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Chiropractic in the United States:
Training, Practice, and Research

Chapter I: A Brief History of Chiropractic
Reed B. Phillips, DC, PhD

**Comments in red by Stephen Barrett, M.D.

Rarely is the birth of a new idea or a new organization the consequence of a singular event. However, the genesis of a new profession, chiropractic, is attributed to the date of 18 September 1895 and the place, Davenport, Iowa. Daniel David Palmer placed his hands upon an irregular protrusion of the spine of Harvey Lillard and with a forceful thrust reduced the irregularity. As a result, Mr. Lillard claimed to hear the wagons on the street, something he could not do prior to receiving the treatment (Palmer, 1910).

**So the story goes. The fact that the nerves that enable hearing are confined to the skull does not seem to discourage chiropractors from telling this story.

At the turn of the 19th century in rural America, health care was a craft more than an art. The integration of science into treatment methods and the training process was severely lacking as evidenced by the condemnation of medical colleges in the famed Flexner Report (Flexner, 1910). The consolidation of cultural authority (Starr, 1982) by the allopathic physicians had not yet been achieved and there were numerous competing practitioners such as magnetic healers, herbal healers, hydro healers, bone setters, and homeopaths. The growth of health care alternatives paralleled revivalism in religious practices and was thought to provide the physiological counterpart to the theological perfectionism of the time (Fuller, 1989). This crucible of confusion, filled with vitalism and magnetism, leeches and lances and tincture and plaster, provided a seed bed for creative thinking and new ideas. D.D. Palmer and chiropractic were, to a certain degree, a product of their environment.

**In other words, don't hold Palmer's far-fetched ideas against him (or chiropractic), because they were largely products of the times and medical training was not much better. Actually, the better medical schools were vastly better than the early chiropractic schools.

In early 20th-century America, allopathic providers obtained greater cultural authority and the respect of those who influenced decisionmaking. Opposition to unorthodox practitioners increased. The allopathic physician charged the doctor of chiropractic with practicing medicine without a license. The doctor of chiropractic retorted that practicing chiropractic and practicing medicine were different. To emphasize this difference, the chiropractic community developed a different lexicon and rationale for its approach (Keating, 1989). Medicine's search for a disease process, assigning appropriate labels, and providing the remedy of the day were different from chiropractic's search for an interference in the nervous system that was stated to ultimately, if not immediately, lead to dysfunction and disease. The doctor of chiropractic rejected the use of medicines and drugs and never incorporated the practice of surgery. Chiropractic was conceived as a more natural approach to healing, drawing upon the body's own recuperative powers.

**In most cases, "drawing on the body's recuperative powers" was all that chiropractors could do, because "interference in the nervous system" does not "ultimately, if not immediately lead to disease," and spinal "adjustments" have no demonstrable effect against the vast majority of human ailments. Nor do they have any proven effect on general health, resistance to disease, or the body's general recuperative ability. For most ailments, chiropractic treatment was the equivalent of doing nothing.

Although adversity characterized much of organized medicine's relationship with chiropractic, this polarity was more frequently related to economic, political, and legal considerations than to clinical ones.

**Palmer taught that spinal misalignments were the primary cause of disease. Even in the early days of chiropractic, the medical profession knew this idea was unfounded. The idea that medical opposition to chiropractic was economically based is absurd.

In fact, D.D. Palmer credits a medical physician, Jim Atkinson, with teaching him about the use of bone setting in other cultures (Palmer, 1910, p. 789). G.H. Patchin, MD, has been credited with helping Palmer edit his book, The Chiropractic Adjuster, and one-third of the first graduating class of chiropractors were medical physicians (Palmer, 1910; Gibbons, 1981).

Following the Flexner Report (1910), medical education consolidated and strengthened its position in society and both medical education and research have received external financial support through grants from the Federal government and private foundations. Federal funds initially supported medical care for veterans and, eventually, for the elderly and disabled. By contrast, chiropractic education remained a tuition-driven, inadequately financed enterprise that received no external support for research. In an attempt to eliminate chiropractic, organized medicine promoted licensing regulations, believing that the inferior education of chiropractic schools would prevent their graduates from passing State Board Licensing Exams (Gevitz, 1988; Wardwell, 1992). This is discussed in more detail in Chapter V. The introduction of Basic Science Boards by the medical profession in 1925 created an additional obstacle to the graduate doctor of chiropractic due to the lack of basic science training in the chiropractic curriculum.

In response, chiropractic schools upgraded their educational process by expanding the curriculum and employing Ph.D.-level instructors to teach the basic sciences. As a result, chiropractors started to pass the Basic Science Boards.

**Statsitics reported by historian J. Stuart Moore indicate that between 1927 and 1953, about 86% of about 47,000 medical students passes the basic science exams, while only 23% of about 2,500 chiropractors succeeded [Moore JS, Chiropractic in America. Baltimore: Johns Hopkins University Press, 1993].

**In the mid-1960s, the AMA Department of Investigation released a study of the educational background of faculty members listed in the catalogs of 13 "approved" chiropractic schools. Only 126 (47%) of 267 were listed with recognized academic degrees, and 23 of these were not confirmed by the institutions alleged to have granted them. Only two individuals had confirmable PhD degrees, one in anthropology and and the other in chemistry. And many who taught basic science courses had no degree whatsoever in the subjects they taught [AMA Dept. of Investigation. Educational Background of Chiropractic School Faculties. JAMA 197(12):169-175, 1966]. This situation did not improve substantially until the Council on Chiropractic Education implemented new standards.

