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Spinal manipulation is dangerous?
In addition to the dangers of chiropractic x-ray, chiropractic treatment itself can pose direct threats to health and life. A small but inexorable number of people are directly killed by chiropractic adjustments. Another, and larger, group is either directly injured by adjustments, or is suffering from a condition that is aggravated and harmed by chiropractic treatment.
In connection with the Jerry R. England case in Louisiana, a number of medical specialists provided affidavits regarding the relationship of chiropractic to their various specialties, which included pathology, bacteriology, physiology, anatomy, neurology, surgery, radiology, orthopedic surgery, physical medicine, and internal medicine. Several of these affidavits discussed the dangers of chiropractic treatment. The experts noted that manipulation does occasionally find a place among the methods of therapy used in scientific medical treatment. "In the area of physical medicine," said Dr. Solomon D. Winokur, a diplomate of the American Academy of Physical Medicine and a specialist in physical medicine and rehabilitation, "manipulation is an integral part of the treatment of conditions arising from the vertebral structures, producing pain within the areas of the vertebral structures at a distant point, either by nerve root irritation or producing restriction of motion within the vertebral structures themselves."
First of all, however, "successful and safe manipulation is possible only where a complete and accurate diagnosis is made. The knowledge and skill for such a diagnosis can come only from extensive training in a well-accredited medical school."
Second, "the conditions [for which manipulation would be the correct treatment] are a very small proportion of all the things a doctor might see ... manipulation of the vertebral column has a very limited place in the overall treatment of disability and disease that occur in human beings."
Third, "manipulation of the vertebral column is potentially dangerous and harmful." Dr. Winokur illustrated the point in detail:
In patients who have a malignant disease of the structure, not only can fractures be produced by manipulation, but dislocation in conjunction with this sufficient to cause paraplegic or quadriplegic, depending on what section of the lower back is manipulated. Similar dislocations are also possible from forceful manipulation for the diseases such as prostatitis, appendix, gall bladder, etc., which also produce pain in the back.
Readers will recall that all three of these diseases are among those mentioned in chiropractic literature as conditions that chiropractors can and do treat.
Manipulation of the neck is particularly dangerous. At the neck region the spinal cord may actually be severed or sufficiently compressed so that the patient becomes completely disabled below the area of the pressure. In addition to these severe effects of manipulation of the neck, the other aftereffects I personally see are that the surrounding structures are so traumatized that the residual pain is far more severe than the original pain for which they were manipulated.
As I read this I remembered the sharp manipulations of my neck and head that had been given to me at the Palmer College and National College clinics, and I counted my blessings. In view of the symptomology I presented, and the treatment I received, at Palmer, I was interested in Dr. Winokur's comments on disc troubles and low-back adjustments. "It is equally possible to create permanent disability in the low-back area with manipulation," he states. "Manipulation of a slipped disc in the low-back region where the diagnosis has been missed and proper precautions not taken can produce enough compression of the spinal cord to render the patient a paraplegic. The most common type of disc problem, a fragment of the disc protruding posteriorly or laterally enough to cause nerve compression, simply is not amenable to manipulation. They just will not go back in; because if they were going back in, they would have gone in of their own accord."
Additional Points were added by Dr. Irvin Cahen, professor and head of the orthopedic department of Louisiana State University Medical School. Instead of moving body structures by manipulation, Dr. Cahen said,
we would prefer the patient to move the affected joint . . . considerable caution must be maintained in this passive approach [of manipulation by the doctor instead of movement by the patient]. . . . Because of this, our specialty, while accepting manipulation as a technique, places considerable limitations upon its usage. . . . I hesitate to use manipulations of the vertebral spine unless I'm certain that such manipulation can basically be performed by the patient's individual muscular reactions. A patient who takes calisthenics will gradually mobilize his spine within his ability, as contrasted to an excessive force that could be applied by the manipulator.
Related problems were emphasized by Dr. Philip H. Jones, emeritus professor of clinical medicine at Louisiana State University and editor of the Journal of the Louisiana State Medical Society. "The chiropractor is potentially dangerous," said Dr. Jones, "because the force is applied in such a way as to give the patient insufficient time to muster his own defensive vascular physical mechanisms."
