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Two years ago, a 47-year-old man consulted a chiropractor for severe leg pain of three days' duration. The chiropractor did not remove the patient's trousers, shoes, or socks. Instead, he examined only his back, diagnosed "lumbalgia," and manipulated the man's spine. Three days later, when the patient's pain persisted, he consulted a medical doctor who realized that the problem was a blocked artery that had been cutting down the circulation of blood to the leg. Had the problem been diagnosed earlier, surgery could have removed the block. By this time, however, amputation of the leg was necessary.
At first glance, this might appear to be an extreme or isolated case of malpractice. But my experience as a chiropractor and as an independent consultant in malpractice cases has convinced me it is not. The chiropractor was merely following what he had learned in school. Chiropractic is based on a false theory . Its practitioners are inadequately trained in diagnosis, and most do not know their limitations . Malpractice is an inevitable result of these circumstances.
Chiropractic was founded in 1895 by Daniel David Palmer, a grocer and "magnetic healer" who believed that almost aft diseases are the result of misplaced spinal bones. According to his theory, "subluxations" of spinal vertebrae cause disease by interfering with the flow of "nerve energy" from the brain to the body's tissue cells. Spinal "adjustments," by restoring vertebrae to their "proper places," allow brain energy to heal the diseased condition.
It should be obvious that anyone wishing to treat a disease would first have to accurately diagnose what needs treatment. But followers of D.D. Palmer's philosophy see things differently: Their obligation is merely to examine the spine, find the subluxations, and correct them. A "medical diagnosis" is unnecessary.
Not all chiropractors espouse this "straight" Palmer philosophy. The more modem chiropractors, known as "mixers," do talk about diagnosis. Antagonism exists between the two groups.
An interesting debate recently appeared in the student newspaper of the Palmer School of Chiropractic . Speaking from the mixer viewpoint was Louis Sportelli, D.C., past president of the Pennsylvania Chiropractic Society. He said:
Literature from "straight colleges" . . . and self deceiving newspaper columns professing the Chiropractic 'truth' has reached an all-time high. . . . Wouldn't it be wonderful if the cause of HEALTH and DISEASE were as simplistic as finding the ever elusive 'subluxation' and then correcting it.
Thomas A. Gelardi, D.C., president of the Sherman School of Straight Chiropractic, replied:
It is obvious that [Sportelli's editorial] was written by someone ignorant of chiropractic principles as expounded by D.D. Palmer . . . . Chiropractic will assume its rightful role in society when those who claim to be chiropractors stop wandering all over the medical therapeutic world and use their full potential in further developing the art and science of locating and correcting subluxations.
Sportelli then responded in a letter:
The vast majority [of chiropractors] are tired of this fanatical concept and definition of what chiropractic is and is not. . . . Then to add a note of tarnish to the silver tongued spokesmen for super 'straight' chiropractic is the question: Are the straights really straight, or do they gather at meetings and conventions to convince their friends that they practice only that which is pure and principled straight Chiropractic? Only to return to the sanctuary of their offices to utilize blood tests,nutrition, physiotherapy, vitamins, and yes, even diagnose. . . .They advertise cures for every condition in the materia medica, yet do not treat conditions. . . ."
As far as the obligation to diagnose is concerned, the courts clearly side with the mixers. A lengthy legal memorandum published in the journal of the American Chiropractic Association concluded: "The legal duty of the chiropractor, as with any other doctor, is to: first, diagnose the patient's problem; second, if the problem can be treated by spinal manipulation, then he may proceed; third, if he determines that the form of treatment required is outside the scope of his practice, then he must refer the patient to another doctor." 
Are chiropractors trained to accurately diagnose and refer? In my opinion, the answer is no. The "straight" schools are dominated by D. D. Palmer's philosophy and the "mixer" schools are certainly not free of it. Dr. Sportelli is probably correct that some straight practitioners are trying to diagnose, but it is also clear that most mixers believe that spinal problems are the basic cause of disease. To illustrate the scope of their work, almost all chiropractors use charts that supposedly show how nerves supply the body's vital organs.
Chiropractic students, past and present, have not been taught by skilled medical diagnosticians. They are legally barred from using many diagnostic tests that could be crucial to proper medical investigation. Nor are they able to study the care of patients in hospitals. Independent studies have concluded that chiropractic schools do not adequately prepare their students to function as primary physicians [5-7].
Since chiropractors are licensed as "doctors," most people who consult them expect to be "properly medically diagnosed." Patients also assume that if their problem is beyond the scope of chiropractic, they will be referred to an appropriate practitioner. Since these assumptions are usually incorrect, the more the patient relies on the chiropractor for diagnosis of his case, the more vulnerable he will be. Patients who use chiropractors as primary physicians, either because they don't know any better or because they have been turned off by orthodox medical care, run the greatest risk.
