Prof. Raoul Tubiana is one of the key figures in hand surgery in France; he was also one of the first of Merle d'Aubigné's disciples. He is still actively involved in research, and he took the time to tell us about the early days of his surgical career, and to give us a vivid first-hand account of the specialty which he helped, in no small way, to usher into the world.

Apoil A.

Argenson C.

Arlet J.

Beaufils & Chambat

Capana

Cartier

Cartillier

Dambreville A.

Doursounian L.

Grosse A.

Gschwend N.

Herbert T.

Judet J.

Kapandji A.

Kelly I.

Kerboull M.

Laude M.

Louis R.

Maigne J.-Y.

Maigne R.

Matta & Mast

Müller

Nguyen Van Nhan

Puget J.

Postel M.

Pouliquen J.-C.

Saleh M.

Simmons J.W.

Tubiana R.

Vidalain

Wagner H.

Weber B.G.

Zweymuller

Interview with Prof. Raoul Tubiana.

M.O.     Professor Tubiana, would you call yourself an orthopaedist?

R.T. I am an orthopaedist who specialises in hand surgery, and I have been very involved with the whole field of reconstructive surgery. I think that is the only area which might differ from the usual concept of orthopaedics. I did my medical studies in Paris. What I remember most about that time, and it was a long time ago, is being a clinical student under Pasteur Valéry Radot, where I was shown the ropes by two remarkable senior registrars, Milliez and Hamburger, who gave me a taste for clinical examination. I prepared for the specialty training entrance exam with Jean Bernard, an outstanding man whose powerful intellect always impresses me.

M.O.    Tell us about your specialty training ...

R.T. I started my specialty training in neurosurgery in 1939, with Petit Dutaillis, but I was called up very soon after war was declared. I was an Officer in the Student Reserve at Nantes and then at Autun, and I was assigned to an infantry regiment at Verdun as an auxiliary medical officer. As soon as we arrived, we were driven back by the German advance; and a few weeks later I found myself at Montpellier. I was completely taken aback by this rout; I was demobbed a few months later, and then returned to Paris to continue my specialty training. I went back to Petit Dutaillis at the Salpétrière, where he was working in a wing of Antonin Gosset's department. At that time, neurosurgery was only just emerging as a discipline. The interminable operations and the large number of deaths did not suit my boss, who was a good man but rather quick-tempered. The atmosphere in theatre was rather tense. All the same, this training in neurosurgery often served me in good stead later on.

M.O.    What did you do next?

R.T. The natural step was to continue my specialty training with Antonin Gosset. His vast department felt like a temple dedicated to abdominal surgery. Gosset officiated, surrounded by his many assistants. Subsequently, those large hospital departments gradually disappeared, but I liked them and appreciated their good points; and I missed them when they were gone. You came into contact with different types of people; and when the department was well organised, as Gosset's was, there were people around you providing guidance and support, and there was a wealth of accumulated experience to draw on, which are things you really miss when you work on your own. Gosset was then at the end of his career, and his way of working had remained completely untouched by the War. He operated three mornings a week at the hospital, assisted by a hospital surgeon, a senior registrar, and a junior surgeon who held the retractors. He always started with an appendectomy to get his hand in, then went on to do a hysterectomy, and finished with a gastrectomy or cholecystectomy. Three times a week, the senior registrars and house officers had to comb all the wards in the department to come up with a suitable list. The ceremony of the surgery itself was arranged down to the last detail, and conducted in an impressive silence in front of an attentive audience that was, on occasions, made up of German visitors. The assistant had to keep his wits about him to ensure there were no hitches and no untimely bleeding.

M.O.    There was a little bone trauma work, wasn't there?

R.T. Only one of Gosset's assistants was interested in the locomotor system, and that was his son Jean, a brilliant man, complex, quirky, and often critical of his father. I am grateful to him for teaching me how to do internal fixation of leg fractures, and for helping me when I was operating on my first case of Dupuytren's contracture. I felt particularly close to Funck Brentano, an uncompromising patriot who had been gassed in the 14-18 War, as staunch a man as you could hope to find. For many years afterwards, I did reconstructive surgery sessions in his gynaecology department! It may sound surprising, but within the Department the War - what was euphemistically referred to as "the events" - was discussed very little. Inside the Salpétrière, we were quite cut off from the world. That didn't in any way lessen the impact of the situation around you as soon as you ventured outside the hospital complex. At the end of 1942, I left France for North Africa, had a few adventures on the way, arrived in Algeria, and signed up immediately.