Actual maladies created by chiropractic adjustments were discussed by Dr. Richard M. Paddison, professor of neurology at Louisiana State University School of Medicine and chief of the Electroencephalographic Laboratory, Southern Baptist Hospital in New Orleans:
Chiropractic manipulation is not without its hazards. There are well-documented medical cases of serious disorder to the cervical spine, cervical disc, cerebellum, spinal cord or to the cerebral arteries which ascend through the foramina in the cervical vertebrae, all of which are therefore subject to be bruised and injured with forceful manipulation. There are also well-documented cases of occlusion of cerebral vessels and injury to the brain stem which involves a key area for regulation of the head and neck and an area through which all important outgoing stimuli from the nervous System or incoming sensory data are fed. Such thrombotic lesions are productive of grave and permanent neurological defects, either by infection of the brain stem or stricture by injury to the arteries which supply these vital regions.
Dr. Paddison's statements are fully supported by case histories in medical journals and by court records. The March, 1963, issue of the Wisconsin Medical Journal carried a case report by Robert A. Pribek, M.D., of serious brain damage to a man whose neck had been adjusted by a chiropractor. The bibliography following his article cited ten other cases of injuries following bead and neck manipulation that had been reported in medical journals between 1947 and 1963. Four of these injuries had been fatal.
Without conducting any search for such cases, but simply in the process of doing research for other chapters of this book, I came across three more. One was a California decision involving a death, reported in the Journal of the American Medical Association in 1940; the second was a serious spinal injury reported in the January, 1943, issue of the Kentucky Medical Journal; the third was a 1953 court action involving a death. It seems likely that a search of hospital records and court records throughout the land would produce others.
The California case involved a six-year-old boy. The mother's testimony in the court action is summarized in the following three paragraphs.
She said he told her that it bad been painful for him to stand fully erect since another child had bumped him in school. Soon he added another complaint-his legs were feeling weak. His parents took him to a chiropractor, who x-rayed the child and stated that the trouble stemmed from a subluxated vertebra. He put the youngster on a regimen of chiropractic adjustments, one every three days.
After four or five adjustments the boy developed a temperature of about 100 degrees. He lost weight, vitality, and color, complained of pain during the adjustments, and began to experience paralysis in his legs and arms.
The mother discussed her son's condition with the chiropractor. He assured her that it was not necessary to bring a medical doctor in on the case, because "the only thing the boy had was a certain pressure on the spinal cord, on account of the misplaced vertebra, and he was
doing the best thing, and nothing more could be done for the child." He kept up the adjustments for four months, at the end of which time the child died.
In the court action the chiropractor stated that he had found in the boy's spine a "subluxation of the second cervical vertebra, impinging the nerves, and causing a congestion in the cord," as well as a "rotation of the second, third and fourth cervical." He testified in part as follows:
Q: Did you make any diagnosis of his condition at that time?
A: In chiropractic, we don't use the term "diagnosis.' I take it that you want to know if I placed a name on his condition?
Q: Yes. I want to know if you came to a conclusion?
A: Yes, I came to a conclusion, but in chiropractic we term it "analysis" instead of "diagnosis." . . . My analysis was that he had a subluxation of the second cervical vertebra, causing an impingement of the nerves at that point.
Q: Well, was that an impingement of the nerves or of the cord?
A: Well, it might have been from both. It was apparent from his condition that there was inflammation of the cord. The inflammation might have been from pressure on the spinal nerves, or upon the cord itself.
Q: So, it was your finding and your conclusion that at all times, from the time of your first treatment to the last, there was some inflammation and congestion of the spinal cord at the region of the cervical vertebrae?
A doctor associated with the county coroner's office testified that the autopsy he performed on the boy's body "showed the body thin, the lungs congested, the left lung being pneumonic, and both lungs studded with small tubercles.... There was no evidence of spinal or other injury.... I had been informed that there was some spinal condition existing, and I therefore examined the spine to see if I could find any abnormality, which I did not find."
