Independent Practitioners under Medicare (1968)

CHAPTER III:
REPORTS ON PROFESSIONS STUDIED
CHIROPRACTIC

Present Medicare Coverage

Although chiropractic services are not excluded by name from Medicare coverage, in effect. they are not covered. The definition of a physician under Medicare does not include doctors of chiropractic, thus excluding all services of chiropractors in independent practice. Moreover.. because Medicare-approved hospitals and other providers normally do not provide chiropractic services, it is unlikely that chiropractors would be employed by any approved provider. Hence, services of chiropractors are excluded from coverage as "other therapeutic services," which are reimbursable to providers.

Requested Change in Coverage

The International Chiropractors Association recommendations concerning Medicare are: "(1) chiropractic inclusion in Medicare; (2) strict confinement of chiropractic care to spinal analysis and adjustment in the restoration and maintenance of health." [1]

The American Chiropractic Association asks for coverage of services of a chiropractor "with respect to functions which he is legally authorized to perform as such by the State in which he performs them." [2] (See Association Statements, Appendix B.)

Professional Associations

A slight schism in the chiropractic community is expressed by the two professional associations representing chiropractors. Members of one group of chiropractors, represented by the International Chiropractors Association (ICA), are called "straights," because their approach is more restrictive, usually limiting diagnostic effort to "determination of structural disrelationships of the spinal column" (the chiropractic or spinal analysis) and the method of treatment to spinal adjustment [1:17]. There also is evidence that this group feels chiropractic has a broader application to the diagnosis and treatment of disease than members of the other association [3].

The ICA, with 4,057 members, is dominated by Palmer College, founded by D. D. Palmer in 1895, in Davenport, Iowa. Its definition of chiropractic is:

that science and art which utilizes the inherent recuperative powers of the body, and deals with the relationship between the nervous system and the spinal column, including its immediate articulations, and the role of this relationship in the restoration and maintenance of health [1:20].

Members of the other group of chiropractors, represented by the American Chiropractic Association (ACA), are called "mixers" and have departed from the original Palmer approach by including dietary and nutritional supplementation and physiotherapy in treatment methods, in addition to the chiropractic adjustment [2(II):19]. Although spinal analysis is the central interest of this group, there also appears to be more emphasis on evaluation of parameters other than the relationship between the nervous system and the spine [2(II):14]. The ACA has 7,327 members. This group defines chiropractic as:

a study of problems of health and disease from a structural point of view with special consideration given to spinal mechanics and neurological relationships [2(II):1].

Utilization of Chiropractic Services

The extent and variation in use of chiropractic services, by selected patient characteristics, are shown in two ways in Table 1. First, the extent of use is shown as a simple percentage of persons in each population group who consulted chiropractors and of those who saw any type of physician (including chiropractors). Second, to show the frequency of the patient's choice of a chiropractor (as opposed to doctors of medicine or osteopathy) as the source of primary health care, the table shows the ratio of the number of patients who saw all types of physicians to the number who saw a chiropractor. Thus, the higher the ratio, the lower the frequency of use of chiropractic services by the group.

TABLE 1
TABLE 1

Extent of Use of Chiropractors and of All Physicians, by Selected Population Characteristics: July 1965—June 1966.

Classification

Percent Seeing
Any Physician

Percent Seeing
Chiropractor

Ratio, Any Physician
to Chiropractor
Total

66.1

2.3

29/1
White

67.4

2.6

26/1
Nonwhite

56.2

0.3

187/1
Rural

63.4

3.0

21/1
Urban

67.6

1.9

36/1
Age 65 and over

68.8

2.9

24/1
Age 25-64

64.2

3.7

17/1
Under Age 25

67.4

0.8

84/1
Head of household
  with some college

75.8

1.9

40/1
Head of household with   high school or less

63.8

2.4

27/1
Male

62.7

2.4

26/1
Female

69.3

2.2

32/1

Source: For physician data: National Health Survey, Series 10, No. 19.
             For chiropractic data: National Health Survey, Series 10, No. 28.

The most definitive conclusion from Table 1 is that chiropractic services are provided predominantly to white people. In the nonwhite population, only one out of 187 patients seeing any doctor saw a chiropractor; in the white population, one out of every 26 patients saw a chiropractor. Only 0.3 percent of the nonwhite population consulted chiropractors, compared with 2.6 percent of the whites, but 1.2 times as many white as nonwhite persons saw any type of physician [4] .In interpreting this information, it would be useful to know the number of white as opposed to nonwhite chiropractors, but this information is not available.

The table also shows the following associations between patient characteristics and use of chiropractors:

  1. A higher percentage of the urban population saw all types of physicians than of the rural, but rural patients consulted chiropractors more often than urban [4].
  2. By age group, patients age 25 through 64 most frequently consulted chiropractors, with the over-65 age group ranking second. Use of chiropractors for the under-25 age group was relatively infrequent [4].
  3. In families in which the bead of the household had some college education, a considerably higher percentage saw some type of physician in the study period -75.8 percent-but only one out of 40 consulted a chiropractor. In families in which the head of the household had a high school education or less, only 63.8 percent saw any physician, but one out of 27 patients consulted chiropractors [4].
  4. A somewhat lower percentage of males than of females saw all types of physicians-62.7 percent compared with 69.3 percent —but males were a little more likely to see chiropractors than females [4].

To summarize, patients' use of chiropractors was as follows: white patients much more often than nonwhite; the age group 25 through 65 more frequently than the 65 and over age group; the lower education group considerably more frequently than the higher education group; the rural population more than the urban; and males slightly more frequently than females. Data on income groups were inadequate to determine relative frequency of use [4].

Concept and Philosophy

In 1895, Daniel David Palmer, a tradesman, founded the system of healing called chiropractic. In his currently used textbook, The Science, Art and Philosophy of Chiropractic (1910, republished 1966), D.D. Palmer gives the following account of the discovery of chiropractic:

I was a magnetic healer for nine years previous to discovering the principles which comprise the method known as chiropractic. . . . I had discovered that many diseases were associated with derangements of the stomach, kidneys and other organs. . . . One question was always uppermost in my mind in my search for the cause of disease. I desired to know why one person was ailing and his associate, eating at the same table, working in the same shop, at the same bench, was not. WHY? . . . This question had worried thousands for centuries and was answered in September 1895.

Harvey Lillard . . . had been so deaf for 17 years that he could not hear the racket of the wagon on the street

I made inquiry as to the cause of his deafness and was informed that when he was exerting himself in a cramped, stooping position, he felt something give way in his back and immediately became deaf. An examination showed a vertebra racked from its normal position. I reasoned that if that vertebra was replaced, the man's hearing should be restored. . . . I racked it into position by using the spinous process as a lever and soon the man could hear as before. . . .

