The names of and are all over the world csotcina.comedic related to the classification of necrose hip. Jacques , an enquiring clinician, teacher, Petri of human qualities, tells us with simplicity the path which led it to the Rheumatology at one time when this speciality was not developed. He shows us that at the basis fundamental work, there are not inevitably heavy structures of search.

 

 

. : You were Instructor de Rhumatologie at the Medical college of Toulouse during more than thirty years. How was the rheumatology when you were House physician?

J.A.: I am obliged to correct the question of seniority a little. I taught the rheumatology during more than thirty years, it is true, but I was Instructor only during twenty years. I initially was Médecin of the Hospitals, as from 1959. I have occupied myself in fact of rheumatology for almost fifty years, since I started to install a Department of rheumatology whereas I was Intern in a Department of medicine General with in 1947. But this speciality did not exist officially. There were some Parisian which had directed the hospital activity towards the Rheumatology like and and Lièvre; in addition there was a clinical high level activity with Aix-the-Baths. So that when I decided to specialize me in Rheumatology, I went to Paris and Aix-the-Baths. During a few months I made this essential training, this course impossible to circumvent.

. : Why to have chosen this speciality?

J.A.: My Master, wanted that I make Psychiatry but that did not last a long time, it was really not for me. I wanted to make a speciality and certain specialities started to be tied up: pneumology of course for a long time, and the cardiology which started to be dealt with by certain number of friends or young Masters. Then like the speciality “musculoskeletal system” or “rheumatology” did not exist, I decided to do that. In fact, I was a little ambitious, a little bit imprudent because I wanted to be an at the same time doctor and surgeon of the musculoskeletal system. But I was already rather old, I had passed the boarding school tardily and it was impossible to make both at the same time. I had already a family on the arms, therefore it was necessary that I go more quickly and I gave up the surgery.

. : With which pathology the Rheumatology was addressed she in the Fifties?

J.A.: It was a speciality very very vast and it is what made the interest of it. They was enthralling because in the content one was interested in all the musculoskeletal system, all the structures ostéo-articular and for example as well with the polyarthritis as with the tendinites, as well with the sciatica as with the disease of , because there was a certain number of a little marginal diseases which did not interest anybody. I recall that (and God knows if I have admiration for Marcel ) could not support the sciatica, that did not interest it absolutely. The rheumatologists had then seized some with Forestier with and thus I also seized the sciatica which I found completely enthralling to discuss, because makes its processing of it is especially medical, a processing of physical care. Of course, I dealt with the polyarthritis which did not interest anybody and who was very ignored. The diagnosis of polyarthritis was hardly carried by the doctors the , even by best; they thought of the rheumatic fever, with articular infections, tuberculosis but rather little with the polyarthritis. And that so much so that I went to seek in the old people's homes of the patients who had enough chronic polyarthritises invalidating and I installed them in the Service of my Master Castlings. This moment, we had changed Hospital, we had passed from the Hospital to and one had a considerable space to fill. Each department of internal medicine had three stages of rooms, without laboratory, office for the examinations and nothing for the doctors, nothing the whole. The Roques father had told me: “, You Listen are interested in the rheumatology, me, that interests me too! You could try to occupy the rooms top with rheumatics, that would help us to fill the service” were We there. And it is as that which I had freehand whereas I was only internal, to install there a small department of rheumatology with polyarthritises, sciaticas, with all that turns around, rheumatisms inflammatory and degenerative.

. : And on the therapeutic level, which means at the time did you have?