After the war was over, I resumed my training in Paris, after a gap of four years. By then I was so senior that I could choose where I wanted to train. I spent a year in Jean Quenu's department at the Cochin Hospital, where I was delighted to meet up with Jean Cauchoix again. I finished my training under Gaudard d'Allaines. That was a wonderful year for me. It was the time when d'Allaines was developing oesophageal repair techniques and beginning to move into vascular surgery. D'Allaines is still one of my role models because of his surgical technique. He was always calm, he moved slowly but with great precision, each stage of the procedure logically followed on from the preceding one, everything was very safe and controlled; he never gave the impression of being rushed. I nearly stayed with him, and I would have done so if I hadn't already taken up a position with Merle d'Aubigné. As I had no experience of paediatric orthopaedics, Merle d'Aubigné had asked Professor Leveuf to take me on as a senior registrar. Leveuf was a very lively little man, very restless, with a very quick mind. Unfortunately, he became ill and died during my first year on his unit. Laurence took over as head of the department. He was an urbane giant of a man, very cultured, but he didn't like operating, which actually suited me very well.

M.O.    What effect did the war have on your career?

R.T. It was the war which was responsible for my specialisation. I was appointed quite quickly to head the mobile surgical team, which meant that I did a fair amount of trauma work under very varied conditions. There were lulls in the fighting, like the one which followed the Tunisia campaign, and during these spells I was able to go and spend some time with the British and American ambulance services who were stationed nearby. The American army medical service organised advanced lectures, and I was lucky enough to attend one of them, given by Major John Converse, on techniques of plastic and reconstructive surgery. To me, this was an entirely new subject. Converse's mother was French, and he had done some of his studies in Paris. He was completely bilingual. He invited me to visit his hospital unit in Algiers, where I spent a few days of leave. I saw the spectacular results that could be achieved with plastic surgery; to me, techniques like early skin grafting and secondary covering of wounds with large flaps, were progress beyond belief. Some time later, I was sent to Corsica, and I had to treat a number of casualties on Elba; then I landed at Toulon and made my way with the First Army to just outside Paris. Then I was summoned to staff headquarters by Colonel Merle d'Aubigné, who was in charge of integrating the various medical services of the French forces at home and overseas. He had summoned me because I was one of the few Paris registrars who were in the services at that time. He was tall, slim, and very elegant in his brand new battle dress; he asked me about the action I had seen, and I told him about my contacts with the medical services in the Allied forces. He was suddenly very interested; he spent a long time asking me questions about Converse's plastic surgery unit, and then he told me that he was planning to create a Centre for Reconstructive Surgery for the First Army. A few weeks later, I was assigned to this centre at the Léopold Bellan Hospital. A few days later, to my amazement, Converse walked in: Merle d'Aubigné had managed to have him seconded from the American Army and assigned to the French medical service, as a consulting surgeon. So after wandering for two years, I found myself settled in a Paris hospital with two senior consultants - one an orthopaedic specialist and the other a plastic surgery specialist, both excellent surgeons. So I was able to do a dual apprenticeship in very favourable circumstances, since we had a very large number of war victims who had been virtually neglected until then. We were given all the serious cases of sequelae after limb trauma, facial injuries, and in particular, a great many cases of nerve lesions, burns, osteomyelitis, bone defects, and so on. There was an enormous amount of work. The registrars from Léopold Bellan Hospital were drafted in to assist us, and they proved to be a great help. Benassy came to join us first, then Cauchoix, together with an anaesthetist called Kern and an intensivist called Lassner, who had both trained in the British medical service in new techniques which at that time were still unknown in France. This was the primordium of what was to become Merle d'Aubigné's department.

M.O.    Did you meet any of the military leaders of the time?

R.T. I am not going to play the old soldier after keeping quiet about it for fifty years. I have told you about the effects of the war on my professional life, and as for the rest of it, well ... But as you are angling for a war story, I shall tell you about the first time I saw de Gaulle. The scene is still engraved on my memory. I saw with my own eyes the command a leader like the General can exert over his troops, just by the power of speech. It happened not long after he arrived in North Africa. I was one of the officers in the Army Corps based at Constantine; with my brother officers, I had been invited to a reception held by de Gaulle. He was standing on a small platform, towering above us - a giant among men. He began with a few words on how the war was taking a more favourable turn, but immediately added that our task was not going to be completed just because there was some hope that the enemy would be driven out of France. And he went on to paint an extremely pessimistic picture of France and the world.

M.O.    De Gaulle being a pessimist! What was worrying him?