I am the originator, the Fountain Head of the essential principle that disease is the result of too much or not enough functionating [sic]. I created the art of adjusting vertebrae, using the spinous and transverse processes as levers, and named the mental act of accumulating knowledge, the cumulative function, corresponding to the physical vegetative function-growth of intellectual and physical-together, with the science, art and philosophy-Chiropractic. . . . It was I who combined the science and art and developed the principles thereof. I have answered the time-worn question —what is life? [5]

The chiropractic philosophy originated by Palmer is the frame of reference of modern day chiropractic thinking. [6] A brief review of this philosophy will aid in evaluating and understanding the chiropractor's capabilities and activities in practice.

A. E. Homewood, D.C., N.D., of the Los Angeles School of Chiropractic (Dean Emeritus of the Canadian Memorial Chiropractic College) and a member of the ACA's Commission on Standardization of Chiropractic Principles, explains Palmer's philosophy in his book The Neurodynamnics of the Vertebral Subluxation (published in 1962; submitted by the International Chiropractors Association), the most widely used chiropractic textbook. Palmer put forth the concepts of Universal Intelligence, Innate Intelligence, and Educated Intelligence. Universal Intelligence is God. Innate Intelligence is the "Soul, Spirit or Spark of Life" or "Nature, intuition, instinct, spiritual and subconscious mind." It is the "'something' within the body which controls the healing process, growth, and repair," and "is beyond the finite knowledge." While Innate Intelligence utilizes the autonomic nervous system, the Educated Intelligence or "conscious" utilizes "the cerebrospinal division for the volitional expression of its function." Nature or Innate has a great capacity to maintain or restore health if it is allowed normal expression within the body. However, mental, chemical or mechanical stress can produce a greater or lesser displacement of the vertebra, or vertebral disrelationship, and this displacement interferes with the planned expression of Innate Intelligence through the nerves. This interference then produces pathology. The chiropractor, by correcting the displacement, allows the Innate to effect the cure [6:30-31, 75-78, 240-241]..

The influence of this philosophy on present day chiropractic is illustrated by this passage from The Neurodynamics of the Vertebral Subluxation:

While it is not the purpose of the writer to derogate practitioners of other forms of healing, it is of the utmost concern to awaken an appreciation in the minds of doctors of chiropractic for the heritage left by D.D. Palmer, which provides the basis for the most complete understanding of the patient as a unit of structure and function yet to be devised by man to this date. Many ingenious approaches to the health problems have been thought out carefully, but none seems to be as all-encompassing as the techniques of D.D. Palmer. The chiropractor needs to experience no twinge of inferiority as he views the mottled array of theories, for the founder of the science of chiropractic appreciated the working of Universal Intelligence (God); the function of Innate Intelligence (Soul, Spirit or Spark of Life) within each, which he recognized as a minute segment of Universal; and the fundamental causes of interference to the planned expression of that Innate Intelligence in the form of Mental, Chemical and/or Mechanical Stresses, which create the structural distortions that interfere with nerve supply and thereby result in altered function to the point of demonstrable cellular changes, known as pathology [6:75-76].

Subluxation

The concept of a vertebral subluxation is central to the chiropractic approach to health care. Dorland's medical dictionary defines subluxation as "an incomplete or partial dislocation." The chiropractic definition is:

Homewood: The vertebrae are then within their normal range of motion, although not functioning at their optimum [6:14].

Janse: A vertebral subluxation may be interpreted as an 'off-centering of a vertebral segment. . . ' [7:146-149]

Weiant: [A subluxation] is a fixation of the joint within its normal range of movement, usually at the extremity of this range [7].

According to these chiropractic leaders, subluxated vertebrae are characterized by fixation and misalignment, within the normal range of motion. This definition is identical to what specialists in physical medicine and rehabilitation call joint dysfunction:

The range of voluntary movement described in anatomy texts is only part of the range of normal movement at any joint. This range of voluntary movement is entirely dependent on the integrity of a normal range of involuntary movement which I call "joint play." As in machinery, the play in all joints is well defined and without it. or with too much of it. the function of the joints becomes faulty. It must be accepted that the movements in the range of joint play individually are not tinder the control of the voluntary muscles, and therefore cannot be performed by deliberate Muscle action. For this reason, their presence or absence can only be demonstrated by passive joint examination, and if they are absent. they can be restored only in inducing normal movement-which is manipulation. Using the voluntary muscles prevents restoration of joint play. The prescription of exercises alone can only delay this restoration when dysfunction is present. . . .

The presenting symptom of dysfunction is pain either locally in a joint or at some place distant from the joint, but sharing a common nerve supply [7].

Chiropractors have recognized this similarity. W.D. Harper, M.S., D.C., former Dean and now President of the Texas College of Chiropractic and a member of the ACA's Commission on Standardization of Chiropractic Principles, says:

This definition [referring to a quotation from James Mennell, an English physician] is quoted to show that the structural concept of the subluxation as an entity and as a fixation within the normal range of motion is also recognized by the medical profession. . . .

The structural consideration of fixation alone as a definition of a subluxation is not sufficiently strong as a foundation for the Science of Chiropractic. The medical definition is just the same.

If this alone is used, there is no difference between chiropractic and the medical practice of teaching their graduates in physical medicine the art of adjusting under a medical doctor's prescription and. therefore, no justification for the existence of chiropractic as a separate and distinct science. THERE HAS TO BE MORE TO IT. THERE HAS TO BE A REASON [7:147].

W. D. Harper, M.S., D.C., goes on to say that there is more to it and that the chiropractic subluxation produces nerve irritation whereas the medical subluxation does not.

Many in the medical profession believe that the chiropractic subluxation is actually a disease process in which the joint has lost its mobility and thereby gives rise to pain and loss of function, and some believe that manipulation may restore normal joint mobility and relieve pain. However, research on joint dysfunction and manipulation is not adequate to support a conclusive statement about the existence of this disease process or the efficacy of various treatments.

Chiropractors, on the other hand, believe that the subluxation is the most significant causal factor in disease, because they feel that it interferes with normal nerve function. However, no evidence has been found in the literature, nor has any information been submitted to this study, to prove that a subluxation, if it exists, is a cause of disease.

The chiropractor attempts to move the vertebra with his hands so that it will not interfere with nerve function. It may be that the chiropractor, in this maneuver, is not affecting nerve function but actually is restoring the normal mobility of the joint. In this manner, the chiropractor may in many cases relieve pain and loss of function with the spinal adjustment. Referred pain to other parts of the body from joint dysfunction may be mistaken for a disease process, and when spinal adjustment relieves the pain, this may be thought to be a cure of the "disease."

Services of Chiropractors

In the following sections of this paper, leading men from each of the chiropractic associations will be quoted extensively. Every effort has been made to quote only those writers who are accepted and respected in the chiropractic community and to quote only from textbooks in current use in the chiropractic schools.