J.A.: As regards anti-inflammatory drug processing there was not large thing of other that Aspirine, but in 49 one saw appearing Cortisone, which was a true revolution. I can speak besides about the first experiment of Cortisone on the polyarthritis which I was charged to lead to Toulouse since one had received small Cortisone inventories which it was necessary to use with standards and a very precise monitoring. I was struck at the time by the fact that a certain number of patients whom one had discussed during twenty days remained cured. That had intrigued me much more than to see them relapsing because we knew that they relapsed. Thus a certain number remained cured and this fact remained to me in the head, and it is like that, gradually, one arrived at the attack fairly extremely which gives a really durable crushing argument to much of polyarthritises. Then arrived rather quickly with its remarkable effectiveness. Let us be honest, which are the anti-inflammatory drugs processing, most effective are Cortisone and , in my opinion he does not have there better…. Like basic processing obviously, there were #D1FFFF Salts. American did not make any, now they make some. #D1FFFF Salts, that lasts and it is a very beautiful invention. Before the war, Forestier used them for the first time in a very precise and systematic way in the polyarthritises. He thus did the first important work which were adopted at once by English and German, but not by American although he went to have his results to them into 37-38.

. : Do you have the impression on the therapeutic level that fundamental progress was made these ten last years?

J.A.: Yes, there was progress since I started to make rheumatology, undeniable progress. Three more notable in my opinion are firstly the prevention of the rheumatic fever, than we still see in the Fifties and than one does not see any more. Secondly the control of the hyperuricemia which makes it possible to control the drop. In 1950, I had seen 100 cases of drop with my friend Charles whereas it had disappeared during the war, can be the cause of the regime which German imposed to us, because it reappeared very extremely after war. The third fundamental progress, it is the prosthesis, in particular the hip prosthese.

As for the medicines , there no were medicines miracles as important as Cortisone, but one can handle Cortisone better than front, one knows of them his dangers, one knows his limits, one handles also best the anti-inflammatory drugs, one handles the antimitotic ones also much best which are used for inflammatory rheumatisms. There is also progress in the field of the osseous diseases with Calcitonine and indisputably.

. : You have seems it makes a very plain and very effective couple with Paul . How did you know it?

J.A.: that goes back to the moment when I was given up a little by the Instructor of medicine which had succeeded my owner, and who did not want any more ego. Mr then collected me. In particular, it enabled me to install a small laboratory of study on the synovial fluid, something which was not done and which I had learned in the United States in 1952. When I returned, I thus installed a small laboratory with the aid of a small purse of the National institute of Hygiene, (a organism which preceded the INSERM). I had touched a microscope and I worked with a Spanish boy who was very skilful from the handling point of view. Paul , raises of , came in this laboratory; we started to work together and to do a little search. One day told us: “You know, the vascular pathology of the bone, I am sure that it is important, you should occupy you”. In Toulouse one could already do many things in this field like the per-osseous and the arteriography. I went to spend a few months, to England in Oxford, in the Service of the Instructor who was the pioneer of the adventure of the osseous vascularization and which put the finger on the importance of osseous circulation in all the pathology of the bone and the musculoskeletal system. I learned how to make intraosseous arteriographies, I learned the anatomy and physiology of intraosseous circulation and while returning I started to work this question with Paul , then the assistant of . When had a Service and that he was owner himself, he had the kindness to also support my installation below at his place in a Department of rheumatology. Thus we were at this time the two fingers of the hand. There were at the same time besides a service of Rehabilitation at the ground floor of the Hospital, they were marvellous, there was a whole unit which one straightforwardly called an ostéo-articular department of pathology. I must that the surgery interested me much. So much so that it rather often sometimes happened to me to tell to : “It would be necessary can be to operate this patient” and answered: “Not, one should not operate”. It was me which pushed with the wheel and which slowed down, it was can be a little paradoxical but it was thus.

. : In was the Sixties, vis-a-vis a painful hip, the diagnosis of necroses often referred to?

J.A.: Not, surely not. One just started to know a little necroses it, but makes some, one sought initially an infection with banal germ, a tuberculosis or a metastasis and only then an hip osteoarthritis. Of course the latter was finally in the consultation of rheumatology the disease of the most frequent hip. Then from time to time one saw a case which was a little bit odd and one referred to the diagnosis of necroses.

. : Which is the history of necroses?