R.T. He was afraid that France would go back to its own particular demons, to the stranglehold of the political parties on the life of the nation, and the mistakes of the Fourth Republic. Most of all, he was afraid that the allies would impose a provisional political regime on France and would trample on our rights. He felt that we had to re-establish the laws of Republic wherever territories had been liberated. France must not be kept outside the peace process and lose its status as a great power. To prevent this, we had to be a part of the victory everywhere, and help the Western allies to contain the age-old problem of Russia's push to gain access to the open sea. It was also likely that there would be a population explosion in Asia and Africa, and a place would have to be found for these peoples in the great scheme of things. The whole of the Western world would have to be united to do this, and France would play a pilot rôle. But would it have the will to do this? Looking at the spectacle of the French military forces, one might doubt it. I can still hear his clipped voice exploding into a hushed silence. The general was gazing over our heads, gazing at his vision. All these ideas might seem trivial now, but you have to see them in the light of a time when Germany still dominated the whole of Europe, which makes them seem both surreal and prophetic. The audience had been expecting the usual harangue, full of high patriotism and low revanchism, and they were stunned by the very serious issues he was raising. At that time, a lot of officers in the African Army were supporters of Giraud, or even Pétain, and they had come more out of curiosity than because they supported de Gaulle's ideas. They suddenly found themselves being made party to his views on world strategy. Their petty reservations were swept away by the sheer scale of the plans in which they were being included. They took a while to come back to earth when the General had finished, and their mood was serious as they left. Aterwards, the disparaging reference to de Gaulle as the "agent of the Brits" was no longer heard in the mess.

M.O.    Let's return to civilian life, and your reunion with Merle d'Aubigné. How did you become interested in hand surgery?

R.T. Partly because it was a new area, where you could still play a part in its development. Also, a series of lucky circumstances had meant that I had already acquired some experience in the various elements of hand surgery - traumatology and plastic surgery during the war, nerve surgery with Petit Dutaillis, vascular surgery with d'Allaines, and orthopaedics with Merle d'Aubigné. All these different strands of my training finally came together in hand surgery, which combines all these disciplines.

M.O.    How did Merle feel about you specialising within orthopaedics?

R.T. He accepted the idea very well, he even encouraged me. Merle d'Aubigné had extremely broad views about orthopaedics. He felt that it could no longer be limited just to bone and joint disorders; these conditions would be just part of a much wider field which would include recent trauma and the whole area of reconstructive surgery of the musculoskeletal system, including the hand. In any case, I had begun to specialise in hand surgery very gradually. As I had started to work on postoperative thromboembolic complications when I was working with d'Allaines, and had continued with it at the Cochin; and as I was aware that hip arthrodesis was notorious for producing this type of complication, I had for some time been given all the fusion cases to do. I had even established a grading system for the risk of thromboembolism, which was the subject of Jacques Duparc's thesis. In addition, as I had acquired a certain amount of knowledge of plastic surgery with Converse, I was put in charge of the general plastic surgery work in the department - leg flaps, and so on. Merle d'Aubigné was an authoritarian, but he did know how to delegate. So although I was only a young senior registrar, in 1949 he put me up at his place on the Quai Voltaire, to deputise for him in his private practice while he was away on a long trip to the United States. So I had the use of a well-heated flat during one of the cold post-war winters. He was also a very loyal friend. When the Centre for Reconstructive Surgery became too big for the Léopold Bellan Hospital and moved to the Foch, he recruited junior surgeons from the Paris public hospital system. The first to arrive were Ramadier, Postel and Meary. All three remained with him and formed the backbone of the department at the Cochin.

M.O.    Why didn't you carry on with a public hospital career?

R.T. I had had four years of life in the services, and I had acquired quite extensive surgical experience under very varied conditions; I had no desire to go back to cramming academic theory. Especially not as it reminded me of a very grim period during the Occupation, at the Salpétrière, when I spent all my free time swotting for the specialty training entrance exam, and taking part in intensive cramming classes. I was naive enough to think that we would soon see the back of those relics of the Dark Ages, the competitive exams, which were rigged. I was also sufficiently conceited to think that I would always find myself a job. I was so vehemently opposed to these exams that I refused to go in for the ones reserved for former military personnel and for people who had been dispossessed during the war. In any case, Merle d'Aubigné understood my position very well and it suited him, because it meant he could put in younger candidates. By way of compensation, he introduced me to the American Hospital, which had a very good reputation; and right up until his retirement he entrusted part of his department to me, with a senior and a junior registrar. I spent more than 25 years with him, and my position as a specialist allowed me a certain amount of familiarity towards him.

M.O.    Merle d'Aubigné obviously made a profound impression on a large number of surgeons at hat time. What particularly vivid memories do you have of him?

R.T. Merle d'Aubigné created the French school of orthopaedics, he gave it its terms of reference, and he established the rules of disciplined operative procedures and evaluation of results, which it had previously lacked. All present-day French orthopaedic specialists have learnt from him directly or indirectly. It is becoming increasingly difficult to bring together the conditions you need to create a School: You need personal charisma; disciplined students; a hospital centre which is sufficiently large and active; a set of strict rules concerning patient selection, operative techniques, and evaluation of the results; and, finally, and most important of all, you need to be a born teacher. Merle d'Aubigné had an extremely lucid and organised mind and a great deal of authority, and he had all the qualities needed to lead a School. He also set the same high standards for himself as he did for those around him. The little Lister wing which he inherited from Mathieu at the Cochin was not large enough to satisfy his ambitions. His tenacity was rewarded with the creation of the new professorial unit of Orthopaedics, the Ollier Wing, which contained a number of departments; and he established appliance centres and rehabilitation centres in the Paris region, as well as centres for paralysed patients. So he created an all-embracing network of facilities. The teaching that went on there had a considerable influence in France and abroad. Two days a week were entirely given over to teaching. On Saturdays, when the operating list for the following week was being drawn up, all the patients were presented; each junior gave his opinion, and the boss had the final say. These "grand rounds" were a completely novel idea at the time. On Monday mornings, Merle d'Aubigné held a teaching clinic, and in the afternoon there were case presentations of the patients who had been operated on the previous week. This was followed by a presentation by a member of the department or by an invited guest. Merle d'Aubigné was one of the last general orthopaedic surgeons who could tackle all the problems in this vast field as a specialist: He could expertly comment on such widely different areas as foot fractures, spinal tumours, brachial plexus lesions, hip conditions, and hand surgery. This is why he aroused such admiration and had such influence over juniors who were confined within more limited branches.