Scope of Practice

Since the philosophy of chiropractic is all-encompassing, its practitioners treat nearly every type of illness. In a survey made in 1963 for the American Chiropractic Association, 85 percent of the chiropractors reporting said that they treat musculoskeletal problems most frequently. Approximately 81 percent indicated that conditions other than musculoskeletal ranked first, second, or third among conditions most frequently treated. The table below shows the percentage of chiropractors stating that they generally cared for the condition listed [9].

TABLE 2

Percent of Chiropractors Reporting
Treatment of Specified Conditions: 1963.

Condition

Percent
Condition

Percent
Headache

98
Impaired Hearing

59
Sinusitis

94
Hemorrhoids

58
Constipation

94
Goitre

48
High blood pressure

93
Polio

47
Common cold

92
Diabetes mellitus

46
Asthma

89
Impaired vision

44
Bronchitis

86
Chorea

42
Low blood Pressure

83
Rheumatic fever

32
Hay Fever

83
Hepatitis

32
Gall bladder

82
Pneumonia

32
Colitis

80
Mumps

31
Diarrhea

79
Acute heart condition

31
Ulcers

76
Appendicitis

30
Deficiency anemia

73
Pernicious anemia

24
Chronic heart condition

70
Cerebral Hemorrhage

18
Genito-urinary

68
Lacerations

12
Mental, emotional

68
Fractures

9
Tonsillitis

67
Leukemia

8
Dermatitis

67
Cancer

7
Hives

60
Diphtheria

4

(The method of obtaining these diagnoses is unknown)

Views of leading chiropractors on the scope of practice appropriate to this discipline are shown in the quotations given below.

A report on a chiropractic research project by Henry Higley, M.S., D.C,, of the Los Angeles College of Chiropractic relates the following findings:

We realize that a large section of the nonchiropractic public appears to assume that chiropractic is confined to the treatment of distresses of the back, They seem to believe that the patients of doctors of chiropractic are limited to those suffering from sciatica, torticollis, and similar conditions affecting the musculature of the back. The careful compilation of patient data from the 1953 records of our chiropractic clinic shows that well over sixty-five different pathologies, e.g., gastrointestinal problems, genitourinary problems, cardiovascular problems, anemia] were represented. The case reports so far collected for the academic year 1962-1963 indicate that they will also represent a large variety of pathologies. Those who are, or have been. in active practice, recognize the varied pathologies met in chiropractic practices, but now we have statistical data to confirm their experience 10].

Hugh Logan. D.C., founder of Logan Basic College of Chiropractic. in his Currently used textbook Logan's Basic Methods, 1950 (submitted to the study by the ACA), makes the following statements:

Inflammatory conditions such as appendicitis, ovaritis, or even neuritis, in their acute stages may be instantly relieved or entirely corrected by a few adjustments. . . . Other acute conditions such as colds, pneumonia, etc., can be put in nearly the same category with appendicitis and ovaritis as far as prognosis is concerned [11].

High blood pressure, especially when due enti3ely to an increased resistance to the flow of blood through strained muscle fibers. may be lowered rapidly and immediately through a corrective Basic Technique adjustment [11:228].

In the case of pain resulting from burns, we have yet to fail to bring about almost complete, let us say seventy-five to ninety percent, reduction of pain in any case coming into our hands within an hour or less after the injury occurs. The possibility of blistering or scarring of tissue also is nullified to a large degree by prompt application of Basic Technique. [11:223].

Regarding tumors, I would say that benign or innocent tumors may be eliminated without great difficulty when the normal functional processes of muscle tissue are restored. In the case of malignant tumors, our prognosis must be guarded, more favorable of course in the inceptive than in the advanced stages [11:227 ].

If Basic Technique can do these two things, then-ease the discomfort of delivery, and provide for the more nearly normal contour and vitality of the newborn, we would say that its application is specifically indicated in pregnancy [11:3231].

A. E. Homewood, D.C., N.D., makes the following statement in his book, The Neurodynamics of the Vertebral Subluxation, 1963, the most widely used chiropractic textbook:

Experience has established the fact that the administration of chiropractic adjusting is efficacious in handling both the acute and chronic cases of coronary occlusion, but no button has been located either theoretically or clinically, that may be pushed in every patient to make the correction [6:207].

Joseph Janse, D.C., President of the National College of Chiropractic and Chairman of the ACA's Commission on Standardization of Chiropractic Principles, in the second most widely used chiropractic textbook, Chiropractic Principles and Technique, 1947, states:

TECHNIC FOR TONSILS.—Indications.—This technique is used when the tonsils are slightly inflamed. . . . After sterilizing his finger, the doctor places the finger tip on the inflamed tonsil . . . he strokes downward using a slight pressure. The amount of pressure to be used is determined by the tolerance of the patient. [12]

In Chiropractic Procedures and Practice, 1965, (submitted to this study by the ACA) by Otto Reinert, D.C., Director of the Department of Chiropractic Technique, Logan College of Chiropractic, the following description is found:

CRANIAL ADJUSTING. . . . In the adult, the effects of this technique are usually of a temporary symptom-reducing nature, but the dramatic results produced in the relief of headache, sinus congestion, some types of deafness and eye conditions, and other conditions affecting the head, justify our attention to this technique and our understanding of its application. In babies and young children prior to the age of five, before the fontanelles have substantially ossified. improvement has been wrought in spastics and similar cases of intracranial congenital injury [13].

James Firth, D.C., Ph.C., former professor at Lincoln Chiropractic College, in his currently used textbook Chiropractic Diagnosis, 1948 (submitted by ACA), states:

Definition—Acute diffuse peritonitis is an acute inflammation of the peritoneum characterized by fever, pain, and prostration.

Adjustment -- The adjustment in acute peritonitis varies in accordance with the location of the primary lesion. Discoverable nerve interference from the 8th dorsal to the lower lumbar region should be corrected [14].

A report by the Palmer Clinic submitted to the study by the ICA states:

The B.J. Palmer Chiropractic Clinic presents these case records to demonstrate the effectiveness of Chiropractic with cases medically diagnosed as multiple sclerosis, encephalitis or sleeping sickness, hydrocephalus, epilepsy, sciatica, cirrhosis and cancer of the liver, and tumors. It is hoped these records will benefit both the chiropractor and any interested lay person who may chance to read them [15].

While giving testimony before the Ad Hoc Consultant Group of the U.S. Public Health Service in November 1968, H.R. Frogley, D.C.. Dean of Academic Affairs, Palmer School of Chiropractic, was asked the following question: "Do you think if an acute appendicitis were identified early enough in the disease process that chiropractic can cure it? [ ]; His reply was: "Yes, I do. I say this strictly from experience. I don't say it from only my experience but from the experience of all who practice [ ].

