• dmards (synthetic)
• polymyalgia rheumatica
• spondyloarthritis

• Download figure
• Open in new tab
• Download powerpoint

Starting my personal research work on spondyloarthritis in the 1980s, I was surprised that my mentor Bernard AMOR proposed me to read the book written in the 1950s by Jacques FORESTIER.1 In fact, I have been really impressed by the content of this book in terms of extreme detailed clinical data (eg, the description of the four different patterns of hip involvement: (a) arthritis a minima, (b) sclerotic pattern, (c) crenellated shape and (d) ankylosing pattern; the latter being probably in relation with periarticular enthesitis) and in terms of the quality of the provided statistics (prevalence and incidence of the different clinical presentations of spondyloarthritis).

Thanks to a specific book dedicated to the personal and professional life of Jacques FORESTIER written by Professor Jacques ARLET,2 I am now even more impressed by this ‘colleague’ (who was one of the first doctors opening an outpatient clinic dedicated to rheumatic patients in Cochin hospital) for several reasons:

This French doctor did not hesitate to cross the ocean in order to present his data in different departments in the USA. At this time (in the 1920s), Jacques FORESTIER started medicine as a neurologist and discovered the advantages of the use of lipiodol in the diagnostic approach of neurological syndromes (he was known in the USA as ‘Doctor lipiodol’3).

More importantly (at least in my opinion) and thanks to the benefit of the visits he did in different departments in the USA and in particular at the MAYO Clinic, he perfectly implemented the concept of standardised outcome measures. He was working 6 months per year in a SpA resort in Aix les Bains where the patients were spending 3–4 weeks per year. For each specific disease, he created a specific file with the following information: demographics, socioprofessional status, impact of the disease in terms of quality of life, clinical findings, laboratory and radiological findings. This procedure allowed him to provide some interesting and detailed statistics in terms of prevalence and incidence over time since he had the privilege to yearly monitor the majority of the patients.

Moreover, apart from these standardised operating procedures, and thanks to his endless curiosity, he was able to distinguish some diseases and also to recognise the benefit of some therapeutic modalities. Here, we will focus on the recognition of two diseases and the description of the treatment with gold salts despite the fact that Jacques FORESTIER did a lot of work in different areas.

In the book on ankylosing spondylitis,1 there is a specific section where he is mentioning the difficulties of the diagnosis at an advanced stage of the disease. For this purpose, he described nine typical cases of what we call today the Forestier’s disease.4 He described this disease as ‘senile ankylosing spondylitis of the spine’. Most of the rheumatologists are currently still referring to the name of Forestier’s disease as  diffuse idiopathic skeletal hyperostosis.5

Concerning polymyalgia rheumatica,6 there is still a debate concerning who, between J FORESTIER and GD KERSLEY, was the first to recognise the disease. Whatever the discussion at this time (in the 1950s), Dr KERSLEY did not hesitate to write the obituary of Jacques FORESTIER.7

In the SpA in Aix les Bains, patients with tuberculosis were receiving gold salts. Jacques FORESTIER noticed that patients suffering from rheumatoid arthritis took a better benefit of the treatment than patients with tuberculosis.8 Thereafter, and based on his own personal experience, Jacques FORESTIER proposed the optimal dose regimen which was still on place in France in the 2000s. At this time (eg, a decade of use of methotrexate and the beginning of use of biologics), there was a debate concerning the benefit to continue to use gold salts in the treatment of rheumatoid arthritis9 with data suggesting that gold salts might be more efficient than methotrexate10 and/or efficient in case of methotrexate inadequate responders.11 Even its toxicity has been a source of debate since on the one hand all the data suggested a high rate of treatment discontinuation because of toxicity10 and on the other hand the fact the toxicity was mainly due to reversible harmless skin or mucose membrane reactions.9 Whatever the final result (no more use of gold salts in many countries), one should recognise that thanks to the findings of Jacques Forestier, a lot of patients have seen their quality of life dramatically improved by this therapy.

Obviously, Jacques FORESTIER was recognised as an excellent clinician and an excellent teacher. Thanks to his capacity to communicate in English, the visit of the SpA in Aix les Bains was recognised all around the world, in particular the annual meeting ‘Week of rheumatology’.12 He became the president of European League Against Rheumatism. However, in France, he was invited in 1976 by the President of the French Republic Giscard d’Estaing not as a rheumatologist but as a rugby player who won the silver medal during the Olympic games in 1920. Another reason to be impressed by this ‘colleague’ and to try to follow in his footsteps.