Francis Chaise strongly contributed to the development of the hand surgery in Nantes. It forms part, with the private clinic Jeanne d' Arc, of a team of nine specialized surgeons. As of the time of its Parisian formation, it was implied in humane missions and it acquired, amongst other things, a single expertise in the field of leprosy. Meet of a missionary surgeon.

. : Ritual question: can you forward yourselves?

. : It is a question to which it is difficult to answer because it joined the philosophical concepts of identity. I can simply tell you that my patronym it is Chaise, my Francis first name and that I exert the hand surgery in an exclusive way to the private clinic Jeanne d' Arc in Nantes.

. : Which are your procedures of exercise?

. : I belong to a group of nine surgeons. Our exclusive, or nearly exclusive speciality, it is the hand surgery. The Jeanne private clinic of arc in which we exert is a private clinic with liberal activity, located in the center of the town of Nantes, who as you know it, drains a mining area of population of approximately 602 006 inhabitants and for which the hand surgery was not developed in a way structured up to that point.

. : Doesn't last nine hand surgeons, that make much for Nantes?

. : That corresponds to my opinion in a way a little right to the regional needs as regards hand surgery because in our exercise there are two aspects. The aspect “programmed activity” that the surgeon can achieve in about any establishment, but also especially the aspect “emergency activity” which is considerable since we operate 6 to 7000 urgencies a year. This urgency activity is fascinating in term of time. It is necessary thus a packed team if one wants a follow-up and an assumption of responsibility of quality, public holidays, the night and the every day of the week. Therefore the parameter setting of our group with nine specialized surgeons does not appear at all excessive and under evaluated perhaps even a little.

. : Does that want to say that you are only in the area?

. : Today, I can answer that we are only since we passed from the Conventions of establishments to establishments with the of Nantes, which is in term of activity an important university hospital, and with much of regional hospitals which address to us their casualties for the assumption of responsibility with the private clinic Jeanne d' Arc.

. : Why the hospitals do not take charges this emergency type with it?

. : Without re-entering in polemical details, it should be understood that the competition of activity over the fifteen last years played full. Our team which defined her development objectives clearly is amplified in a considerable way, at the same time in volume and competence, to reach them. The remained on its bases rear with only one specialized operator who ended up throwing sponge. In consideration of which Conventions of operation with the which we had asked… and who had been refused to us, were finally signed at the request of the in front of an irrefutable fact which it was nevertheless necessary well to admit in order to organize the assumption of responsibility of the traumatic hands at the regional level.

. : Which “economic” analysis do you make this situation?

. : I am not economist, but a long time ago that I was interested in the cost by pathology and the operating costs of the services. It is clear that the costs of operation of private establishments are much lower than than are the operating costs of the public body simply for reasons of wages of the personnel. That does not correspond to a medical activity but more to one social status of the personnel which is definitely paid in private establishment. Moreover, the hand surgery can be made in structures not having heavy reanimation nor of complex structures very eaters of personnel such as one finds them in the hospitals. Thus the private clinics, provided that they are organized for that, i.e. they organize of the surgical units and the permanent reception facilities, can completely ensure the public service missions for the hand. It is besides what we have done since we are “pole urgently” specialized in hand surgery, in an official way for two years.

. : One could be astonished by the fact that the urgencies are not made at the hospital, but one can also see an good example of private-public collaboration there on the urgencies…

. : A few years ago we had asked the , in order to avoid a sterile competition, to build a surgery department of the bicephalous hand together, private-public. The leading authorities did not give following this project and even rejected us in a a little dry way. We nevertheless continued our development and busy time, those which rejected us or the successors understood that collaboration is undoubtedly more effective than hard competition, for the interest of the patients of the area.

. : Why the public structures did reject your project of collaboration?