In Opportunities in a Chiropractic Career 1967 (submitted by the ICA), produced with the cooperation of both chiropractic associations, the following is found in the chapter entitled "A Typical Day at the Chiropractor's Office:"

IN WHAT FOLLOWS the names used and the situations depicted are all fictitious. The account has been prepared, however, by a chiropractor of more than 40 years' experience. He has drawn upon his recollections of his own days in practice and his wide contacts with professional colleagues to reconstruct what might be considered a fairly typical day in the professional life of the chiropractic doctor. . . .11:45 A.M. The doctor hurries to the home of the little girl with a fever.

By now she has broken out with a skin rash. He arranges the cushions on a firmly upholstered day-bed to improvise a chiropractic table, places the little patient in the appropriate position, locates the point where adjustment is needed and delivers the adjustment, all the while ingratiating himself with the little girl in a joking fashion. The fever begins to subside right away. . . .

The afternoon goes along much like the morning. Fourteen patients have appointments: a woman who recently had a gall bladder attack, a young boy who is an epileptic, a clerk with a stiff neck, another low-back case, a six-year old bed-wetter, a high school boy with acne, a garage mechanic suffering from bursitis of the shoulder, a young woman with painful menstruation, a teen-age girl with a rheumatic heart. a middle-aged woman with spinal arthritis, a woman with a severe bead cold, a man who is constipated. a woman who is too fat, and another whose thyroid gland is overactive [16].

Thus, although chiropractors see more patients with musculoskeletal problems than any other kind. it is apparent that they consider themselves competent to treat a wide variety of illnesses. This belief stems largely from their philosophy or approach to health and disease. As a result of this belief, chiropractors do not limit their practice to the care of patients with musculoskeletal problems but instead undertake the treatment of other patients representing a broad spectrum of diseases.

Approach to Diagnosis and Treatment

Chiropractic methods are derived from its philosophy, involving the role of the Innate in the Curative process, and of subluxations as the ultimate causal factor in disease. The result is an approach quite different from that of conventional medicine and osteopathy, as shown in the following quotations about the role of diagnosis:

For the chiropractor, diagnosis does not constitute, as it does for the medical doctor. a specific guide to treatment. It is not a major goal of the doctor of chiropractic to specifically name a disease. He does not look upon diseases as an entity to be combated. For him disease is a process: it is physiology gone wrong. The problem is to ascertain why it has gone wrong. and what needs to be done to right the wrong. This is a goal not attainable by routing [sic], conventional diagnostic methods [16:14]

Because of the emphasis constantly being placed upon diagnosis by the medical profession. it is difficult for the average lay person to realize that the chiropractor need not diagnose and therefore diagnosis is unimportant to him [15:3].

Thus, instead of making a diagnosis in terms of a specific disease, the chiropractors chief interest is in making a diagnosis in terms of what vertebra is subluxated and producing "interference with normal nerve transmission and expression." [1:20] This type of diagnosis is made through the use of chiropractic or spinal analysis which consists of palpation and X-ray of the spine. The importance of spinal analysis in chiropractic practice is explained by Janse:

It is impossible from the spinal analysis alone to make a diagnosis of the nature of the disease. What the spinal analysis determines is that disease of a certain organ exists; the special examination of the organ then establishes the exact nature of the disease. For example. detection of a subluxation at the fourth thoracic segment determines the fact that there is disease of the liver, but whether the disease is cancer or congestion it is impossible to state; only the special examination of the liver and the general symptom complex can determine this.

A thorough understanding of the above principle makes the diagnosis of disease in certain parts of the body extremely accurate, and the palpation of the vertebral column for the detection of subluxations is one of the most valuable aids at our command, in the making of a correct diagnosis [12:277].

Because the chiropractic approach to treatment is so greatly influenced by its philosophy, the main therapeutic concern is to correct the subluxation, either to prevent pathology from occurring or to allow the normal flow of Innate Intelligence so that nature can effect a cure. The subluxation is corrected by an adjustment or dynamic thrust to the appropriate vertebrae. This adjustment consists of a quick, "specific, and purposeful movement manually delivered'" [16:15] Also, if there is stress in the soft tissue, which can produce a subluxation according to chiropractic philosophy, these tissues are adjusted directly to correct the subluxation.

It should be pointed out here that many chiropractors do not believe that a subluxation is the only cause of disease, that spinal analysis is the only diagnostic too], or that the chiropractic adjustment is the only valid treatment. The following quotations from chiropractic books and statements submitted to this study indicate some recognition of other elements in the cause and cure of disease.

Fundamentally. chiropractic recognizes that while many factors impair man's health and his inherent tendency toward recovery from disease. disturbances of the nervous system are among the most important factors of disease etiology [2(11):3 ].

Diagnostic Aids [include] x-ray machine (spinal x-rays), skin temperature recording instruments, general equipment such as otoscope, ophthalmoscope, stethoscope, and sphygmomanometer, reflex hammer [and the use of various laboratory tests]. [1:17]

It is impossible from the spinal analysis alone to make a diagnosis of the nature of disease . . . only the special examination [of an organ] . . . and the general symptom complex can determine this [12:277].

In contrast to both of these kinds of doctor [doctors of medicine or osteopathy], the doctor of chiropractic gives no medicine and [sic] no surgery. This is not because he feels that he has the answer to every health problem and believes that drugs and surgery are never necessary [16:7].

However. the concepts of the subluxation and of the spinal analysis and adjustment form the basis of chiropractic thinking and activities: they arc greatly emphasized over other concepts of diagnosis and treatment and disease causation

The chiropractic way offers the safest, sanest, and most promising approach to the great majority of human ailments [16].

In the broad field of prophylaxis, chiropractic has no peer. It remains for the chiropractic profession to educate the general public to the availability of such a complete and encompassing mode of health care [16:268]

The future augurs well for the continued proof of his [D.D. Palmer's] contentions and the recognition that chiropractic is a method without equal in the correction of the majority of visceral and somatic health problems [6:269].

Of all the causes of disease, there is one which is more universally present than any other, and that is subluxation of vertebrae 12:48]

The conflict of chiropractic with other concepts of health and disease, especially concerning treatment, is illustrated by the following quotations from textbooks currently used in chiropractic schools. The authors are leaders in chiropractic education and in the professional associations.

James Firth, D.C.. Ph.C., in his textbook, Chiropractic Diagnosis, described the chiropractic treatment of influenza:

Since there are several forms of influenza, the adjustment will vary according to the form. In all forms the middle and lower dorsal areas should be adjusted. In the respiratory form, middle or lower cervical or upper dorsal should be included. . . . In the nervous or cerebral form the upper cervical region should be included [14:79].

A. E. Homewood, D.C., N.D., in The Neurodynamics of the Vertebral Subluxation, states:

The doctor of chiropractic is well aware of the presence of bacteria and concedes that these minute organisms play a role in many diseases. He would, however, emphatically deny that micro-organisms are THE cause of the diseases with which they are associated. . . [6:265].