J.A.: It is known that it is a disease which was described on the plan by the German authors, in particular by at the beginning of the century and even one can say that they have, as of the beginning, thought that it was due to an ischaemia and even to an arterial obliteration, which is the assumption which is still regarded as most probable. But I think that one passed beside the diagnosis for a long time, and that the patients were dealt with within the vast general framework of hip osteoarthritis and the chronic . They almost said all, referring to even the pre-radiological period but while schematizing a little.

. : How did your interest develop for necroses hip?

J.A.: instead of making a drilling with a full drill had the idea to make a drilling with a hollow drill and when it withdrew its drill, it withdrew osseous core at the same time. Here, it is as that which that occurred. There was in fact a “mixture” of therapeutic search, since drilling had already been described in Lyon, in particular by , in hip osteoarthritises and of histopathologic search. I must say that, there, the existence of my small laboratory of nothing the whole but which nevertheless made it possible to make studies the synovial ones and bone decalcified under the microscope, allowed rather quickly to describe the lesions of necroses at all the stages and thus to reactualize, to renovate all this question a little. Our major contribution, it is primarily the , the concept that necroses it starts whereas there is no radiological sign, which became an obviousness, but what was very disputed for a long time.

. : Your classification understands four stages because it included the famous pre-radiological stage. Did you always describe this stage or is this a later addition?

J.A.: Not, not, stage I one always described it because it always appeared essential to us. The remainder being rather banal finally, because when one starts to see appearing the radiological signs the diagnosis is quickly referred to, and then when there is a depression, good, it is finished, the diagnosis is sure and unfortunately the forecast too. Therefore, stage I purely histological it was that the crucial point, it is that our contribution and it is on this subject that one was very disputed. My friend who is one of the specialists in the osseous came to spend one day whole to Toulouse and it spent the hours to look at our cuts while concluding: “Ben yes, you are right indeed”. But for much, it was another disease. Now since the MRI arrived, nobody any more discusses this concept and what appeared essential it to us is precisely that one could can be to cure the patients at this stage.

. : In fact, you were shown at the stage I to drill many reflex sympathetic dystrophies and the MRI now shows us that they exist but of relatively low number compared to necrose.

J.A.: Yes, this question of reflex sympathetic dystrophy is very interesting, very important because it returns to the day order since the Austrian surgeons around Hoffman and of the tell: “But you know, the reflex sympathetic dystrophies, it is stage I of necroses, not in all the cases, but in a certain number of cases” and they add: “Why not to drill them since thanks to drilling one abolishes the pains immediately and thus they more quickly are cured”. The first proposal, I answer: “Not, I do not believe that the reflex sympathetic dystrophy is stage I of necroses” and I discussed during hours with Hoffman and on this subject. In addition, the of the reflex sympathetic dystrophies is completely different from the from necroses at the stage I such as we described it and who is generally a lesion of necroses diffuse marrow and not edema, fibrosis, which one sees in the reflex sympathetic dystrophy. There is there too a fact which was not very well understood by my French friends. I can affirm that they are two different diseases even if there is a context which makes that they are can be dependant in certain case and that the etiologic circumstances are sometimes rather close.

. : Since we are with the histology, is there a correlation between the histologic classification of necrose and radiological classification?

J.A.: It is a more difficult problem, I will explain why. Initially I answer the question. “Yes, approximately, there is a relation between the radiological stages and the pathologic stages but not always. And why? My explanation is the following one. Firstly we base itself on drillings, i.e. on a party only of the femoral head and it is not always at the good place that one makes drilling isn't? Secondly it should be known that the radiological stages which are currently supplemented by the stages in nuclear magnetic resonance cannot give us an histopathological diagnosis authentically. One wrongly to tell: here is the extent of necroses, on a radiography or on an image of nuclear magnetic resonance because are indirect images but absolutely not histology and thus, when one wants to make the measurement of volume or extension of necroses, it is very approximate. The area which is located above this famous limit between death and the sharp one did not always die in a final way. I do not believe that one can say that all is sequestered. There is a difficult problem which is not well solved.