M.O.    Why did you say that it is becoming increasingly difficult to bring together the conditions needed to found a School?

R.T. I think that the splitting up of the large departments, as has happened in the public hospitals, is not conducive to the type of environment in which a School can be created. Of course, you can bring a number of departments together for teaching purposes, but as experience has often shown, in this country it is not possible to establish common principles regarding treatment, because each head of department wants to do things his way. I think that it is more likely that new Schools will be established in private institutions, such as those in Switzerland or the United States.

M.O.    In all the photographs we have of Merle d'Aubigné, he looks very much the grand seigneur...

R.T. Merle d'Aubigné was a gentleman in every sense of the word. His ancestor Agrippa was one of Henry IV's companions. His impressive bearing and his elegance set him apart from other people. He came from a line of Protestant ministers on both sides of the family, and he had inherited very high standards and a deep sense of justice. For example, he insisted that patients were called by their names, at a time when people used to say "woman number 16, Pasteur ward". However, his democratic ideas did not stop him being rather intolerant, and his outbursts of anger were legendary. In my view, this anger was brought on by too much stress and responsibility. As he used to say of his teacher Lecène, "his nerves just snapped." After these outbursts, when he was often unjust, he would be charm itself. I often saw him on holiday, and then I found him to be a perfect companion, except when he took the helm of his yacht. I preferred not to crew for him.

M.O.    You are a Cochin man through and through, but your French Hand Institute is now housed in the centre run by the Judets. How come?

R.T. There was a certain rivalry between the two establishments, but it didn't prevent their mutual respect: Merle d'Aubigné had a high regard for the special qualities of Robert and Jean Judet. The Judet brothers were very friendly towards me, and they often supported me, both at the College of Surgeons and elsewhere. Recently, I was very moved by the warmth with which Jean and Henri Judet welcomed me, after a twist of Fate had brought me to their Jouvenet Institute. And Raymond Roy Camille was at the Cochin first, as indeed was Henri Judet, and he was one of my closest friends. He was a wonderful man, with a great sense of friendship, very generous, and I miss him a lot.

M.O.    In the 1970s, you were one of the three French specialists in hand surgery, with Jean Gosset and Marc Iselin. How did that come about?

R.T.    Iselin and Gosset didn't know about me for a long time. I was not credited by name, but was an anonymous member of the "Merle d'Aubigné team". And then things fell into place once I had founded the Hand Study Group; they were the first two presidents after Merle d'Aubigné, and after François Iselin had come to the Cochin as a registrar. Marc Iselin had the distinction of being the first person to teach hand surgery in France.

M.O.    Jean Gosset was against the idea of hand surgery as a specialty. Why do you think he felt like that?

R.T. I think that Jean Gosset had not yet taken into account the effects that microsurgical techniques were going to have on the treatment of hand injuries. Learning these techniques takes a very long time, and above all you have to practise constantly, which requires a specialisation which had not seemed to be necessary before.

M.O.    Although you are not an enthusiastic practitioner of micro-surgery, you encourage your students to train in it...

R.T. Enthusiastic is not quite the right word. I have always felt that microsurgery was a technique and not a specialty, and that the most important thing for a hand surgeon was to have a functional approach and not to allow himself to be confined by any one technique. Having said that, I used a loupe for surgery for a very long time. I had times six magnification loupes made in England, which were adequate for what I was doing at the time. I was in my sixties when microsurgery became popular. I felt that it was wiser to leave the high-magnification techniques to my colleagues. I was very well in with Bernard O'Brien, who pioneered microsurgery in Australia where the technique took off immediately, and we came to an agreement which turned out to be extremely profitable: O'Brien sent his assistant Wayne Morrison to spend a year with me perfecting his hand surgery. For my part, I sent Alain Gilbert to O'Brien in Australia to learn microsurgery. The two young surgeons later worked together for two years, and they both acquired an international reputation.

M.O.    How have you managed to train so many people?