J. Robinson Verner, D.C., in his Currently used textbook The Science and Logic of Chiropractic, 1956, states:

Fear often plays a vital part in rabies, Many bites would not be serious and possibly do no damage at all if it was not for the additional factor of fear. It is because of this fear that many otherwise minor cases are fatal [18]

The preface of the currently used textbook Rational Bacteriology, 1953, by C.W, Weiant, D.C., Ph.D. (Dean Emeritus of the New York Institute of Chiropractic and a member of the ACA's Commission on Standardization of Chiropractic Principles), J.R. Verner, D.C., and R.J. Watkins, D.C., reads as follows:

This outline is written with two objects in mind. It aims, first of all, to give to the Student and the drugless practitioner those basic facts and principles of bacteriology which underlie the hygiene of the communicable diseases and sanitation. which create an appreciation of the true role of bacteria in disease, and which make possible the interpretation of diagnostic laboratory reports. Incidentally, this is the knowledge usually required to pass a state board examination in the subject.

The book has, however, a second more important object, namely. that of making public some of the outstanding results of medical and bacteriological research of the past few years which undermine the whole germ theory of disease causation and the practices of serum and vaccine therapy or prophylaxis based thereon. It is hoped by the authors that this material. all of which will be found carefully authenticated, may speedily become of service not only to professional groups, but to all laymen. especially parents and educators, who are interested in having the truth prevail [19].

The authors, in presenting some chiropractic theories related to bacteriology, advise chiropractic students as to those passages that are not acceptable for State board examinations, as shown in the first paragraph below:

REMARKS (on the significance of streptococcus)

These remarks are not a part of the accepted medical ideology, but are comments of evaluation which become clearer throughout this book. Thus it is well to keep them apart from state board examinations.

It will be noted that streptococcus pyogenes is an organism of low resistance. Women in childbirth appear to be especially susceptible to streptococcus infections via the genital tract, but there is every reason to believe that this bacterium is a normal inhabitant of the skin and mucous membranes. since it can nearly always be found on these tissues in healthy people. It is often spoken of as a "secondary invader." We might interpret this to mean that it is not until the body has been decidedly weakened by some such condition as diphtheria or bronchopneumonia, that bodily resistance against streptococcus breaks down. . . . The streptococcus is not a basic factor in pathogenesis [19:35].

Both gonorrhea and cerebro-spinal meningitis respond readily to non-medical methods [19:43].

Tuberculosis is not contagious in adults [19:75].

Diphtheria antitoxin and toxoid are both not only worthless in practically every case but also virulent and injurious in all cases [19:178-179].

James Firth, D.C., Ph.C., in his textbook describes the chiropractic treatment of leukemia:

Since the blood forming tissues are innervated by the sympathetic division of the vegetative nervous system, the indicated adjustments are in the dorsal area of the spine. Inspection, palpation, nerve tracing, and x-ray study are of assistance in determining the location of nerve interference [14:234].

Thus, the chiropractor's approach to health and disease is radically different from that of osteopathy and medicine.

Although osteopathy began in a manner very similar to chiropractic, with emphasis on structural relationships as the cause of all disease, it has since broadened its approach to health and disease until now it recognizes and uses all the knowledge and methods of the medical and other health professions.

Manpower

Nearly all chiropractors are in solo practice. Both the ICA and ACA report no members practicing in hospitals [2(III:6, 1:21]. The ACA reports 85.4 percent of its members in general practice and 14.6 percent in specialties (roentgenology, orthopedics, nutrition, physiotherapy) [ Between 17,000 and 19,000 of these practitioners are in the United States, with 15,000 to 17,000 in active practice [23].

Almost 40 percent of the chiropractors in the United States are located in five States; about 20 percent are in California, 8 percent in New York, 6 percent in Texas, and 5 percent in Missouri [21]. it is sometimes thought that chiropractors are located in rural areas and are therefore in a better position to provide service to the rural population; however, Do data are available to demonstrate this [22].

Quality: Indicators

In the health care field, as in many other fields. the capacity to give good quality service can be correlated with the quality of the education of practitioners, as well as the quality and extent of research upon which practice is based.

Description of Chiropractic Schools [23]

There are 12 chiropractic schools in the United States. The Palmer College of Chiropractic in Davenport, Iowa is the oldest and largest, with a 1967 enrollment of 936. In 1962, 25 percent of chiropractors reported they had graduated from this college; another 25 percent had graduated from either the National College of Chiropractic in Chicago or the Lincoln Chiropractic College in Indianapolis, Indiana [9:5] The total 1967 enrollment in ten of the schools was 2,273; data are not available from the other two.

Appendix C (Selected Data on Schools of Chiropractic, gives selected data on the various schools.

All the schools offer the Doctor of Chiropractic degree (D.C.). At least four schools offer a bachelor's degree, which is obtained by acquiring 60 hours of college credit and 60-68 hours of credit from the chiropractic college.

The Palmer College also offers the Philosopher of Chiropractic degree (Ph.C.). H. R. Frogley, D.C., Dean of Academic Affairs at Palmer, explains this program as follows?the Ph.C. program is not, never has been, and should not be compared to the Ph.D. degree of the liberal arts colleges. Rather, it is a program to encourage the graduate Doctor of Chiropractic to develop deeper convictions and understandings of the chiropractic premise by reading, practical experience and assistant teaching, and then to express his thoughts regarding the philosophy of chiropractic in a brief thesis. We do not have an in-depth research opportunity attached to this program [24[

Other chiropractic colleges also offer postgraduate courses.

The U.S. Office of Education and the National Commission on Accrediting do not recognize any accrediting agency for schools of chiropractic. However, the two chiropractic associations each have an accrediting program. Schools accredited by either the American Chiropractic Association or the International Chiropractors Association are listed in Appendix C (Selected Data on Schools of Chiropractic), together with selected data about their faculties.

All chiropractic schools offer a four-year course (at least 4,000 hours) which leads to the D.C. degree. The first two years deal mainly with basic science subjects with some outpatient clinical experience at the end of the second year. The last two years are devoted mainly to chiropractic subjects and outpatient clinical practice. There is no inpatient or hospital training.

Most chiropractic schools include in their organizational structure a division of basic sciences or preclinical subjects and a division of clinical or chiropractic sciences. The basic science divisions usually have departments of anatomy, physiology. chemistry, nutrition, microbiology, public health, and pathology.

The clinical divisions are more variable in their substructure. The teaching of chiropractic and diagnosis is the chief emphasis of these divisions and at least seven of the schools have a department of chiropractic and a department of diagnosis. All the school have courses in chiropractic principles and techniques, and in roentgenology.

All of the schools teach pediatrics, obstetrics and gynecology as part of the standard curriculum. At least ten of the schools teach public health. Nine of the colleges have dermatology and nutrition as part of the regular Course of study. Psychiatry, psychology and first-aid are taught in at least eight schools. At least seven schools teach geriatrics, six teach toxicology and orthopedics, five teach neurology, four teach ophthalmology, otolaryngology, endocrinology, physiotherapy and minor surgery, three teach syphilology and one teaches diagnostic cardiology.