. : There are probably several reasons but main it is that the hospitals are extremely complex victims of administrative regulations and that the unions “public-private” are so heavy things to build that finally that was not done. I do not think that it is about unwillingness, but it is an irrefutable fact which unfortunately does not appear to me in the process of correction. I believe that the hospitals to the maximum under their political pressures. They do not open a clear way towards the private one in particular as regards formation. It appears rather obvious to me that the experiment that we have in hand surgery should be able to make it possible interns to make training courses in our establishments to learn from the techniques which are not taught with the because competences are not there.

. : But it is the role of the to join together competences to ensure a teaching!

. : It is completely right, but this situation is not specific to medicine or the surgery. The schools of joinery learn to the pupils a certain number of procedures and methods but cannot all learn to them from the experiment of an excellent professional carpenter who has worked for 30 years. My own experiment of hand surgery is an at the same time metropolitan and extra-metropolitan experiment; this experiment largely exceeds all that I could learn within the framework from my academic works. It was built gradually and it is rich. So that I can forward it, it is necessary that people come to me. The one but of trade-guild it is not a question. There is always a share of self-training in our trade and all the artisanal trades which one can forward only if people mix with.

. : But since there is not urgently “hand” in the university hospitals of yours area, how is this surgical knowledge forwarded?

. : It was forwarded until a recent past to volunteers who came on our premises to spend six months to personal capacity and apart from any university course. Currently, there is an intern of the , paid by the , but it would seem that this situation doesnot can be prolonged because of administrative reasons. In addition, we have intern foreign. The request is particularly important for the French-speaking countries. During these six-month periods we try to transmit to our “interns” at the same time our surgical methods, our work method, our method of operation and they set out again with a work published in the society of hand surgery. On the whole a course which is not negligible in their general training. Lastly, at the end of the training course, and for those which that interests we make an effort by our personal networks, to find a post in another formative structure so that they can supplement their formation in this field if specialized.

. : You are for mobility?

. : The knowledge is not at a place, the knowledge is everywhere and I believe that each one to be formed, some am his speciality, philosopher or surgeon, must go to see elsewhere what occurs, because it occurs there always more than what one believes. It is necessary to be able to move. It is necessary that the supervisions which manage the formation understand that there is knowledge in private establishments, in semi-public establishments, and it is necessary that the people in formation, according to the objectives which they laid down, can circulate there. It is necessary that they will see elsewhere what occurs, that they visit. The more one will visit and the more one will learn. At the time of my formation in Paris, there was no structure which enabled us to be sufficiently formed with the hand surgery in order to deal with the totality of the difficulties which could arise in this speciality. It thus was necessary that I “will walk”.

. : Admittedly, he is necessary to walk, but why did you leave Paris?

. : One came to seek me! One of my current colleagues came to require of me to install with him a center of hand surgery in an private establishment of Nantes. Movable and real opportunities offered made it possible to build a project which was at the same time enthralling in term with a future and coherent in term of integration to Nantes medical tissue. The future suggested by the society which recruited to us appeared radiant. It appeared more interesting to me to leave my birthplace and my family for Nantes to launch me in an activity isolated in a private clinic from Paris and this, under economic conditions which did not appear to me to correspond so that I wished like mode of exercise.

. : How had you been trained with the hand surgery?

. : I initially learned the surgery from the peripheral nerves at Laurent . The hand surgery I learned it a little in plastic surgery at Pr Beams in but the remainder I went to learn it in North America. There, I turned in various services, as private individuals in a very great service of the east of Canada, or I remained one year. I could achieve two goals of my formation: traditional cold surgery, and surgery of the paralytic ones. There was indeed, a completely exceptional surgeon in term of knowledge of neurological pathologies which they are central or peripheral, Doctor , and I spent one year near him like resident. I was with him each day, in consultation and in intervention and he enormously learned to me. There, I opened at the same time with this neurological pathology which continues to impassion me and I learned the essence of the hand surgery. I had another great experience, in term of hand surgery and term of corrective surgery. I was two years attending of the Instructor Tunis at the Institute of csotcina.comedy, where I undoubtedly spent the two more beautiful years of my life at the same time on the personal level and the professional level.