R.T. I think that it is mainly due to the attraction of the department at the Cochin, and also perhaps to my writings. I feel the need to write in order to clarify my ideas, and I can only learn while I am teaching. I have been lucky enough to have friends around me, rather than students. It began with Jacques Duparc; we worked together a lot, first on his thesis and then in other areas. He helped me in my non-hospital practice, and naturally became interested in hand surgery, in which he became an expert. He and I were both founder members of the Hand Study Group. Over the years, I have watched generations of young colleagues go through the Cochin. Some of them took a more particular interest in what I was doing. It is thanks to Malek, Thomine, Valentin, Baux, Alnot, Dubousset, Lisfranc, Achach, Roux, Caffinière and a few others that I was able to carry through my work on the hand and on burns. They all helped me to produce my work on hand surgery, and I am very grateful to them for that. For 15 years I managed the Burns Unit at the Cochin. It was an extraordinary experience for me, on both a human and a professional level. The experience was often painful, because you never get used to patients dying when you think you have saved them, which was unfortunately the rule when the burns exceeded a certain percentage of the body surface area. My hopes were dashed so many times after it had looked as though the patients were getting better! Serge Baux was a great help to me during the whole of this period. On the other hand, I found treating burns sequelae to be very satisfying. It reminded me of my surgical work during the war, and I was able to refine my previously acquired techniques of face and hand reconstruction .

M.O.    When did you leave the Cochin?

R.T. I left in 1972 to create the first Hand Institute at Neuilly, together with Régis Lisfranc and Alain Gilbert. Alain and I have been working together for more than 25 years, and I am constantly glad that I have such a brilliant and loyal friend working alongside me. We are always working on new projects, including the imminent publication of a new atlas of hand surgery techniques, produced in collaboration with Alain Masquelet. The Hand Institute has gradually increased in size: It had six surgeons at the Franklin centre; and now, at the Jouvenet centre, it has twelve. Again, I have seen generations of French and foreign residents passing through. Some of them, some of the best of them, are now on the staff of the Institute, such as Caroline Leclerq and Christian Dumontier. Others have been working for us without pay, such as Kuhlmann, Rousseau, Masquelet and many others who have come from a wide range of countries.

M.O.    What influence do you feel that foreign schools have had on your career?

R.T. A very substantial influence. I have already mentioned how valuable I found my contact with British and American surgeons during the War, and particularly the influence which John Converse had on me. Merle d'AubignÈ was also attracted by things foreign. Before the war, he had admired the major orthopaedics centres of Vittorio Putti in Italy and of Böhler in Austria, which inspired him later on. He spoke English perfectly, and immediately after the Liberation he established close relationships with the British and the Americans. He sent me to Herbert Seddon, who at the time had a department in Oxford which specialised in the treatment of peripheral nerve damage. This was the start of a close collaboration between the two departments. In 1949, the French Orthopaedic Society chose Dupuytren's contracture as the subject of its annual report (a custom which has since been dropped), and I was given the task of producing it in collaboration with J.I.P. James, who was then Seddon's assistant. This led to a lot of cross-Channel travel on both sides. As I was in charge of plastic surgery and hand surgery at the Cochin, I began to prolong my visits to England, since these new disciplines were not taught in France. The most important plastic surgery departments were run by two New Zealanders, Sir Harold Gillies and Sir Archibald McIndoe, both knighted for their services in the War. They were excellent surgeons; they were cousins, charming men, with a great sense of humour, and they were always surrounded by a bevy of gorgeous female volunteer helpers. McIndoe would only travel in a Rolls, and he savoured his success in an England which was still Victorian. Guy Pulvertaft, the most famous hand surgeon, was quite different. He was austere, very religious, dedicating his life to the service of his patients and of those close to him. He taught me the technique of flexor tendon grafting, and became one of my best friends. A group of eminent British surgeons who were interested in the hand had created a "Hand Club", which was limited to 10 members and which included Watson Jones, McIndoe, Capener, Pulvertaft, and other well-known figures. The club met twice a year, and the working sessions, which were quite short, ended in a splendid dinner. I was invited on a number of occasions. However, these elitist meetings could not escape the democratisation which was also affecting England. A new generation of surgeons led by Graham Stack founded a "Second Hand Club", which was much more active; and, again, I was a member from the start. That was where the idea of creating similar study groups in France came from. In 1948 or 1949, my friends Daniel Morel Fatio and Claude Dufourmentel, and I myself, founded the French Plastic Surgery Society; and then a few years later I founded the Hand Study Group, with Duparc, Vilain, Michon and Rabischong. Each of us played an important part in the development of the Hand Study Group. The aim of these societies was to bring together surgeons who were interested in the new disciplines, and to provide teaching of the techniques involved, in order to compensate for the long-standing deficiencies of the universities.

M.O.    You advocate training in your specialty in private establishments. Should we see this as a result of the influence of your contacts with the United States?