Of the 10 schools that list textbooks in their catalogs or self surveys, all make extensive use of standard medical textbooks, especially in the teaching of basic sciences. Such books as Gray's Anatomy, Zinsser's Microbiology, Bloom and Fawcett's histology textbook, Boyd's pathology textbook, Dorland's Medical Dictionary, Noyes and Kolb's psychiatry textbook and Cecil and Loeb's medical textbook are frequently listed.

There is no one textbook written by the chiropractic profession that is used in all the schools. The most commonly used chiropractic textbook is A. E. Homewood's The Neurodynamics of the Vertebral Subluxation 1962. Other textbooks written by members of the chiropractic profession and used in their schools are listed in Appendix C (Chiropractic Textbooks Cited)

The libraries of the various schools are small, the average number of volumes being 4,454 and periodicals about 55.

From the course titles mentioned earlier, it is evident that the same types of subjects are being taught at schools of chiropractic, medicine and osteopathy, and that chiropractic Students are being trained to function as primary sources of patient care—as physicians." Therefore, qualitative evaluation of their educational system must compare these schools with medical and osteopathic schools.

Medical school courses leading to the M.D. degree also are four years long, with basic sciences during the first two years, followed by outpatient and inpatient training combined with classroom work during the last two years. Medical students then take a 12-month hospital internship and most take a one to five year residency before starting independent practice [69]. Osteopathic programs are similar. In 1966-67, the number of volumes in the average medical school library was 98,824, and periodicals averaged 1,684 [69:735].

Evaluation of Chiropractic Education

The discipline has undertaken educational evaluation. For example, in 1964, Dewey Anderson, Ph.D., at that time Director of Education for the ACA,, presented a memorandum giving a thorough and objective evaluation of chiropractic schools. The memorandum is quoted in this section.

Some basic data on faculties of the chiropractic schools are shown in Appendix C (Selected Data on Schools of Chiropractic), and Table 3. Appendix C (Selected Data on Schools of Chiropractic) shows that the average student/faculty ratio for chiropractic schools is 19 to 1 (1965-68), whereas for medical schools it is 1.7 to 1 (1966-67).

A review of self-evaluating surveys of the schools reveals that many faculty members with only a D.C. degree teach many totally different subjects. This was true, for example, of at least 11 of the 18 faculty at National College. One professor had taught such varied subjects as physical and clinical diagnosis, pathology, dermatology, clinical neurology, ophthalmology, and dietetics, while another had taught pathology, anatomy, chemistry, physiology, psychology, and public health.

 

TABLE 3

Degrees Held by Full-Time Faculty
Members of Schools of Chiropractic,
Compared with Medical Schools

Number*

Percent*
Faculties of Chiropractic Schools (N = 112)

112
    Doctors of Chiropractic

105

94.9
    Doctorates (3 Doctors of Osteopathy)

4

3.5
    Master's

12

10.7
    Bachelor's

50

44.6

4

3.5
Faculties of Medical Schools (N = 19,296)

19,296
 
    Doctors of Medicine

13,277

69.0
    Others doctorates (5,654 are Ph.D.'s)

5,803

30.0
Source: Self-surveys of eight schools-1965, 1966, or 1967; Medical Faculty Roster, Division of Operation Studies, American Association of Medical Colleges 1966-67.

*Adds to over 100 percent because some hold more than one degree.

Data on degrees held by faculty members, along with student/faculty ratios and deans' degrees shown in Appendix C (Selected Data on Schools of Chiropractic), raise grave doubts about the basic preparation of the graduates, despite the titles of the courses offered by the schools. This serious concern is reflected also by Dewey Anderson, Ph.D, in his evaluation; he summarizes the faculty deficiencies as follows:

Proportionately too many part time instructors; too few giving their major professional time as fully employed faculty members engaged in instruction, administration, and research. Too many instructors teaching the basic sciences without having had any advanced or graduate training in these sciences. Too many instructors not trained or qualified as teachers nor masters of their fields, resulting in slavish devotion to textbook teaching and instruction considerably below the level of post-college professional education.

Teaching loads of those who do give full time to their schools are usually too heavy to allow much needed outside preparation or research. Membership and participation in professional, scientific or learned societies is almost nonexistent. Nor is there any substantial program of faculty-student research which forms the lifeblood and growth of the other professions [26].

All schools except Palmer require at least a high school diploma for admission, but four of the schools require only a C average in high school. The Palmer catalog mentions no specific mandatory requirement for admission. Northwestern requires two years of college. Since September, 1968, the National, Lincoln and Los Angeles schools have required two years of college for admission. Very few of the students have college level degrees. For example, approximately 2 percent of those at the Los Angeles College of Chiropractic had bachelor's level degrees, 5 percent at Lincoln and 5.8 percent at Texas. In contrast, 84 percent of students entering medical school have bachelor's degrees or higher, and 91 percent of medical students had a B average or higher in college [24:753].

About the quality of the student body, Dr. Anderson's evaluation comments:

Students sit on the other end of the "log of learning" and no matter how fast and well the faculties are upgraded to professional school level the crux of chiropractic education rests with the quantity and quality of students. . . .

Numbers in and of themselves will not solve your educational and professional problems. One of the most serious handicaps under which the schools labor now is that of trying to teach at the post-college professional level students who for the most part have not gone beyond high school, and who in high school were not in the upper half of their classes. For many of them a professional college course is too difficult to master.

This results in downgrading instruction so that they can pass the courses, and this happens all too frequently, or in dropouts, which is wasteful and an unsatisfactory blemish on the educational process [26:4].
Chiropractic Research

The lack of chiropractic research is recognized. For example, Dr. Anderson, in his evaluation of the chiropractic schools, emphasized the great need in this area:

As for a body of faculty-student research so badly needed by the profession, this will take considerably longer for most colleges, although a few among them can produce noticeable research results within two years. Again, it is a matter of making funds available for this purpose. Here, too, the convention must act if it chooses to benefit by a solid body of research, the lack of which is one of the most glaring weaknesses of chiropractic, causing a distorted public image leading to much misunderstanding and considerable failure in practice [26:4]

The lack of research is due to a number of factors. Certainly the lack of funds is one. However, considering the qualifications of the faculties of chiropractic schools, it seems unlikely that most faculty members with the qualifications listed would have the capability to undertake basic research. Another major reason for the lack of research is that the chiropractic philosophy has led to a deemphasis on research since the chiropractor believes he already knows "basic truths and principles" [6:7] and since "Innate" is thought to be beyond finite knowledge. The following quotations from chiropractic authors illustrate this:

Many of these latter theories do not stand with the light of present day knowledge, yet the teaching of D. C. Palmer will be found consistent with the facts of our present stage of intellectual insight and are likely to be found capable of withstanding investigation in the light of new knowledge yet to be discovered-for these are basic truths and principles [26].

