Barry C. Draper

Reflections, Memories and Sources

Fleas, Ruby and the Power of Chiropractic

This essay details my experience with a woman who believed her profound incapacity was due to her failure to respect what she termed the power of chiropractic. Whilst the clinical setting may be a fertile locale for the analysis of power, the essay seeks not to allocate supplementary relations or uncover unspoken truths by privileging none but a remarkable woman's interpretation of that power.

Fleas

Although now pursuing an academic career, for many years I engaged in full time practice as a chiropractor in the rural areas of south eastern Australia. I commenced practice in the early 1980s, a time which brought the introduction of formal undergraduate training programs in chiropractic to the region and the enactment of legislation governing its practice . In some rural areas a small number of overseas trained practitioners, particularly those from the US, had already established successful businesses and these were slowly being joined by a trickle of local graduates who had begun to filter to the 'bush.' The vast majority of practitioners utilising manipulative techniques at the time and the largest group from which the public sought care were, however, unqualified in any formal sense.

Although legislation restricting use of the title 'chiropractor' to those with recognised qualifications had recently been introduced, many unqualified practitioners continued in business and referred to themselves as chiropractors in spite of the threat of prosecution. University graduates like me referred to such unqualified practitioners as fleas. My lecturers taught me that fleas acquired their limited skills either experientially after having been the patient of a qualified practitioner, or through reading a few books on manipulation and massage. I came to believe that like their animal namesake, fleas would be an annoyance yet offer no real threat to my ability to conduct a successful practice: once a registered practitioner came to town, the fleas' days would be numbered.¹ In the minds of clever young graduates like me, the superior intellect and skills I had acquired at university would be an irresistible drawcard for patients who, I was sure, would abandon their patronage of the fleas forever, the moment I opened my doors.

Upon establishing a practice it took a very short time for me to realise that this would not be the case and that the fleas would continue to prosper. While I won over some of their patients I lost just as many who, having found my service unsatisfactory, would readily consult a flea. Many patients, however, sought care from both fleas and myself: from the fleas at times when I was not available and vice versa. Although this did not seem to effect the growth of my practice, I was perplexed as to how patients could swap and change practitioners, dependent only upon whose doors were open at the time. Surely a public exposed to both qualified and unqualified practitioners could see that I was different and that what I had to offer was based on the most up to date knowledge and skills, and not old wives tales. Surely patients would choose science over ignorance. With time I learned that patients considered there to be little difference between what the fleas and I did. In their eyes, we were essentially using the same methods to massage and manipulate; were performing our activities with the same sort of equipment; and perhaps more importantly, charging similar fees! Patients did, however, acknowledge that there was a considerable difference in what the fleas and I had to say.

I was regularly amazed at the explanations patients told me their fleas had provided, regarding what was wrong with them and how they would go about fixing it. Fleas apparently put dislocated muscles back in place, drained blood clots off nerves and changed the direction of flow of electricity in and out of muscles. Fleas variously told patients that their ligaments and spinal cord were stuck together, their nerves and blood vessels had become wrapped around each other and that by using manipulation they could straighten out the spinal cord when it had become twisted. I heard of intestines which had become wrapped up around the heart and hearts which had twisted on their axis causing chest pain. It seemed that fleas were capable of healing all maladies and that every second patient would have been confined to a wheelchair had it not been for following their instructions.

All of these constructs were absurd according to my training. On a daily basis I would find myself angrily explaining to patients that what fleas had told them made no sense and was biologically or anatomically impossible. And whilst this elevated my blood pressure, my detailed explanations of efficacy or mechanism seemed to not influence patients who largely continued to embrace the fleas account of the matter at hand. My efforts extended to making use of expensive anatomical models, complex charts and drawings, and handing out photocopies of the pages of eminent texts in order to better inform patients. All, however, was unappreciated as one after another requested I put their leg back into place or perform some other incomprehensible feat. Patients obviously cared little that I was offering a detailed scientific account of whatever ailed them.

Although I was happy to be making a living, my failure to distinguish myself from the fleas caused me considerable angst. I could accept that people might find benefit from what the fleas did, although my arrogance put this down to placebo, which of course was not applicable to my offerings! It was, however, at the crucially important theoretical level that a distinction could and should be made. After all, it may have been possible for an untrained practitioner to appear to replicate what I did, but surely they could not—without the benefit of the sophisticated education I had received—challenge the way I thought? I wanted patients to see there was a difference and that it was important. Both science and I deserved their respect.