Mr. was a remarkable man, completely organized, and I learned near him from the work methods, of the methods of approach of the patients, the methods of behavior of file, in short, the organization of a service. I had access to pathologies which had disappeared from metropolis, in particular the poliomyelitis. We operated each week 40 to 50 patients victims of severe lesions of poliomyelitis and I thus learned much on the assumption of responsibility from the paralytic one. On the whole, my course in nervous surgery was the neurological peripheral with in France, the neurological exchange and medullary with Louis with Canada, and the poliomyelitis with the Instructor in Tunis where I was assistant and truly in charge of of very a formative top quality and care.

. : Where did you do yours ?

. : My two years in Tunis were validated as but I made also six years of at the Saint-Louis hospital in the Instructor . I had there a a little marginal activity of general csotcina.comedic surgery and an activity of hand surgery and peripheral nerves which was very largely prevalent and which I developed. At the end of my not seeing university future within a reasonable delay, I accepted which was quoted to me in Nantes to install this center of hand surgery. I never regretted this choice.

. : How much were you?

. : One started to three. They was the years 84-85. The life was hard because it was the guard one day out of three. It is true that the quantity urgently annual discussed was less low than today. But one did not speak much about the vacation which one took in a very split way. Gradually, the developing service one made come then two then all the continuation from the operators who are there now. The construction of our service, I say “our” service well because it does not belong to me into clean, always was done according to criteria human. We always privileged human qualities compared to professional qualities. The trade, one can always learn it, human qualities, unfortunately, I do not know if one can change them truly.

. : You arrive, you install your small unity, that turns well?

. : That turns quickly and very well. At the same time in urgency and at the same time in programmed surgery.

. : Do you have a field of predilection?

. : My field of predilection since always it is nevertheless the peripheral nerve. With downstream from the lesions of the peripheral nerves, the hands paralytic, a little the paralytic foot but in Nantes I do not occupy myself any. Lastly, the paralytic hand it is the field for which I prepared, it is that in which I will have spent the most time, will have reflected the most and will have spent the most energy.

. : What represents in practice current the paralytic hand?

. : The post-traumatic paralytic hands become rare because fortunately our microcomputer-surgical techniques are effective. The nerves better and better are repaired, because one repairs them in urgency and one also repairs the close arteries and the tendons. This basic philosophy in urgency is source of less paralytic hands than one could have some 20 years ago. Thus to continue to exert in the field which impassions me, I will operate overseas where this pathology still exists in impressive quantities. Since my Parisian boarding school I was likely to tie links with the Command of Malta which at the Saint-Louis hospital had a pavillon devoted to the assumption of responsibility of the patients victims of leprosy. In Paris, I could discuss tens of patients victims of leprosy and leprous mutilation. I was really formed with this surgery and in parallel I returned in circuits of mission overseas at the same time to Africa, and Asia, to discuss the mutilations of this terrible disease which unfortunately attracted the hand surgeons forever. They would have to however give much to these patients terribly weakened by their disease.

. : Are there still much leprous?

. : Yes, the last statistics of WHO which under are certainly very evaluated for heaps of administrative reasons, make that one counts 736 030 new cases a year on planet 202 002 only in India and the remainder being distributed between Brazil, Burma, Southeast Asia.

. : In short, of what does the damage of leprosy consist?

. : It is an infectious disease which is due to a well isolated agent, the mycobacterium leprae or bacillus of . It is a disease whose first signs are cutaneous in the form of anesthetic cutaneous tasks. But the germ has a considerable tropism for the Schwann cells which it will destroy and involve also by a local immunizing mechanism very complex a destruction of the nerves. It is a practically irreversible destruction of the nerve, which wants to say that these patients will develop paralyzes of the large trunks with in the long term, of the hands and the paralytic feet. These paralyzes sensitivo-motor coaches will continue by themselves to evolve/move in spite of a medical care which kills the . It should be understood that leprous, even if it is cured from a bacteriological point of view, will continue to have on him this sword of Damocles which is this paralysis sensitivo-motor coach which can continue to evolve/move and mutilate it if nothing is done to protect it.