R.T. Absolutely! In 1951, I was awarded a Fulbright scholarship to spend a year in the United States. My main objective was to meet Sterling Bunnell, the founder of hand surgery. The number of people with irreparable hand injuries during the last war led the American Army Chief of Staff to give the task of organising the treatment of people with hand injuries to Bunnell, a San Francisco surgeon who was already getting on a bit. Nine specialist centres were created in 1944, and Bunnell's list of requirements for surgeons who were going to work there included training in orthopaedics, neurosurgery, and plastic surgery, because, as he said, there isn't room for three different surgeons in such a small space. Later on, the surgeons with this training founded the American Association for Hand Surgery. I spent six months in San Francisco. Sterling Bunnell had, by then, become a legend in his lifetime, and his Surgery of the Hand was the Bible for hand surgeons of my generation. Bunnell was above all a naturalist, searching for laws which applied to nature in all its manifestations, animal, vegetable, and mineral. He had made comparative studies of fish fins, birds' wings, and hands. For the surgical treatment of hands, he had established "basic principles" based on anatomical and physiological concepts, which are still in use.

M.O.    What was he like as a man?

R.T. He was like some some other great people, in that his behaviour could sometimes appear extremely eccentric. He was on terms of complete familiarity with a very wide range of animals. He shared his house and garden with snakes, alligators, and birds. There isn't time here to describe some of the strange scenes I witnessed. When I was with him, I learned how to think, and his influence on me is still profound. Then I went to visit the famous school of surgery in Chicago, founded by Kanavel. His successors, Koch, Mason and Allen specialised in hand surgery. I was very struck by Michael Mason, who was extremely courteous both in theatre and in his private life, and I was deeply impressed by the intelligence and dynamism of Harvey Allen, who unfortunately died soon afterwards. Finally, in New York, I divided my time between Professor Emmanuel Kaplan and William Littler. Mr. Kaplan's modesty was only equalled by his very wide knowledge. He had studied medicine in Russia and in France before settling in the United States; he was a child of several cultures, and had translated the books of Duchenne and de Bourgery so that they would become known in the English-speaking countries. He approached hand surgery as an anatomist, taking an essentially functional view, and he was helped in his laboratory by two of his students who had a great future ahead of them, Dick Smith and Morton Spinner. My meeting with Bill Littler profoundly influenced my career. We were about the same age and had similar tastes. I admired his surgical technique, one of the most perfect I have ever seen, and in particular I admired his creativity. In order to become a great surgeon, it is not enough just to select your patients carefully and to be a good technician; you also have to be creative, and that is a much less common quality. Bill and I were to see a lot of each other. That sabbatical year was the beginning of my American adventure. I was to go back every year.

M.O.    Did you meet only English-speaking colleagues?

R.T. No, of course not. As soon as the Hand Study Group had been founded, it attracted a number of surgeons from neighbouring countries. At that time, there were few surgeons in Europe who specialised exclusively in hand surgery. I myself did so only after I had left the Cochin in 1972. Amongst the most senior hand specialists were Claude Verdan and Erik Moberg, two great personalities and very close friends. Then we welcomed Bonola and Morelli, Enrique from Salamanca, and, a little later, Hanno Millesi, Dieter Buck- Gramcko, Giorgio Brunelli, Paolo Bedeschi, Eduardo Zancolli from Argentina, John Hueston from Australia and many others. Finally, there were increasing numbers of Americans, including Joseph Boyes, who was one of Merle d'Aubigné's neighbours in Spain, and Alfred Swanson: I had introduced one of my former residents to him, and he married her. My relationship with the two of them is really one of family friend. It is difficult today to conjure up the friendly and hardworking atmosphere which prevailed in these small hand study societies at the time, when the specialty was still new and when the size of these societies meant that all the members were on first name terms. There were not many specialists, and they were all driven by the same enthusiasm; they travelled a lot and they met each other frequently. Progress was so rapid that at every meeting there were new techniques to report, which led to long discussions. Our foreign colleagues liked to come to France, and the Hand Study Group, which they still speak of with nostalgia, played a very important role in the development of the specialty. There were almost as many foreign members as French members, and meetings were held in the most beautiful parts of the country.

M.O.    How do you see the Hand Study Group developing?

R.T. Obviously, I am proud to have been one of the founders of the Hand Study Group, which has now become a Society with several hundred members. But the atmosphere has changed. You cannot go back. Like many other groups, the society has been a victim of its own success, which has led to envy and has produced rivalries which have been sharpened by an increasingly difficult economic situation. The Orthopaedic Society also went through a time of crisis as it grew; however, that crisis was resolved a long time ago. It will be the same with the Hand Study Group, where we now have a "think-tank" to make proposals to the Governing Body on the major directions the Society should take. At SOFCOT, this is done by the Committee of Past Presidents. Incidentally, all learned societies ought to have a permanent committee to reflect on proposals and put forward their own ideas; to conduct a dialogue with the authorities, which tend increasingly to interfere with their affairs; to co-ordinate national and international policies in the long-term; to bring the conference explosion under control; to give guidance in the domains of ethics, teaching and publication; and, also, to guide relationships with other learned societies with related concerns.