The adjusting of each and every articulation of the human frame was stressed by Dr. Palmer in a number of places in his text. as follows. "It is, or should be, the business of the Chiropractor to restore to normal position any displaced portion of the bony framework

What more could any doctor require of his science? What more has science, metaphysics or religion to offer the conscientious would-be healer? [6:7]

They [the phenomena of life] can never be fully comprehended by such procedures as experimenting with tissue cultures, photographing the revelations of the electron microscope, or working out the details of molecular exchanges across cell membranes. Laboratory investigations can yield only partial truths, obtained in artificial settings far removed from the context of nature [17:110].

The little research that is done seems to be directed at proving that D.D. Palmer's teachings were right, rather than taking an objective look at all possible causes of disease. The following quotation illustrates this:

In an effort to formulate a satisfactory basis for study of chiropractic principle and theory, and substantiate the rationality of chiropractic techniques for the treatment of human misery and disease, the author has leaned heavily upon the basic principles established by the founder of the science and art of chiropractic and made a diligent effort to scan the literature of biological science to cull from it the anatomical, physiological and other basic science facts which assist us in understanding the mechanism by which chiropractic methods bring relief to suffering humanity [6:6].

As part of this study, the chiropractic associations were asked to supply evidence of the scientific basis for chiropractic. The ICA discussed the chiropractic theory generally and supported their contentions with four research studies. The first study, entitled "Belgian Chiropractic Research Notes," presents observations and opinions of various chiropractors, chiefly concerned with the mechanics of subluxations and their correction [27]. The second study, entitled "Electrocardiographic Changes," attempts to present EKG evidence of improvement of various heart conditions after adjustment; the group categorized as having no manifestation of heart disease showed the greatest improvement, although "improvement" was not defined [28]. The third study, entitled "Audiometric Changes," purports to show that a chiropractic adjustment improves hearing. Hearing acuity was measured before and after adjustment; no other variables were considered. Of the total cases 581 showed improvement and 359 became worse [29]. The fourth study was entitled "Neurocalometer, Neurocalograph, Neurotempometer." This study attempts to demonstrate the effectiveness of chiropractic with eight cases, which are presented with testimonials or letters from the patients. No other reasons for improvement. or the possibility of spontaneous remission, were considered. Patients were said to have multiple sclerosis, encephalitis or sleeping sickness, hydrocephalus, epilepsy, sciatica, cirrhosis, and cancer of the liver and tumors, although these diagnoses were not documented and symptoms of two patients seemed to indicate a different diagnosis from the one given. Improvement often was based on the findings of an instrument called the neurocalometer, which detects differences in skin temperature and is claimed to detect nerve interference. What indicates improvement according to this instrument is not defined, but is reported in terms of them reading being better or worse. The patient said to have tumors still was having the same pain for which she had entered the clinic, but there was "no indication of consistent return of original sick pattern" on the neurocalograph [15:125]. One patient, said to have epilepsy, seemed to get much worse. After his drugs were discontinued and he was started on spinal adjustments, his seizures increased in frequency from 5 a day to 150 a day, He then improved, but still was not seizure-free a year later.

The ACA, like the ICA. started their documentation of the scientific basis of chiropractic with a general discussion of the theory, quoting from 22 books, 2 monographs, and 19 articles. In the section on research they provided several documents in their entirety. Most of this evidence related to spinal mechanics, back problems, and the possibility of referred pain from the vertebra. The only document submitted to this study in its entirety that related to a broader application of chiropractic was entitled "Physiology of Subluxation." [30] This was a review of the literature. rather than a research study. Some of the research cited was questionable: for example, great emphasis was placed on an animal study done on two rabbits, one the control and one the subject. There was no conclusion in this paper that a subluxation was a significant cause of disease.

Of the 22 books and 19 articles quoted, only 5 might be considered studies concerned with the possibility of a subluxation producing disease, and most are from the osteopathic literature. None of these states or implies that a subluxation is the most important cause of disease with universal application, nor do they show that it is a significant cause [2(II):1-13].

Summary: Chiropractic Education and Research

Education

Two notable features of the chiropractic educational system should be mentioned: first, the wide range of the courses, which indicates an effort, in principle at least, to give to students a basic knowledge similar to that of medicine and osteopathy; and second, efforts at self-improvement, as indicated in Dr. Anderson's evaluation and in the accreditation programs of the two professional associations.

However, significant shortcomings in chiropractic education include:

  1. Lack of inpatient hospital training;
  2. Lack of adequately qualified faculty;
  3. Extremely low admission requirements for students;
  4. Lack of a nationally recognized accreditation body;
  5. Such dissension within the profession that two separate accreditation programs must be maintained.

These shortcomings raise serious doubts as to the qualifications of chiropractors generally to make an adequate diagnosis and effectively treat patients. The doubts are compounded when seen in the light of the chiropractic philosophy, which has been shown to deemphasize proven factors in the causation of disease and the necessity for differential diagnosis and for therapy other than manipulation. Thus, it appears doubtful that improvement in the educational program can proceed, despite efforts in that direction, until:

  1. The need for differential diagnosis and forms of therapy other than manipulation is recognized;
  2. Fully qualified, specialized faculty are available to teach the scientific courses.

Research

Some difficulties are encountered by nonchiropractors in evaluating chiropractic research. One is that the nonchiropractor looks for documentation of diagnosis, the accuracy of which is central to the validity of the research; but to the chiropractor, naming the disease is not so important, as mentioned in an earlier quotation, since subluxation is considered the cause of the illness. This raises the problem of definitions, since the nonchiropractor may not understand the chiropractor's interpretation of this causal relationship. Measurements of "improvement" also present problems, the nonchiropractor looking for specific indices to show improvement. In one chiropractic study, improvement is shown in terms of readings on a "neurocalograph," an instrument that is not used for this purpose in other disciplines. Finally, tests of statistical significance are difficult to apply to chiropractic research, due to small study samples,

Current Status of Chiropractic

The previous sections of this report make it clear that chiropractors function as physicians, caring for a wide range of human ills and practicing independently without supervision. They do not function as technicians or as paramedical personnel. As stated by Harry Rosenfield, Counsel for the ACA, in his testimony before the Ad Hoc Consultant Group of the Public Health Service in November 1968, "Chiropractic is not an additional service to be added to Medicare not already included. It is an alternate form of providing services already approved by [for] M.D.'s and D.O.'s. . . ." [31]

Since the U. S. Supreme Court is the ultimate arbiter of constitutional law in the United States, its decision on chiropractic is a significant measure of the current status of the profession. In 1965, the Court ruled that the Equal Protection Clause of the Fourteenth Amendment of the U. S. Constitution does not bar a state from requiring chiropractors to have medical school degrees. Thus it upheld a lower court ruling, which said: "If the education obtained in chiropractic schools does not meet the standards of . . . the United States Office of Education, it may well be that the Legislature of Louisiana felt that in the public interest a diploma from an approved medical school should be required of a chiropractor before he is allowed to treat all the human ailments chiropractors contend can be cured by manipulation of the spine." [32]

Special Studies of Chiropractic

The decision made by other governments concerning chiropractic is also a measure of its current status. In 1965, Justice Lacroix of the Superior Court of Quebec was asked by the Quebec government to undertake a comprehensive independent scientific study of chiropractic and to resolve the question of the scientific basis of chiropractic." [33]

The Canadian Royal Commission on Health Services made the following comments about the high quality and objectivity of this report:

We have consulted with Mr. Justice Lacroix and are convinced that the investigation being made by him is an impartial and thorough one. Justice Lacroix's inquiry is still proceeding. His findings and recommendations will be formulated only after this volume has been completed.