Over those first few years of practice, my sincere belief that the rhetoric of my scientific explanations would triumph over ignorance and folklore was continually challenged. My tolerance for the absurd explanations fleas provided to patients was, however, yet to meet its greatest challenge, which came in the form of Ruby.

Ruby

One winter's afternoon I was informed by my receptionist that a new patient had been driven to the clinic by a friend and that this patient had remained in the car because she was unable to move from it. In itself this was not unheard of, from time to time patients in severe pain required assistance making their way into the clinic. Expecting this to be the case, I made my way to the car park, only to be taken aback at the scene confronting me. The friend, a man I estimated to be in his late sixties and whose name was Lionel, led me to an old Ford station wagon which appeared chock-a-block full of rubbish. Peering through the driver's window I could see rolls of toilet paper, plates, empty plastic orange juice containers, pots and pans, old books, magazines, sheets, blankets ... the list went on. Making my way to the rear of the vehicle I was able to discern a human face buried deep within the plethora of junk. Lionel opened the tailgate and introduced me to Ruby, who lay beneath a blanket exposing only her head at one end and bare feet at the other.

'Hello,' said Ruby, with a warm smile and in cheery voice.

'You have some pain do you Ruby?' I asked, trying hard not to reveal my astonishment at her surrounds, 'Let's see if we can get you inside and help you.'

'Oh no, I can't get out of the car,' she replied.

'I know it must feel like that—' I began to explain, but Ruby interrupted:

'No, I don't get out of the car, this is where I live.'

My eyes slowly panned the surrounds in greater detail. In addition to what I had observed through the drivers window I now saw several packs of opened tissues, assorted fruit, a radio and a small television near the rear door. Two cats—one black, the other pure white—appeared to be sleeping, both tucked into one side of Ruby's torso. There were tools: I saw a hammer and a pair of garden shears; several pot plants, one of which was flowering; and a three foot long piece of plumbing pipe.

Composing myself I asked, 'Do you have any pain today, anywhere?'

To which Ruby replied, 'I just need some specific maintenance adjustments.'²

I explained that before I could do anything I had to obtain a few more details. I invited Ruby to tell me more precisely the reason for her visit and as much as she wanted to about her circumstances. She sighed and in an exacerbated tone which made me think she had been asked to tell her story many times before, explained that she had never married and had laboured for many years as a factory worker in the city. Three years ago and at the age of sixty-three, she had returned to the country town in which she had grown up to care for her elderly mother who passed away soon after. Over a period of time she had developed lower back pain and attended a local GP who obtained radiographs. The GP informed Ruby she had arthritis in her back and that she would have to put up with the pain as nothing could be done about it. Although initially accepting this explanation, Ruby became increasingly frustrated by her discomfort and eventually decided to attend a chiropractor in a nearby town at the recommendation of a friend. Ruby had previously heard of the term but had no idea what a chiropractor did, and was guided by her friend to an old house on the outskirts of the town. The chiropractor viewed her x-rays and found what she was told were severe subluxations,³ which he explained would render her ninety percent cripple and unable to walk or stand should she not receive specifically designed chiropractic adjustments. He explained that this would be delivered in two phases. The first, an initial round of intensive treatment, would halt the progress of the existing subluxations and the second, involving regular monthly maintenance visits, would detect and fix any new subluxations which might develop. It was essential that the treatment commence as soon as possible as any delay might spell disaster. The power of chiropractic, he insisted, was the only worldly thing that could save Ruby from a life of misery.

Ruby was extremely concerned by all of this and commenced the initial phase of daily treatment immediately. This continued, however, for several months, much longer than she had imagined and what meagre savings she had accumulated were soon drained. Unable to afford to continue, Ruby made the decision to dismiss herself from care, despite the risks to her health this might entail. The chiropractor telephoned her several times over the next few weeks, angrily warning of the dangers she faced by not attending his office. Ruby explained that she would resume care once she could afford to and committed to finding some work, a part time job perhaps, but that this would be difficult because of her age and the poor economic circumstances which generally prevailed in the area. The chiropractor told her she was irresponsible and had poor priorities. Spinal health was paramount he said: she would ignore the power of chiropractic at her own peril.