. : Why?

. : Because all these paralyzes complex sensitivo-motor coaches occur among people who live in precarious medium. They are people who live without shoes for the majority, eat with their hands, work with their hands and end up being wounded. On an insensitive finger a small wound is not perceived, is not discussed and infects themselves. That gives a whitlow, a , a and the finger finishes, like one tells vulgarly, with the “bucket”. Currently, I am in a well developed programme of rebuilding of hands without fingers. We organized for example, 15 days ago, an important symposium in Vietnam on the rebuilding of the hands without fingers. One is confronted with terrible problems among which one tries to release from the priorities: prevention of the disease, early detection, started medicamentous therapy, prevention of the infirmities by the early , indoctrination of the patients, social rehabilitation. Work is immense but the splendid return on investment. What could be more important for an hand surgeon than to allow one mutilated leprosy to take again functions and to nourish its family. It is what we call in Malta the return to dignity.

. : What is what causes the leonine face of leprosy?

. : It is the cutaneous and subcutaneous multiplication bacillus. That created of the nodules which of germs and which develop if pathology is not discussed. One does not see of it seldom now safe if, the patients are not detected in time. That starts with the mucous membranes, it is a disease which touches all the parts but with a major predilection for the hands and the feet.

. : How is made the contagion?

. : By direct contact. The problem it is that in spite of very heavy and very targeted tracking campaigns one does not make decrease the number of new detected patients each year. By knowing that in these new patients, classification WHO, it there 20% people who suffer already from mutilations. Thus one is very late in this field.

. : But what a surgeon can make in a pathology which concerns precariousness!

. : In the Order of Malta which has existed for 9 centuries, our objective is not only to carry blows of bistoury on the right or on the left, on feet or hands which would be mutilated. The key objective is to develop at the same time a rehabilitation and processing, tracking, prevention policy. One tries to be located at all the levels of the problem. We linked Conventions with of ONG specialized in rehabilitation, thus we work with Handicap International, to loop the therapeutic channel. We succeeded in Vietnam, where we are installed for a very long time, after having spent much of energy, much of time, and of course much of money, to install a channel of care which led to a remarkable result. Vietnam now left the list of the countries where the rate of leprosy was endemic. This experiment, we export it. Much country would like well that one will work thus for them. Thus we start to export our methods in Laos and soon to Kampuchea or the same procedures are implemented so that the patients are detected, discussed, rehabilitated. Everywhere where one cannot set up the whole of the channel of care necessary, the risk of failure is great. That will thus not lead in term of medical effectiveness, it is not worthwhile to imply heavy and expensive means. We want a participation clear of the States or we exert, and a participation of the public authorities through their hospital structures before engaging us. All the missions were installation on a contract of State in State so that each one is partners and not simply giver/receiver.

. : That supposes the states nevertheless are sufficiently stable…

. : A political will is needed, and there is political will only supported by economic means. If not the political wills are not effective. Vietnam is an good example. According to the figures, it would seem that India makes a completely considerable effort. Other countries are clearly late, as private individuals the African countries. And it is not specific to leprosy unfortunately.

. : From which does the financing about Malta come?

. : Givers. It is a NGO but the difference between the Command of Malta and the other NGO it is that it has 9 centuries of existence, and that at the beginning it was a State. That remains a State with a seat which is in Rome, of the passports, an organization like a state without territory. The Conventions which link us within the various missions, in which one is engaged, are missions of State in State. One begins missions only after Convention of State in State. Historically, the knights about Malta had the role first of assisting the pilgrims who thus went out of Holy Land to Jérusalem. It was a medical help for travellers and one knows very well that the first leprosies which were imported on our premises, returned from the Crusades.

. : Which is the place of the surgeon in the therapeutic channel?