This doctor and another called to testify stated that the child was apparently suffering from meningitis, and the second doctor added that the condition probably included secondary tuberculosis of the spine. Asked what effect chiropractic adjustment of the second cervical vertebra would have in such a case, the doctor who performed the autopsy replied, "It would be detrimental, as rest and quiet would be absolutely indicated in those cases." Adjustments, he stated, would accelerate or increase the existing inflammation.
Both doctors agreed that chiropractic treatment in such a case not only harmed the child by keeping him away from proper treatment, but was in itself contraindicated. If the child had had correct medical attention, they said, his chances of recovery would have been good. The jury found the chiropractor guilty of malpractice, and awarded the mother $10,000.
This case compares interestingly with the Marvin Phillips case (See Prologue). A generation later, Los Angeles County Deputy John Miner, confronted with a situation that has many elements in common with this one, brought not a malpractice action but a charge of second-degree murder. The case above strongly emphasizes Miner's contention that, until the Phillips case, the penalties for utter irresponsibility toward human life in the field of health have been grotesquely trivial.
In the Kentucky case a woman was admitted to a hospital the day after she had had a chiropractic adjustment of her lower spine. Following the adjustment, a swelling developed over her buttocks and she suffered loss of control of her bowels. An operation was performed under the direction of a neurosurgeon, and it was found that the fifth lumbar disc was almost completely ruptured.
In the 1953 Missouri case, a Missouri housewife had been suffering from a stiff neck, eye trouble, and occasional headaches. She went to the family doctor who gave her a full examination. The stiff neck, he said, was due to a muscular strain and the headaches were caused by her need for eyeglasses. Apparently dubious, she went to a chiropractor with her husband. The latter's testimony at the trial was as follows:
The chiropractor told her that she had some misplaced vertebrae. Placing her face-down on his chiropractic table, he began to adjust her spine, moving up toward her neck. Then, asking her to step off the table, he changed it to a vertical position, and told her to stand in front of the table, facing it. He took her head in his hands and moved it sharply, first in one direction and then in the other. Each time something popped, and the woman screamed. "I'm falling," she said several times, but the chiropractor continued to manipulate her neck.
After the adjustment the chiropractor and the woman's husband helped her to a chair. She was unable to hold her head up, her hands and face were numb and she began to vomit. She said that she felt no pain but she appeared to be in convulsions. She was helped to a cot where she continued to vomit and seemed to be without control Of her movements. At this point the chiropractor called a medical doctor. The doctor recommended that the woman be taken to a hospital, which was done; but she did not respond to treatment and died about eighteen hours later.
An autopsy revealed no condition that could have caused her death other than the injury inflicted by the chiropractic adjustment. The injury was one to the spinal meninges resulting in intraspinal bleeding and compression of the spinal cord.
The examination failed to show any displacement of any vertebrae. Perhaps the most chilling aspect of the case was the testimony of two chiropractors who were called as expert witnesses by the defense. Both testified that the defendant had done nothing in his treatment of the woman that was not in accordance with the accepted practice of chiropractors generally in that community.
Head and neck adjustments probably pose the greatest physical dangers to patients. All eleven cases covered in Dr. Robert A. Pribek's Wisconsin Medical Journal article and its bibliography involved this type of manipulation. One of the references in the bibliography is to an article by Doctors Roger A. Smith and Montgomery N. Estridge, reporting two cases in the November 3, 1962, issue of the Journal of the American Medical Association. They state that head manipulation "can be fraught with real dangers and even result in death. Serious damage to the underlying nervous system can be inflicted by less than vigorous adjustments of the head."
One of their two cases was that of a thirty-three-year-old woman who developed stiffness and pain in her neck. She sought out a chiropractor and was given an adjustment of the head without ill effect. About a week later, however, when she was given a second adjustment of the head and neck, she suddenly developed nausea, vomiting, and vertigo, and lost coordination in her arms and legs. She was hospitalized the same day. A physician visited her and noted that she was somewhat drowsy, although she could be easily aroused. The original symptoms, however, persisted. Her drowsiness increased, her blood pressure rose, and within about eight hours she went into a coma and her breathing stopped. She was put in an artificial respirator and rushed to surgery. The operation revealed rupture and herniation of the cerebellar cortex. After the operation her condition remained unchanged, and three days later she died.