Several months went by and in spite of not resuming treatment, Ruby felt her pain had mostly resolved. One morning, however, for no apparent reason she developed acute low back pain and found herself unable to get out of bed. She concluded what the chiropractor had predicted had in fact occurred and from that day forward she would not, without the support of others, be capable of standing or walking. Sadly, she realised that chiropractic could have saved her if only she had followed through with treatment. She was, however, thankful that she could still move her legs and made a commitment to herself to continue with maintenance care in order to prevent her ninety percent incapacity extending to one hundred percent. She sought no immediate emergency or medical treatment as she believed nothing could help.

Although initially distraught, Ruby soon realised that significant changes to her life would have to be made and she began organising an existence in the recumbent position. The few friends she had in the town were at first sceptical of what had happened and some accused her of lying about or exaggerating the extent of her disability. Once she had 'educated' people with regards to the power of chiropractic, however, most accepted her explanation of the predicament and began helping her organise a new life in the home in which she had grown up. They visited several times a day to attend to her every need; shopping for her, cooking for her, washing her, toileting her and feeding her cats. Ruby contacted a different chiropractor, being too embarrassed to consult her initial practitioner and began to receive regular monthly adjustments in her home. As the months passed, however, she had become bored and decided to make the best of her fate. She had always wanted to travel yet had little chance to do so prior to this. She made the decision to go on the road to see Australia at her own time and pace and to this point had been away from home for seven months.

Ruby had relied on friends, acquaintances, and even strangers along the way to drive her car from town to town, staying sometimes for days, sometimes for weeks. At camping grounds it would not take long, she explained, for someone intrigued by her appearance to approach and be convinced to act as her chauffer for a short while. Along the way she had sought chiropractic care wherever and however she could, although she felt that she was well overdue for treatment at this point. She was now interested in settling in this region and was even considering entering a caravan park and moving out of the car.

I explained that I would return to the practice to obtain a patient file in order to record this and further elements of a history then conduct an examination but this provoked an angry response:

'For Gods sake you don't need all that, I've told you what's wrong, you're a chiropractor just adjust me,' she yelled.

I confess to being thoroughly intimidated by her. Being young, inexperienced and unsure of how to react to the forceful and bizarre personality before me, I found myself then crawling into the back of the vehicle, making my way at Ruby's direction to the rear of the front seat, squeezed tightly between it and her head. Whilst she remained unperturbed by this, I found myself shaking.

I began treating Ruby by performing adjustments to her fifth and third lumbar vertebrae as she lay on her side. Then, without hesitation she rolled on to her back where I performed adjustments to her fourth thoracic and fifth cervical, or neck, vertebrae. Throughout this neither cat moved. All segments of the spine to be adjusted, and the methods used to do so, were prescribed by Ruby. I was told I had no discretion in the matter:

'Just adjust the bones I tell you and nothing else. Only use the techniques I tell you, be specific, otherwise it won't work and I won't even be able to turn over,' she insisted.

Following the adjustments Ruby stated she felt considerably better and that if she decided to stay in the region she would contact me again. She then searched amongst her surrounds and after removing several items handed me a crumpled envelope on which was scribbled '$20 for Chiropractor.' Before I could thank her she had instructed Lionel to close the tailgate and drive to a supermarket as she had a 'hellishin thirst.' Lionel appeared to move very quickly to comply with this command and as they drove off I returned to the practice with my tail between my legs.

Two weeks went by and Ruby telephoned, requesting I make a house call to a caravan park where she was staying. I had been thinking a great deal about her and was troubled by several things that I was determined to get to the bottom of. Given the way she had moved about in the car when I first saw her, I could not help but be suspicious that there was no significant abnormality preventing her from standing or walking. Yet why was she like this? I was eager to find out the name of the initial 'chiropractor' who had provided what I considered to be a highly unprofessional and unsophisticated explanation of her circumstances. Surely this person must have been a flea? The clinical and legal ramifications of not conducting a full examination or viewing radiographs of her spine also concerned me. What if there really was something dramatically wrong with her, could my treatment make her worse? As I drove to the park I decided I needed to be considerably more professional and firm with her. This time I would get the answers I required. This time I would take control.

