure 5: Photo during a rhinoplastic preparation course in the Anatomical Institute of the Charité hospital in 1922. From right to left, sitting: Prof. Joseph, Prof. Kopsch, unknown Spanish surgeon; standing: Dr. Jacques Maliniac, Dr. Gustave Aufricht, Dr. Zoltán Nagel.                

Major work: ‘Nasenplastik und sonstige
Gesichtsplastik nebst Mammaplastik’ (‘Nasal Plastic Surgery and Other Facial Procedures, and the Plastic Surgery of the Breast’)

In his major work, ‘Nasenplastik und sonstige Gesichtsplastik nebst Mammaplastik’ (‘Nasal Plastic Surgery and Other Facial Procedures, and the Plastic Surgery of the Breast’), as well as in over 30 publications and contributions, Joseph systematised corrective, reconstructive and aesthetic rhino- and facial plastic surgery and redefined them in their aims and techniques. He established the intranasal techniques of rhinoplasty, saw  the dual task of rhinosurgery in the improvement of function and form, and  saw aesthetic surgery as a medical task. Jacques Joseph is the founder of modern rhinoplasty and one of the most important pioneers of facial plastic surgery.    

Figures 6a-c (from left to right):
6a: Patient with ‘hanging septum of medium severity’.
6b: Following a bilateral segment resection (complete shortening and removal of the hump).
6c: Operation plan for nasal shortening according to Joseph. Scheme of resection and condition following resection (above: view of the septum, below: view of the lateral wall)

Despised and Tormented by the National Socialists

When the National Socialists took over power in Germany in 1933, few recognised what kind of catastrophe was in the making. It began immediately for Jewish Germans and ‘dissidents’. Joseph – like many others too – had not taken the increasing Brown danger seriously. On the heels of the greatest recognition and esteem there followed - nearly overnight - the deepest official disdain. The stenotypist he had employed to finish his  textbook, and who lived in his house, spied on him and blackmailed him on the instructions of the Gestapo. Joseph was permitted to carry out only a few plastic surgical operations, after demeaning ‘special approval procedures’. The unbridled and violent anti-semitism of the time made it increasingly difficult for Joseph to practice.

Dies in 1934 of a myocardial infarction

Emigration was probably already planned, when Jacques Joseph died on  12 February 1934 in Berlin-Wilmersdorf. On the way to work, still in the hall of his house, he suffered a fatal myocardial heart attack. His physician, Dr. Berliner, filled out the death certificate. In his clinic the long-employed surgical nurse Grete sent the patients away: ‘Dr. Joseph will not be coming in today.’ The family placed notices of death on the next day in the ‘Vossischen Zeitung’ and the ‘Berliner Tageblatt’, stating that Prof. Jacques Joseph M.D., specialist for nasal and facial plastic surgery, had died of cardiac insufficiency in his 69th year of life.
Figure 7: Thanks to the stubborn efforts of Prof. Briedigkeit, Jacques Joseph’s grave has been rediscovered after being thought lost. Prof. Briedigkeit at the find location in the Jewish Cemetery in Berlin-Weißensee.

Figure 8: The damaged gravestone after being laid free.  

The German specialist press, already mostly brought into line by the Nazis, took no more notice of Joseph’s death. Obituaries appeared only in foreign specialist journals. Death by violence, which has been alleged several times [6], would seem to be excluded, both in view of the text and the time of the notices’ appearance, and in view of the official entry itself [19]. Nor does suicide by means of poison, which Stürzbecher thought possible [18] with regard to the repeated mishandlings which Joseph suffered at the hands of Nazi thugs, seem likely.

Buried in the Jewish Cemetery in Berlin-Weissensee

Jacques Joseph was buried in the Jewish Cemetery in Berlin-Weissensee. His grave was destroyed during a bombing raid in the Second World War and was believed to be no longer identifiable. One of us (W. Briedigkeit) succeeded, after much difficult research, in finding the partially buried and overgrown gravestone of Joseph’s grave in August 2003. The stone, made of black granite, has been retrieved, identified and the former inscription deciphered. The site of the grave and the gravestone are currently being reconstructed.
Joseph’s wife Leonore, who had been married to him since 1892 in a very happy marriage, which helped him in his medical and scientific ambitions, was able to leave Berlin and died at a ripe old age in 1968 in the USA [17].

Literature with the author.

Correspondence address:
Prof. Dr. med. H. Behrbohm
Abt. für HNO-Heilkunde,
plastische Operationen
Park-Klinik Weissensee
Schönstraße 80, 13086 Berlin