M.O.    Should hand surgery really be separated from the rest of orthopaedic surgery?

R.T. It is inevitable that the field of reconstructive surgery of the musculoskeletal system will be divided up into a number of branches. Even at the beginning of my career, very few orthopaedic surgeons were able to cover the whole of this vast field. Hand surgery itself now tends to be subdivided. However, we must preserve a unified wider context, at least for teaching purposes. All future surgeons working on the musculoskeletal system must have a common core, with an extensive knowledge of the anatomy and physiology of the system; they must learn the full range of bone, skin, tendon, nerve and blood vessel repair techniques, which demand an exceptionally rigorous technique and meticulous asepsis. Finally - and this is important - all those going in for orthopaedic surgery need a grounding in fundamental research. Obviously, it is not a question of turning all future musculoskeletal surgeons into researchers; however, they must be able to understand the language of basic scientists, and they must be able to develop a rigorous attitude which can be applied to clinical research. Future American orthopaedists are going to have to spend time in a laboratory. This is the only way surgeons will be able to collaborate with basic scientists, and also with engineers, which is vital nowadays given the increasing use of implants in orthopaedic surgery. We must always remember that basic scientists and engineers work in a field that goes way beyond our own discipline. We are the ones who should approach them and get them interested in our problems, and reduce the gulf between clinical research and fundamental research.

M.O.    You are always publishing; how do you feel about the supremacy of the English language in the medical literature?

R.T. I am, of course, very concerned about the declining use of French world-wide. What can we do about it? When I was running the Annales de Chirurgie de la Main, I tried a number of solutions. First, we published French articles with long abstracts in English and in Spanish. Then we brought out a bilingual journal in English and in French, in which each article was translated into the other language, which used a lot of paper and cost a lot of money. Finally, I tried the solution of a French journal and an English journal published independently of each other. That was equally expensive, and the English version of the journal did not sell well abroad. In fact, the Revue de l'Orthopédie had a similar experience. Should we go back to a bilingual solution? I think not, because the great majority of foreign surgeons are now used to reading English. Should we stop publishing a French journal? Surely not. We must maintain a French-language journal. Of course, it will only have a relatively small readership, although there are still French-speaking communities here and there, who must not be neglected. The journal will be read if the articles are good, because, at the end of the day, the only thing that matters is quality. That is also true of books.

M.O.    The problem of English is actually a problem of American supremacy, because even the English complain that the Americans don't read their papers ...

R.T. This is a difficult subject and a very sensitive one, because it is one of the central preoccupations of the French: How do we preserve our identity while becoming part of a world order in which we are no longer the decision-makers? There is no simple answer, particularly as the whole matter is complicated by politics, by national sensibility, and by misunderstandings. Of course, now and then one may be very irritated by the way American culture dominates everything; and it is galling to find that the Americans will not cite papers that were not published in English. But isn't it also possible that the Americans themselves are just as irritated by a certain intellectual smugness of the French - a smugness which unfortunately is usually because of what we once were rather than because of what we are doing now. And could not the Americans be annoyed by our endless criticism, which they see as ingratitude, after their crucial role alongside us in both World Wars? Obviously we should not slavishly accept everything that comes out of America; we should stand up for our values and defend the French language. But our cause will not be best served by routine opposition to everything American. We should accept from them what we find useful, and reject things we have no use for. Let's not be too unfair to the Americans: When all is said and done, they have made a major contribution in the area of medicine; they have given us new techniques; they have taught us how to write scientific papers; and, most of all, they have made a very substantial contribution to the field of research. Also, they are very receptive whenever we have something interesting to offer them. I am against any knee-jerk anti-Americanism, which is too convenient a way of masking our own weaknesses. It is at the commercial level that American dominance is most dangerous: Almost all the French instrument-makers and medical publishers are now under American control. I feel that other European countries have made a better job of standing up for themselves.

M.O.    How do you see the future of orthopaedics, and especially of hand surgery, within Europe?