Upon arriving I told Ruby in a polite but insistent manner I needed to see what radiographs she had, that I would be performing some tests and that she must tell me the name of the chiropractor who told her she could not walk. Ruby replied that I did not need to see her x-rays and she did not need any more tests but that she would happily provide the name of her initial chiropractor. In the most doctor like and intimidating voice I could muster I stated in no uncertain terms this was unacceptable, I could not treat her and would leave unless she complied. With a wry grin Ruby told me to relax, stop taking myself so seriously, sit down on the tailgate of the car and have a cup of tea. Somewhere from beneath her belongings she extracted a thermos and two cups. I discretely extracted several cat hairs from mine as Ruby sat up and poured. We drank the tea in silence then Ruby commenced a search during which a large number of articles including both cats were thrown to the front seat of the car. After several minutes, interjected with some colourful expletives, I was handed a radiograph jacket which appeared and smelt as if it had been used as toilet litter by the disposed felines.

Lumbar spine radiographs taken by her GP revealed moderate degenerative changes in the low back which one would expect to see in almost all patients of Ruby's age. There were some signs of misalignment in one or two of the vertebrae but nothing in terms of pathology which might explain her paralysis. As for any further examination, Ruby promised that if I still wanted to do this she would consider the matter next time. She suggested that I now get on with doing what she was paying me for as she was expecting visitors and, sheepishly, I complied. Before I left she scribbled the name of her initial chiropractor on a scrap of paper. I was told that it might do me some good to go and watch what he did as perhaps I might learn something.

Over the next few weeks I set about investigating Ruby's story and found that my misgivings regarding the individual's qualifications were correct, being non-existent. According to qualified practitioners in his area, the gentleman concerned had been employed as an abattoir worker early in life but opened up practice as a 'chiropractor' after recovering from a back injury. To their knowledge he had undergone no formal training and had indeed boasted to patients that he had taught himself in a few weeks what practitioners nowadays took five years to learn. In spite of this he had established a large practice in the area, but his reputation of holding reasonable technical skills was countered by what many considered his entrepreneurial approach and tendency to intimidate patients. This was the information I needed. I was sure that if I could convince Ruby her beliefs were based on the ramblings of a predatory quack she would see things differently.

Upon receiving her next call I attended the caravan park armed with this information, keen to tell Ruby of the news which I believed would change her life. I was delighted to see that she was now living in a small caravan, several neighbours and park workers directing me to her abode, some staying to view the chiropractic treatment which was considered a novelty. Ruby appeared to enjoy being the centre of attention and seemed to have had no trouble organising and directing people to do whatever she requested. The caravan had been arranged in a manner which was nothing short of ingenious. Mirrors hung by hooks from the ceiling allowing Ruby to view all angles of her surrounds. A series of pulleys and wires had been strategically installed so as to allow manipulation of dials on the television (no remote control), to turn a tap on and off and to open and close the door. A clasping device attached to the end of a stick allowed her to grasp small objects such as tissues and toilet rolls, to extract dried cat food from a large bag at the end of the bed and to turn on and off electrical switches. Ruby was chirpy and proud of her new surrounds. The cats too, appeared content. This time she allowed me to perform a neurological assessment of her lower limbs which revealed normal reflexes and dermatomes with lower limb muscular strength still capable of moderately strong resistance. Her legs, whilst atrophied slightly, appeared otherwise normal. Nothing else showed up. No hard clinical evidence could be found that would support her impression she was incapable of standing or walking. I told Ruby of my findings and asked her to tell me in more detail what she believed prevented her from standing. She insisted this could only be done over a cup of tea.

According to Ruby, the initial chiropractor taught her that chiropractic has the power to change people's lives, sometimes for good and sometimes for the worse. This is because of the special relationship between the bones of the spinal column and the nervous system. He explained that whilst normally forming a protective housing for the spinal cord, if sufficiently twisted or out of place, the bones could squash the cord interfering with the function of the nervous system. Her bones, she continued, were now so far out of place as to make a return to normal impossible. She felt she had been extremely foolish in ignoring the power of chiropractic and not undertaking the initial phase of treatment as required and that she had only herself to blame for the way things had turned out. Furthermore, if she were to not receive regular and specifically delivered maintenance spinal adjustments, her condition would worsen such that she would have no control over her legs whatsoever. The power of chiropractic was now, through well placed and regular adjustments, the only thing saving her from full paraplegia.