To physicians and surgeons, the wonder of the matter is not that there are so many such injuries reported but that there are so few. In an article in the May 30, 1959, issue of the Journal of the American Medical Association that reports two cases, Robert J. Joynt, M.D., and David Green, M.B., of the State University of Iowa Department of Neurology, speculate that only persons with large vascular arteries leading to the brain are notably susceptible to such accidents. This explanation, they said, seems most likely to account for "the rarity of brain-stem vascular accidents after manipulations in a population which is overly exposed to such treatment."
The theme is picked up by Doctors Smith and Estridge in their 1962 article. "The ideal treatment in these cases is prophylactic [preventive]," they state. "Can there be some practical method of determining which patients are susceptible to vascular embarrassment to the brain stem following head manipulation?" For persons receiving chiropractic treatment it could be a life-saving question, but I found no interest in the matter registered in any of the large volume of chiropractic literature I read in the course of writing this book.
A number of medical doctors have told me alarming stories about patients they have treated who were first treated by chiropractors. Typical is the case encountered by a doctor who described it to me with the patient's record folder open in front of him.
In April, 1965, he was visited by a lady who was accompanied by her grown daughter. The lady stated that she had been suffering for about three months from a pain in her lower back going down into her left hip and leg. She visited a chiropractor who had a ground-floor office in a building on the same block as the office of the doctor, less than a hundred yards away.
The chiropractor X-rayed her, told her she had some subluxations, and started her on a series of adjustments. The lady found, however, that her condition did not improve, and she decided to seek a medical doctor's opinion.
The symptoms, the doctor said in describing the case to me, "were highly suggestive of an orthopedic problem in the lower back."
With the lady and her daughter sitting there, my doctor called the chiropractor on the phone and asked if be might have the X-rays that the chiropractor had made.
"I can't do it now," the chiropractor replied, "I'm about to go out."
"I'm just down the block from you," the doctor replied. "The lady's daughter is sitting here. She'll run right over and pick them up from you."
"I have no time for that," the chiropractor said.
The lady's daughter nevertheless jumped up and ran down the lock to the chiropractor's office, arriving there within moments after the phone conversation. She pounded on the chiropractor's door and rang the bell. There was no reply. It was a ground-floor office; the young lady looked in the window and saw that the chiropractor was there. But he would not let her in; and he never provided the X-rays.
The doctor sent the patient to an orthopedic specialist. He X-rayed the woman and found that her fifth lumbar vertebra was fractured and the intervening disc space had been narrowed. The treatment she received was the exact opposite of that given by the chiropractor; instead of being vigorously manipulated, her back was immobilized and she underwent a period of bed rest.
The woman had tripped on the steps of her church just before the pain began, and had had no accidents between then and the time she was X-rayed by the orthopedist. There are really only two major possibilities. Either the woman's back was already fractured and her disc compressed when she went to the chiropractor, and he failed to comprehend his X-rays; or she had a lesser condition when she went to him, and he damaged her back. [At Palmer College Clinic I presented the same syndrome of symptomatology. In neither instance did the chiropractors show any sign of recognizing its possible meaning, either in my case where the condition did not exist, or in the woman's case where some kind of condition did exist.]
Perhaps most tragic of all is the injury and death that chiropractors can inflict on their own children by delaying proper medical treatment. "I have been able to obtain and review the chart of a chiropractor's child who died at Charity Hospital in New Orleans," say Dr. Richard M, Paddison. In his affidavit made for use in the England case, Dr. Paddison said, "This child [was] presented at one of the private hospitals in town; the parents were told it bad meningitis. The father preferred to take it home to treat it. The child was returned to the private hospital [some time later] in relative extremis. A spinal puncture was then performed under the father's protest and it was found that this child was suffering from Haemophilus influenzae meningitis. In spite of the prompt institution of vigorous and intensive antibiotic therapy, the child died."
Of course, people also die under medical care. The issue is whether there is a responsible application of scientific medical knowledge. On the question of the validity of chiropractic, let us first hear from chiropractors and chiropractic groups in Chapter Ten, and then turn to the views of medical researchers and scientists in Chapter Eleven.
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