There are two main types of chiropractic malpractice: (1). failure to diagnose conditions that require timely medical attention, and (2) Damage from manipulation of body parts that have been weakened by disease or previous trauma. Here are some cases I recently reviewed:
A 58-year-old woman consulted a chiropractor for low back and left hip pain. The chiropractor performed a cursory physical exam and x-rayed only her lumbar spine. Diagnosing "lumbar nerve pressure syndrome," he manipulated her low back area with her left leg flexed. The patient's problem was actually a fractured hip. Manipulation disturbed the fracture and made normal healing impossible. As a result, the patient required surgical implantation of an artificial joint.
A 38-year-old man who consulted a chiropractor for low back pain was * x-rayed, examined briefly, and treated with spinal manipulation. Despite three months of treatment, his pain persisted and he consulted a second chiropractor who treated him in a similar fashion. When his pain persisted, he went to a medical doctor who ordered tests that led to a diagnosis of Hodgkin's disease. The patient's pain had been caused by swollen lymph glands. It disappeared with treatment of his underlying disease.
A 58-year-old man with back pain became paralyzed from the waist down after spinal manipulation by a chiropractor. Unknown to the chiropractor, the patient's spine had been weakened by metastatic bladder cancer. The chiropractor's evaluation did not include a medical history, an orthopedic evaluation, or a urinalysis. An x-ray film was taken but was of such poor quality that it was diagnostically useless.
A 50-year-old man required surgery for a prolapsed lumbar disc that was ruptured by chiropractic treatment. Careful orthopedic evaluation would have indicated that what the patient needed at the time of his chiropractic visit was not manipulation but bed rest and traction.
A 63-year-old woman who relied on a chiropractor to treat her for neck pain, headaches, nausea, and dizziness died as a result of a brain hemorrhage. Unsuspected by the chiropractor, her symptoms were caused by high blood pressure in urgent need of medical management.
A 55-year-old man who consulted a chiropractor for pain in his midback, chest, and left shoulder was told that his pain was "nerve pressure" from a spinal subluxation. His problem was actually a heart attack requiring immediate hospitalization.
This last case is of particular significance because few conditions are less appropriate for chiropractic care than an acute heart attack!
A Pennsylvania chiropractor is now facing prosecution for advertising that "intense, fearful constricting chest pain" is a reason to see a chiropractor. Other ads figuring in the case claim that blurred vision is a reason to see a chiropractor and that " pinched nerves" can cause abnormal blood pressure, hay fever, sinus trouble, arthritis, pleurisy, glandular trouble, goiter, bronchitis, colds as well as stomach, liver, kidney, and gallbladder problems.
At the preliminary hearing, a medical cardiologist testified that severe chest pain could represent a heart attack requiring emergency care and that delay in getting such care could be fatal. Seven chiropractors testified in support of the advertising claims. Here is the testimony of one of them:
At a subsequent hearing, the chairman of the Pennsylvania State Board of Chiropractic Examiners and faculty members from three of the nation's 13 chiropractic colleges endorsed the ads as accurate and representative of what is taught in chiropractic schools .
Although chiropractors enjoy undeserved status as primary care providers, they have become politically powerful. For this reason, it is unrealistic to expect state legislators to curtail their abuses or restrict their practices. Nor is it likely that chiropractic can build a safe and rational health care system on a foundation that is delusional. Malpractice litigation therefore may be the most effective way to alert the public to chiropractic's dangers.
Peter J. Modde, D.C., practiced chiropractic near Seattle, Washington, for about 20 years. A 1964 graduate of Palmer College, he became president of his county chiropractic society and chairman of his state society's public relations committee. Somewhere along the line, however, he concluded that chiropractic theory was a delusional system and that chiropractors were not adequately trained in diagnosis. He began limiting his practice to physical therapy of patients that had been evaluated by medical doctors. He also persuaded medical doctors in Seattle to offer a special 300-hour course in diagnosis. When his fellow chiropractors rejected this idea, he became thoroughly disillusioned, began publicizing his views, and offered expert testimony in malpractice cases. Prior to that time, suing a chiropractor was very difficult because it was almost impossible to find a chiropractor willing to testify against a colleague. Modde not only stepped on chiropractic toes by denouncing subluxation theory as a delusion, he also accused his colleagues of incompetence and threatened their financial well-being. For this, he was expelled from his state and national associations, his malpractice insurance was canceled, and an unsuccessful attempt was made to revoke his license. He continued his reformist activities for about ten years but finally switched careers into real estate. His book, Chiropractic Malpractice, describes his experiences with more than a hundred cases. This article appears to be the first one by a chiropractor published by a mainstream medical journal. Although the quality of chiropractic care has improved considerably since this article was published, chiropractic philosophy remains a millstone around the profession's neck.
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