I explained that I believed this assessment to be incorrect and that my tests and interpretation of the x-rays indicated that she was indeed capable of being upright and not confined to her present surrounds. I explained the mere fact that she could use her legs to turn over and move up and down the bed meant there was no compromise to the cord, the nerves or any other structures. I asked if she believed the problem to be more of a mechanical nature, that her spine could not support her in anything but a recumbent position. She replied that she knew her bones to be strong and that in any case, twisted spinal bones alone would not lose their strength. The problem, she repeated, was with the nervous system, if I knew anything about it I would have no problem understanding what she meant and there was no need to discuss the matter any further. Appropriately offended, it was now time to play my trump card. In a self congratulating manner I informed Ruby that my investigations had revealed that her initial practitioner was not a real chiropractor, had never been to university, was not registered and was a quack. He was uneducated, incapable of forming a proper diagnosis and nothing he had said could be believed.

'People like him are called fleas, they need to be picked off and thrown in kerosene,' I exclaimed, naively expecting her to embrace the merit of my argument.

This, however, did not go down as well as it could have and Ruby hurled the whiter of the two cats towards me—terrifying both man and beast. Angrily she stated that he was a very well respected man, much older and considerably more experienced than me. I, on the other hand, was a young fool who thought I knew everything and knew nothing. An uncomfortable silence pervaded before, in a somewhat more gentle voice, Ruby stated that I was a chiropractor of considerable skill and knowledge and a very nice young man but that I could learn as much from her as she could from me. Though wounded, I accepted the backhanded apology but I was not exactly sure what she meant.

Over the subsequent two years I attended Ruby at her request, which was usually every three to four weeks. She became as interested in my background, my family and my views as I in hers. Following her adjustments we shared many cups of tea and traded views on politics, love and life. From time to time I reminded her that the initial chiropractor's diagnosis was wrong and that if she allowed me to assist her, she would, in fact, find that she could walk. I explained I was pleased she felt my adjustments helped but they were not preventing her from losing control of her legs. I offered to bring in other chiropractors and medical specialists, all of whom would agree with me, however this fell on deaf ears. On one occasion I arranged to be accompanied by a counsellor who put it to Ruby that many services were available which might make life easier for her. Ruby remained unmoved refusing all offers of professional help, stating she preferred to rely on the kindness of residents in the park to assist with her daily needs. On another occasion, as I was arriving one of the local GPswas leaving the caravan. I asked if Ruby was OK and he replied that she had a mild urinary tract infection.

'She tells me what a great job you're doing,' he said with a grin.

I replied, 'I have no idea what is going on with her.'

'You're not alone there,' he said and drove off.

Ruby's continual reference to the power of chiropractic and how it had both punished and rewarded her irritated me.

'How can it be so powerful if you can't even get out of bed?' I argued.

'Something powerful can pluck you from the jaws of death but it can also drop you into the fires of Armageddon,' was her standard poetic reply.

I asked her to define the power. Was it an invisible force, a personality, was it something to do with God? Did she really believe something had punished her and was now rewarding her? Could the power be influenced, could she not pray to it now and beg it for forgiveness? Surely if her plight were real, I argued, this was more to do with the mechanics of the spine and not some mystical force. Ruby advised I held a very Western and mechanistic interpretation of reality and some things were less tangible than others, especially to ignorant fools like me.

I asked what other practitioners, those she had consulted throughout her travels had said about her condition. Some had apparently mounted arguments similar to mine and one had even refused to treat her. These, she stated, were usually 'only new at the game' and did not have the experience to deal with her unusual circumstances. Others had willingly accepted her explanation and provided the service she required. Sometimes I became angry at her attitude and on more than one occasion accused her of manipulating the situation and not wanting to change things; her new life, pushing people around and being the centre of attention, was of her own making. To this she would argue I did not understand the human body, I was a disgrace as a chiropractor and my job was to provide adjustments and not make judgments. Her conviction she would not wish her circumstance on anybody, she did not wish to impose herself upon anyone and she would change things tomorrow if she could, seemed genuine.

From time to time I repeated my tests and observations, and found no change to her neurology and very little observable change to her muscle bulk. I presented plastic models of the spine to her, showed her images in text books and read her articles from journals but nothing I could do or say could change her mind. Ruby appeared to remain convinced of her disorder and of the necessity of ongoing care. With time, I simply stopped arguing and provided what she requested of me. Her helpers also appeared to continue their lives unquestioning in their acceptance of their role in maintaining her lifestyle. Although from time to time people would become upset by her persistent demands, Ruby seemed to have a knack for calming any rift and it would never take long before she had all of us jumping through hoops yet again.