. : It seems now allowed that the very small ones necrose do not evolve to the fracture and that the large ones necrose, i.e. of more than 50% almost always evolve to the fracture. What do you think about it?

J.A.: I am of agreement with the concept of volume which explains the forecast partly, but one should not too much pack. It is sure that if drilling makes a success of it east can be also because the natural evolution of a chamber of necroses modest is done towards the cure. It is the case of the remote cysts of joint surface: or these cysts remain stable or even they possibly cure. On another side, if there are very important lesions, they cure? Unfortunately, I am not time when one systematically made the measurement of the volume of necroses, therefore I do not have personally very precise documents but I have the memory of apparently important lesions on the radiological images and which cured with drilling.

. : One associates today with drilling novel methods like an osseous autograft, a vascularized autograft, a filling with cement, an electric stimulation of osteogenesis, an injection of marrow , even an injection of ostéo-inductive protein. What think about it?

J.A.: I believe obviously that there are important things in all that, but that depends on the stage. I am not sure that one improves much the results of drilling at the stage I. the statistics of which is that which made the most drilling with graft - they are completely interesting and important - are not very different from simple drilling at the stage I as for the results. With regard to the injection of product ostéo-inductor, I find that it is very interesting and I await the results. Then, with regard to the vascularized Clerc's Office, I am not sure that it is really useful to do that at the stage I, on the other hand at the stage II with radiological lesions which appear bulky and with the proviso of not precisely perforating the hull which is still in good state, I believe that this technique deserves to be continued but between expert and skilful hands, because it is nevertheless a difficult technique.

. : What . ?

J.A.: It is the Association of Search on Osseous Circulation. One discussed much on these initials during the meeting founder in London in 1989 and we ended to this solution because it also functions in English: Association Circulation. It was accepted by all, there was of French, English, Japanese, American. It is a foundation of search, but of clinical research as well as experimental. There is in this association of the clinicians, the csotcina.comedic surgeons who do not do much search and of the pure researchers who make search of experimental physiology and search of nuclear medicine, etc… and even of the . It is very vast and it is not solely centered on necroses osseous. In fact, it is all bone pathology and all the physiology of intraosseous circulation which are in question because one can say that in any bone pathology there is intervention of circulation. We are approximately 200 in this Association which I chaired during five years. My successor was John-Paul Jones, csotcina.comedic surgeon in California. Currently, the Chairman is a Dutchman, , csotcina.comedic surgeon. This association is cosmopolitan with a rather good quantity of American and there are many people of the Far East: Japanese, Korean and even some Chinese and some people of Singapore.

. : Where the next meeting of will take place. ?

J.A.: The next meeting of will take place in April 99 in Sydney in Australia organized by Pr and and then in theory he will hold there a meeting around the year 2000 in Toulouse. meets once a year, it is very open in the sense that one invites all those which that interests. There are always listeners who are not members. In addition, publishes a bulletin twice a year; this bulletin is very interesting on the innovations, on works in progress and then there are summaries which are very invaluable and which make the turn of all that is published in the world in the field of osseous circulation, and in particular of necroses, but also close diseases. Consequently, to have the complete collection of the bulletins of . - there is a thesaurus, there is an index - it is to be able to refer to hundreds of items on osseous circulation. As is a very modern Association, if you want more, possibly to subscribe you, it is enough for you by Internet to make: http://www.csotcina.com/

. : You wrote a book on the life of Forester. Was the importance of work of this researcher recognized with its fair value?

J.A.: well, I believe it yes, and I give some for proof what occurred at the time of an international congress of rheumatology of San Francisco in the Seventies. This Congress started with a homage, spectacular to Jacques Forestier with a film on big screen, etc… and I believe indeed as apart from his speculator role of its father in the creation of the European League against Rheumatism, it brought essential information in the field of the rheumatology and contributed to fantastic progress as well in the processing by #D1FFFF Salts as in the diagnosis and the description of new diseases like the or like the pseudo-polyarthritis. It was a man of great human quality and a clinician completely except par and I believe that this was recognized by the rheumatologists of the whole world.