. : The surgeon in my opinion, a completely essential role. With regard to the hands, there is a preventive role which is to make . Leprosy is a disease which makes inflate the nerves. As in the canal syndromes, that causes a loco-regional . I measured the nervous pressures and in the carpel tunnels there is a of some millimeters of mercury. In leprosy, the is enormous. In a normal nerve, it is about 1 to illimeters of mercury, in leprosy, one has of the 307 951 millimeters of mercury in the nerve. What wants to say that the paralysis is inexorable from a mechanical point of view to which adds the problem of vascularities. It is about an immunological mechanism leading to intravascular depositions of complex antibody-antigens. The destruction of the Schwann cells and myelin by the bacillus of make that the patients will paralyze themselves but the mechanical component, i.e. the swelling of the nerves is undoubtedly the prevalent mechanism in much of forms. Therefore, the surgeon intervenes by making early . It should be released these nerves before they are paralyzed in consideration of which, one obtains a certain number of results in term of return of the sensitivity, and motricity. It is the preventive surgery. It is on top that it is necessary to fight, it is on top that one always fights and everywhere where one passes one makes exchange rates on this subject. There are modules of formation to the surgery of neuropathies . There one can gain. Then, the paralysis being made up, the nerves having died, one concentrates on the after-effects.

. : I.e.?

. : For the level of the hand, it is necessary to consider the long fingers and the inch. Initially the hands are rehabilitated, then one makes transfers and stabilizations by or arthrodeses. There is a whole battery of techniques which makes it possible to give again hands to which the function is rather close to the functions of a standard hand, except the sensitive disorders which unfortunately are not reversible. On the level of the feet, one observes primarily paralyzes of the raising devices. should be made early external popliteal sciatic nerve. There are good performances and when unfortunately the nerves are condemned, should be made transfers. The paralyzed foot is reanimated and it is necessary to fit the foot paralyzed it is absolutely fundamental. If not, it is wounded, it makes an evil perforating which will be infected and early or late it is the amputation of the foot, even which is the usual transformation of an evil perforating after has ten year of development. The amputation would not be dramatic if there were fitters with the corner of the forests, but unfortunately they are rare. We work with fitters of Handicap International. The patients whom we are constrained to cut down immediately are installed, rehabilitated with their prosthesis to walk and find a range. There is nevertheless in this terrible disease a leading role to play which is a role of conductor who leads us to discuss with the public authorities and to work with the organisms with medical sighting and physiotherapeutic sighting. There is even, in Mauritania, ultimate term of the rehabilitation, created a trade protected for leprous. With Philippe with which we have Co-founded an charity association called Mains of the World, we have worked for 6 years with an association Mauritanian of which the aim is to reinstate in the socio-economic life the patients mutilated by leprosy. The chairman of association is besides leprous and they found an idea rather original of work which is the guarding of parking area. This association manages guarding in parking areas of car of the capital which is . There are 13 parking areas and that done to almost live a thousand of people who normally were dedicated to beg in the streets. We intervened primarily with Philippe to rebuild pollici-digital grips. To ensure the safety in their parking area, they need a stick and they could not hold of stick. We developed surgical procedures that one invites “operations sticks” to allow these people to hold a stick and thus to be made adhere to. Finally the objective as of these missions which we ensure that it is in Mauritania, in India or we also intervene, or Asia east of patients by the means of the rehabilitation in which the surgery is only one link.

. : You nevertheless manage to make turn yours shop to Nantes?

. : Yes, the shop in Nantes turns very well I reassure you. We never worked as much, nor never seen as many patients. Our productivity is excellent, our functional costs are undoubtedly very low since our Director to smile it. It is necessary to be organized for that and only a team welded by the friendship and of the common objectives can reconcile the metropolitan exercise of quality and the share of humanitarian aid overseas in which takes part our colleagues and associated.

. : You function like a service?

. : A society was created. One is paid society, therefore in term of incomes we all are equal, he does not have there an inequality in the operation of society. There are the same tasks, each one has consultations as many, as much of surgical unit, as many holidays… One is all exactly equivalent and one lives like that since 15 years while avoiding, without too many difficulties besides the sterile conflicts, which destroyed many medical groups.