After three years at the practice my wife and I made the difficult decision to leave the country and return to Melbourne and it was with considerable regret that we placed the practice on the market. It took little time to find a suitable purchaser (who also promised he would continue Ruby's care) and it was with great sadness that I visited her for the last time. We both shed a tear and wished each other well. I left Ruby's caravan wondering whether I had acted professionally and humanely. Should I have pushed her further to undertake other investigations, should I have brought in more professionals? Her mind was made up and with time, right or wrong, I had accepted her position. Over the next few months Ruby and I traded a letter or two but the communication soon waned and life went on.

The Power of Chiropractic

Rural Australia of the late 1970s and early 1980s saw a strong public utilisation of the services of untrained practitioners, ostensibly because the service provided was effective.⁴ Narratives used by practitioners to explain the efficacy of their therapies were by contemporary standards, however, somewhat unsophisticated and sometimes took on a quasi mystical tone. The power of chiropractic was a term used by some practitioners to explain their efficacy. The power accounted for how and why chiropractic was successful in both restoring health and preventing illness. Practitioners and patients alike believed its effects to be wide ranging in terms of the body regions which could be influenced by it, and the conditions for which it would provide benefit, if properly applied. Similarly, the effects of not utilising the power when required could be dire with various adverse consequences arising should treatment regimes not be adhered to.

The title of this essay was chosen because it reflects the significance the power of chiropractic held for Ruby. It is also deliberately ambiguous reflecting the temptation to nominate other locations or forms of power which might account for her situation. The clinical setting is a fertile locale for the analysis of power relations with—amongst other things—class, the law, science and reason variously nominated as mechanisms through which power is expressed, usually as a means by which practitioners exert control over their patients. Whilst not to deny the fecundity of these analytical frameworks, power, of course, does not have to be unidirectional in either its intent or impact. Power may circulate and change trajectory. It may be multidimensional and dynamic.

Ruby was not an unintelligent woman. Whilst from a humble background, she held sophisticated views across a wide range of subjects. But what explained her peculiar predicament? What was the power of chiropractic in this complex situation, and where did it reside? Was this a question of mental illness, a bizarre lifestyle choice or was Ruby the subject of some kind of indoctrination or brainwashing? Did she truly believe she was incapable of walking, was the whole matter a ploy to manipulate those around her, including me, and if so to what end? Why was she so sure about what the flea had to say? Why was I so unconvincing?⁵ Why did science not triumph over the mutterings of the ignorant? On the other hand could there have been something I did not fully understand and making her incapable of walking?

On face value it appeared that for Ruby, the power of chiropractic resided in its dichotomous ability to avenge and redeem. She had essentially lost the use of her legs by prematurely withdrawing from the initial phase of treatment, a punishment for ignoring the power that she saw as just. On the other hand, the power expressed its benevolence when she showed it due respect through faithfully seeking regular maintenance care.

Although Ruby's story is rich in its scope for further scrutiny, this is as far as my conscience allows my personal analysis to extend. It is out of respect for her I have not explored issues of patient autonomy and self determination, the ethical and moral responsibilities of the practitioner, belief systems and placebo: I have not attempted to unpack the various dimensions in which power may have been at play. This would require second guessing what was going on in Ruby's mind and at the end of the day, who am I to raise doubt by privileging an alternative explanation to the one she has provided? Rather than risk removing Ruby from centre stage, I have tried to present an encounter as I recall it: with warmth, some humour and fond memories of an extraordinary woman.

Royal Melbourne Institute of Technology

Notes

^1.� In spite of their lack of training, many fleas established, and to this day continue to conduct, successful practices.

^2.� Adjustments are a type of spinal manipulation designed to influence a narrow range of spinal segments. The term maintenance refers to spinal adjustments performed on a regular basis, often every month. The rationale is to 'maintain' an ongoing degree of flexibility in the spinal segments.

^3.� A subluxation is a misalignment of a spinal segment.

^4.� Over time I came to learn that far from being of placebo value only, the therapeutic techniques many fleas provided were extremely effective. I came to learn a lot from them.

^5.� I could never accept the theoretical constructs used by the fleas although with time I came to appreciate their appeal. Many patients want the most simple of explanations as to what ails them, if indeed they require an explanation at all. For many, details are not necessary. I was cognisant then, as I am now, that actions speak louder than words: what I said mattered less than what I did. As a young graduate I wanted to display my newfound knowledge to the world but in the end it did not matter. What mattered to patients was that they got better, not the elaborate particulars of why or how.

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