. : You are an Instructor Toulousain without accent, why?

J.A.: well because I was not born in Toulouse. I was not born in midday although my parents are of , one and the other, but I was high in the East and in Paris. I did not have any reason to take the accent, my parents did not have it either. I did not take it too much since I am in Toulouse, although I adopted with much enthusiasm the Toulouse practices as a whole.

. : You are with the retreat but you organize international congresses on Osseous Circulation and Necroses it. Do you have time to take leisures?

J.A.: My activity decreased much, as well with regard to the hospital activity, since it is now null, as the activity within the framework of the Congresses. Ca does one or two years now that I do not occupy myself any more. Previously, whereas I did not have any more a hospital activity, I dealt with the bulletin of and I made most of the analyzes, items but maintaining all this is finished. In any event as from the moment when I left the hospital I had nevertheless much more free time.

. : What do you make some?

J.A.: well, I read, I walk, I do a little mountain, and then I have started to write for a few years, and to paint. I paint for a long time, finally I did that especially the summer during the three weeks of holidays that I took. Maintaining my activity preferred, it is to read and write, another thing that medicine and then to paint, since I walk less.

. : It appears that you made conferences on . What attracted you towards this novelist?

J.A.: I am not the only one to like . There are precedents. regarded it as one of the largest contemporary novelists. I like much because I find that it is not only one author of detective novels, it is a fine psychologist, expert of the human core, it belongs to these extraordinary novelists of which one with the impression which they have all considering, very known; one wonders whether they have a brain with share. It is also that in there are many doctors. liked the doctors, it had friends doctors in great number. I had fun on a hundred works of to extract the medical characters, the portraits of doctors whom it made. It made portraits of any kind of doctor, since the country doctor, to the pathologist, while passing through the owners, etc… always rather remarkable.

. : Which nonmedical works did you already publish?

J.A.: I had written tales but which were never published and that I wrote for the family. The first work that I published, it is the biography of Jacques Forestier. That interested me much and as from this moment, I decided that I was going to write another thing that medicine; because in the biography of Forest Jacques, there are two medical chapters, but all the remainder it is its life and God knows if it were rich other things. Then, I wrote a second biography, that of a completely extraordinary priest, Rivières, which I knew, that I had met and with which I were to make besides a small book in the form of dialog. But he died and thus I wrote his life because one entrusted all the famous letters of writers to me whom he had received. This book had a certain success. Then I wanted to continue in the field of the biography but I was finally inserted in the history of people in Toulouse, the history of Toulouse at the century. I made a first book on the life in Toulouse under Louis Philippe, a second book on the Second Empire in Toulouse and now I study, to make a third book, the life in Toulouse around 1900 at the Beautiful Time, which I hope to leave, if God lends life to me, around the year 2000.

. : Do you think that the studies of medicine should be more largely open to the students having for example a literary Baccalaureat?

J.A.: Yes, that yes I answer, without question. I made, but at the time it was easier, the double baccalaureat, baccalaureat maths and baccalaureat philosophy. I was thus rather good in maths but I think that the level of my class was not terrible! I can say that I did not make use of mathematics in my trade of doctor and that I will have had evil with me to be useful about it. It sometimes happened to me nevertheless to ask for the help of some statisticians. I think that the scientific rigor in this medical field, which is the same rigor as the rigor in the biological field, is not the same one as the mathematical rigor. It is a rigor with a share of approximation and this share of approximation it is very important to hold account of it, as in philosophy. Thus I think that scientific rigor = scientific honesty, it is the same thing isn't? And this honesty one learns it in the French, one learns it in Latin, one learns it in the History, seriously, with good instructors, and I think that contributes to make a good doctor.