R.T. I think that teaching in Europe will gradually be harmonised. The conditions under which the various disciplines are practised will depend on the internal politics of each country for a long time yet. But what concerns me most is the question of seeing that French research is published more widely abroad. It is a very serious problem. We have excellent congresses: SOFCOT and Hand Study Group meetings are still the most brilliant in their field in Europe; but they now attract fewer visitors from abroad. In addition, our studies are not sufficiently widely published. It is not the quality of the surgery which is in question - some of the best surgery in the world is done in France. We have to look elsewhere for the cause of this paradox. Certainly, the use of French has declined. There is no two ways about it. When I think of the tours I used to do in Latin America or the Middle East, only 25 years ago, when everybody spoke French ... Now, you have to translate your French into English in order to be understood, even in the Latin countries. But it is not good enough just to blame the declining use of the French language, because there is another, more serious, reason why French studies are not being published more widely, and that is our lackadaisical attitude to research. Any scientific paper that wants to be taken seriously has to have a research content - and yet, French surgeons have not had the right kind of education to give them the scientific approach that is needed for research. Of course, there is a group of professional researchers at the French Science and Medical Research Councils, but they have no real concept of clinical practice, and they are only concerned with laboratory studies. That is a terrible handicap, because the liaison with the clinical world should be provided by physicians and surgeons who work in the clinical arena. It must be said that professional researchers sometimes display the condescending attitude so typical of French civil servants, which is hardly conducive to cooperation. Also, it is true that in France it is very difficult for a surgeon to spend some time in a laboratory. However, and I must repeat this, it will increasingly be necessary for surgeons to have acquired a "research-mindedness" during their training, so that they will be able to collaborate effectively with basic researchers, computer scientists, and engineers.

Some surgeons will go further and become true researchers, which is what is happening now in America or Sweden.

M.O.    How can you promote research?

R.T. Neither the academics nor the orthopaedic surgeons have been in any great hurry to develop research, except perhaps in the traditional French domain of anatomy. The excuse is that we haven't got the money or the premises. This is not strictly true: There are laboratories, but they are underused. As regards funding, there are sources, particularly European ones, which the French make very little use of. I have to say it yet again, what we really need is to develop a research-mindedness. In addition, the surgeon researchers who do exist need to be given some official status and be paid for their research activities. In other words, the national education system should create a number of permanent Academic Surgery posts with a career structure. I also think that senior registrars and perhaps even the more junior surgeons should be made to spend time in a laboratory, as part of their specialty training.

M.O.    Apart from hand surgery, you have a keen interest in art, especially painting ...

R.T. I have always enjoyed the company of artists, I like being with them. It's a question of empathy. When I was young, I spent a lot of my time with painters. I love painting, and I enjoyed following the development of the painters I knew. At the time, the world of painting in Paris was a real international fellowship. Once you had been introduced into it, you had access to all the studios. I looked after a few painters, and I became medical adviser to and friends with several of them. Some of them eventually become famous, including the Giacometti brothers, Alberto and Diego, who both presented me with a bronze sculpture of a hand. Vieira da Silva and her charming husband, Arpad Szènes, were neighbours in the country; I used to play table tennis with Arpad. There was Atlan, a gentle man who painted only military scenes; Poliakoff, whom we used to invite round to play the guitar; and Rufino Tamayo, who became a national celebrity in his native Mexico. Others, like Pierre Dmitrienko or the great Japanese painter Key Sato, enjoyed fleeting fame, then were unjustly forgotten. And there were others who never emerged from anonymity, despite all my efforts - I am thinking especially of Ferdinand Desnos. All these people are dead now. Fortunately, I still have a few friends from when I was young. Later on, I spent more time with writers and musicians. The musicians often suffered from upper limb disorders, which is how I began to be interested in that type of problem.

M.O.    You have been a hand surgeon for 50 years, and here we are at the end of the 20th-century; how do you see the next fifty years?

R.T. It is difficult to see into the future, and one is all too likely to be wrong. However, I can't help being concerned about the reduction in the status of doctors, both socially and financially. Surgeons specialising in the musculoskeletal system have not escaped this decline. This situation may not be peculiar to France, but here it has damped down the enthusiasm which accompanied the spectacular development of the specialty over the past few decades, and there is a lack of confidence in any economic improvement in the future. This is likely to deter the best of our younger generation from this profession, which is a marvellous profession, but one whose future is uncertain. For as long as surgery depended mainly on a knowledge of anatomy, I would say that we were quite naturally the front runners. In the future, imaging, endoscopy, physics, chemistry, pharmacobiology, and computing will play an increasingly important role, and we will have to try to defend our place. We will probably have to change our medical education system, and the hospital system; and the earlier we do it, the better. As for developments in hand surgery itself, specialists who originally confined themselves to the hand and wrist will tend more and more to deal with the whole of the upper limb, or more precisely with lesions of upper limb structures which affect the hand. I am not sure that the inclusion of the two proximal joints of the upper limb is a very good idea, because they are very different anatomically and in the way they need to be tackled. For orthopaedics in general, there will be two main trends, one towards subdivision into sub-specialties, and one towards a more global approach encompassing both bone and joint surgery and soft tissue surgery. Where will France stand in this development? We have some trump cards which will be important: We have an excellent tradition of surgical technique and a thorough knowledge of anatomy, which we have acquired from working on fresh cadavers, an advantage unknown abroad but one which is tending to disappear at home. The position of French orthopaedics will depend on the ability of our compatriots to preserve what we have achieved, to become more involved in research, to pinpoint subjects for research which are of interest to the international community, and - whatever their feelings on the subject - to express themselves fluently in English.