. : Do you have common ?

. : Yes, we have an organization of service, except that each one among us, of young person with oldest, is titular full-time and surgeons with whole share. None among us is within the framework of a course or a hierarchy as could the being of the interns and senior registrars. I find that it is the best operation which can exist in a liberal context. There are at the same time medical activities which are enthralling, because it is an enthralling trade and one with the management of our service where each one has a task. I deal with the management of the beds, which is not always easy, others deal with the personnel, others of the accounts… There are all of the functions of responsibility in addition to the surgery, and one manages to publish every year of the items of quality, of the communications in international congresses. I thus find that one has an at the same time intellectual and practical activity of good quality. Several among us are implied with the more top-level with the , the , the College of the teachers… one can when one wants!

. : With you to understand, it is the ideal structure for a surgeon. Do you think that all the private clinics should be structured like that?

. : I think that there is a tendency towards the installation of such society within the private clinics. What makes our success, it is that one chose oneself on human criteria. Human qualities being there, that could only well function. After one distributed the stresses, the holidays and the incomes with equality. Whatever the activity one shares with the centime close the incomes. There is thus no competition because our to become it was already built and it is common. Moreover, this peace allows a professional blooming. I on the previous day helped with pleasure one of my colleagues to make an intervention which it had never made. Each one benefits from the experiment of the other. I do not deal at all with elbow and Philippe is interested on this subject, therefore as soon as I see of it a problem of elbow which leaves my true competences, I address it to him. Of course, that functions only in the condition that each one among us plays the game. From where interest of the selection of the team members, on human criteria. That says our contract provide for measurements if one of us decreased frankly and voluntarily its activities, but we never had to implement these regulations.

. : Why you chose the surgery?

. : When I started to work in the hospitals in Paris, I fell into a service in which I burst myself! It was the service of Mr Lance in csotcina.comedy in Saint-Louis, where Jacques was senior registrar. It was teaching except par. The external one made part of the team and was with the grind, the block and the consultation… Normally one made six months of , I asked to mend and I remained one year. I felt already that csotcina.comedy it was my business and I was impassioned by this surgery. In complement, I went afterwards to Mr de in in Rheumatology and that was the illumination of the intellectual illuminations. De was a Mr of a fantastic medical crop with assistants who gave the impression of any knowledge all the time to me. One did not leave any more the service, one did not want to leave any more so much there were , , conferences. Then, in third position, I went to Mr who was titular parasitic pulpit of pathology and tropical medicine in Paris. It one was crowned catch… For reasons of family crop I was high in the spirit of the sharing and with like model Doctor . Pr resembled to him with large #FFFFFF moustache, dressed four pennies, shoes with soles which hung, of the holes to the socks but a fantastic medical crop and an exceptional humanism. I was delegated to his consultation, and it did much of it. With each consultation, one saw people who arrived from Africa, and Asia, for diseases which one had never seen in Europe. He in a few seconds told me “you see it is that”. He spoke about the heaps of exotic, African languages in particular. He spoke to the patients in , in and I found that fabulous. I wondered how one could join together as much talent and of crop? The question for me was to know how to succeed in flaring me in csotcina.comedy, knowing that I wanted to combine the surgical act, the medical knowledge, the scientific research and the opening on the world. Finally, the pavillon of Malta at the Saint-Louis hospital, through leprosy, gave me all that.

. : But what attracts towards tropical pathology?

. : The voyage, exoticism… and the misery of the countries in the process of development with the possibility of attenuating the misery of people effectively. I never detached my functions of surgeon of our essential function, which is to help those which are in the need. And which has more the need for a doctor or a surgeon that a pauper mutilated to find his dignity? The duty in the world of which my mother pointed out each day to me the importance is not it not either the highest way for a surgeon, even very specialized, to follow its occupation?

To finish I would like to point out this sentence of “One never should be solved to accept the unacceptable one” that young people should meditate before giving up medicine towards more lucrative channels but also less humanistic.