Further efforts to improve the quality of the educational process eventually led to the creation of chiropractic's own national accreditation agency, the Council on Chiropractic Education (CCE), which achieved Federal recognition from the Department of Education in 1974. This agency implemented educational standards for the curriculum and the admission processes. Those schools failing to meet the CCE standards closed their doors. By 1995, all chiropractic colleges achieved accreditation by the CCE. Much like the Flexner Report's impact on medical colleges, the CCE elevated the educational standards of many chiropractic schools.

**The process of improvement took place about 60 years earlier in medical schools than in chiropractic schools, and the quality of education in chiropractic schools still leaves much to be desired.

Until fairly recently, chiropractic had been attacked by allopathic medicine as an unscientific cult with no research to support its claims of efficacy (Keating, 1993; Wardwell, 1992) (see Chapter VII).

**The "cult" label was appropriately applied when the majority of chiropractors openly espoused spinal problems as the primary cause of health problems. Most did so until at least the early 1970s.

Research was neglected in the early years of the profession. Without funding for research and facilities in the tuition-driven, for-profit educational institutions, the limited resources of the early colleges were focused on teaching skills needed for success in practice rather than on developing the knowledge base of the profession.

**Lack of funds was not the main reason for lack of research. The main reason was that the vast majority of chiropractors were not research-minded and already "knew" that "chiropractic works."

Gradually, pockets of hope emerged: Watkins, Weiant, Higley, Illi, and Janse, among others, sought answers for unexplained treatment outcomes and recognized that a research base could be used to refute the claims of adversaries. The evolutionary development of the Foundation for Chiropractic Education and Research (FCER) has helped to foster a research mentality (see Chapter IX). Beyond sponsoring research studies, FCER embarked in 1977 on a program to support the training and development of the chiropractic researcher. There is now a growing cadre of critical thinkers within the profession and an expanding number of research-oriented individuals outside the profession who are studying chiropractic. By 1996, Federal research grants had been awarded to four chiropractic colleges.

**Unfortunately, research by chiropractors has produced very little of value.

In recent years there has also been much greater collaboration between chiropractors and the greater scientific and clinical communities in training, research, and practice (Mootz, 1995). Multidisciplinary practice is more common as are editorial and technical collaborations, joint research initiatives, and medical physician support of chiropractors in litigation (Mootz, 1995).

**I'm not sure whether the collaboration should be described as "much greater." The cited reference gives a few examples but no raw numbers.

With the profession's increasing involvement in critical investigation and professional improvement, the label of chiropractic as an unscientific cult has difficulty sticking.

**I haven't seen the phrase used since the mid-1970s. Chiropractic quackery is still rampant, but attempting to tar the profession with a single brush is no longer appropriate.

Research has demonstrated that manipulation, a primary mode of care for the doctor of chiropractic, is effective in the treatment of acute low back pain (Shekelle, 1992). The inclusion of manipulation as a recommended treatment in the Federal guidelines for the treatment of acute low back pain is the result of the findings of researchers both within and outside of chiropractic (Bigos, 1994).

**Most of the research was not done by chiropractors, and the findings do not necessarily correspond with what the average person will encounter in a randomly chosen chiropractic office.

As research evaluates the value of chiropractic for other clinical problems, the capabilities and limitations of chiropractic care will become more apparent, appropriate interdisciplinary relationships will be established and patient care will be improved.

**If such a process takes place, it will do so very gradually. As far as I can tell, chiropractic research has very little influence on chiropractic practice. For example, as far as I can tell, studies showing that various chiropractic diagnostic tests don't work have not stopped any of them from continuing to do them.

It has taken 100 years of self-directed, bootstrap efforts utilizing internal funds to bring chiropractic into the mainstream of health care.

**I am not sure what criteria Dr. Phillips uses to conclude that chiropractors are part of mainstream health care. Most of their marketing gains have been achieved through political means (legislation and lawsuits) rather than scientific development. I believe that the average physician still has a low general opinion of chiropractors.

As a mainstream provider, the issues of role and scope of practice are now receiving serious attention. Is chiropractic an alternative to medicine? Is there a complementary role that includes collaborative care? Should chiropractic remain a separate and distinct profession or seek inclusion into medicine as a subspecialty in musculoskeletal conditions? Should chiropractic education seek affiliation with major universities housing medical education? Answers to these questions will have a significant effect on the future of chiropractic education and practice.

References

Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, US Dept of Health and Human Services, December 1994.

Flexner A. Medical Education in the United States and Canada. New York, NY: Carnegie Foundation for the Advancement of Teaching, 1910.

Fuller RC. Alternative Medicine in American Religious Life. New York, NY: Oxford University Press, 1989.

Gevitz N. A coarse sieve: basic science boards and medical licensure in the United States. J Hist Med & Allied Sci 1988;43:36-63.

Gibbons RW. Physician-chiropractors: medical presence in the evolution of chiropractic. Bull Hist Med 1981 ;55(2):233-45.

Keating IC, Mootz RD. The influence of political medicine on chiropractic dogma: implications for scientific development. J Manipulative Physiol Ther 1989;12(5):393-8.

Keating JC, Rehm WS. The origins and early history of the National Chiropractic Association. J Can Chiropr Assoc 1993;37(1): 27-51.

Mootz RD, Haldeman S. The evolving role of chiropractic within mainstream health care. Top Clin Chiropr 1995;2(2):11-21.

Palmer DD. The Chiropractor's Adjuster: A Textbook of the Science, Art and Philosophy of Chiropractic for Students and Practitioners. Portland, OR: Portland Printing House, 1910.

Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Brook RH. Spinal manipulation for low-back pain. Ann Intern Med 1992; 117(7):590-8.

Starr P. The Social Transformation of American Medicine. New York, NY: Basic Books Inc., 1982.

Wardwell WI. Chiropractic: History and Evolution of a New Profession. St. Louis, MO: Mosby Year Book, 1992, Chapters 6 and 8.

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