We believe that the report and findings of Mr. Justice Lacroix will be definitive and have application not only to the situation in Quebec but throughout the rest of Canada. Pending the report and findings of Mr. Justice Lacroix, we recommended in Volume I that the medical services benefit should include chiropractic treatment when prescribed by a physician. We do not wish to make any recommendation to include chiropractic treatment as a health service under our programme beyond this until the Quebec Report is available [34].

Justice Lacroix's research team studied in detail chiropractic theory, chiropractic education, chiropractic practice, and all legislation on chiropractic. His study was not confined to Canadian chiropractors, but covered all facets of chiropractic in other countries, especially the United States and Europe.

The study included visits to the chiropractic colleges in Canada and the United States, visits to Europe to evaluate the status of chiropractic in that region, evaluation of thirty-one briefs submitted by various groups, and a review of the literature. Public hearings were also held and numerous interviews undertaken.

Findings of this report were as follows:

  1. The technique of manipulation used by chiropractors is to be retained, because it is effective and can produce beneficial results in cases where correctly indicated. It has besides been an integral part of hospital medicine for about twenty years, although traditional medicine, while accepting the technique, absolutely rejects the chiropractic doctrine.
  2. The essential condition for this therapeutic method to produce effective, beneficial results and to be used without danger, is that it be used only in cases indicated by a sound and complete differential diagnosis. However, the training given in chiropractic schools does not prepare them for such differential diagnosis which, moreover, in Quebec, does not seem to be considered necessary for the practice and purposes of chiropractic.

    Furthermore, several of the methods required for differential diagnosis, are not used by chiropractors, either because the law forbids it, or because they themselves consider, on their own account. here in Quebec, that these methods are useless for chiropractic diagnosis (which does not need to be as complete and extensive as that of the physician).

    We are therefore of the opinion that, in view of the present state of the course of study and training received by chiropractors and given their conception of diagnosis, they are not qualified to make a differential diagnosis, which we consider to be an imperative preliminary to manipulative treatment.
  3. Treatment by manipulation is difficult and dangerous. It may not therefore be administered except by people with long and adequate specialized training in this technique.

Whether they are doctors, chiropractors or osteopaths, they must in each case have become specialists in the field of the spinal column.

The preponderance of the evidence received indicates definitely that the teaching of this technique [manipulation] is not part of the medical curriculum and we believe that chiropractors, who have taken a long course in an accredited school, may have received instruction and training giving them a sounder preparation for the administration of this spinal therapeutic method than the physician who, in spite of his medical studies, has not been taught it.

It remains to be determined, in view of the requirements of differential diagnosis, whether this administration of treatment by those who are not doctors requires to be controlled and, if so, what should be the nature of the control [33:75].

Additionally:

  1. It appears well established that the general requirements for entrance in colleges of chiropractic, recognized by various Canadian and American legislation, are decidedly too liberal, and inadequate to guarantee a caliber of student sufficiently well-prepared and trained to take effective advantage of the instruction in theory corresponding to that given at the university level.

  2. The courses of study in basic science, although inferior in content to those of North American medical faculties, nevertheless seem. adequate to offer a general training, but one may receive the impression that these courses as designed at present, do not aim to take the student beyond this general training nor to prepare him adequately to make a differential diagnosis. The reason for this is perhaps because chiropractors do not use these basic sciences as a foundation for their therapeutic methods or chiropractic procedure.

    On the other hand, the course of clinical instruction in chiropractic technique or- procedure is certainly of high quality. However. it is organized solely in terms of the skill to be acquired in the use of the technique and is not directed towards the knowledge required in differential diagnosis.

  3. The training required of teachers is definitely inferior to that required of teachers in medical faculties or science faculties of recognized universities. The result is that the caliber of teachers is inevitably average or lower still in some cases, for a great many, if not the majority, possess only a B.Sc. and have no valid experience in scientific research.

    A great number of these teachers are chiropractors who have received training in basic sciences of very little value.

  4. Finally, either because of difficult financial circumstances or the indifference of the States and Provinces where the practice of chiropractic has nevertheless been legalized, or perhaps also on account of the constant and strongly demonstrated opposition of the medical profession in these Provinces or States, it is evident that the physical organization that we saw in some institutions. and had verified in addition by others, has weaknesses and deficiencies which, except perhaps for the clinical instruction in chiropractic technique itself, are likely to affect the quality and value of the training.

    It may be objected that we have verified existing conditions in only three colleges, but nevertheless these three colleges are accredited by the National Chiropractic Association (now the American Chiropractic Association). and therefore are deemed to satisfy the standards demanded for the efficient training of a chiropractor [34:101-102]

 

In 1960, the Stanford Research Institute [35] undertook a study of chiropractic in California. The study concentrated on five areas:

  1. a general description of chiropractic
  2. a study of the use of chiropractic
  3. a survey of chiropractic practices and facilities
  4. a description of chiropractic diagnostic and therapeutic electrical apparatus
  5. a study of chiropractic educational institutions.

Data were gathered in the following manner:

  1. Review of literature and requests for information from the California Department of Public Health. State Board of Chiropractors, and other official agencies.
  2. Interviews held with 500 chiropractors in the State.
  3. Visits to schools for: a. Review of files b. Classroom evaluation c. Laboratory evaluation d. Interviews with all students and faculty members.

The following conclusions were reached in this study:

  1. The number of chiropractic practitioners and students is declining.
  2. Chiropractors. although comprising the second largest group of healers, serve less than one-thirtieth of the market for healin2 services.
  3. There is a high degree of internal dissension among chiropractors.
  4. Chiropractic education has not succeeded in obtaining financial support from its own practitioners, from its friends, or from government sources [35:99].

Positions on Chiropractic

Various forms of recognition have been accorded chiropractors. It should be noted that recognition has not been based on a judgment as to the validity of chiropractic theory. Chiropractic students receive Federal funds under programs established by the GI Bill of Rights. Chiropractors are reimbursed under Title XIX (Medicaid) in 15 States. Medicaid is a State administered program, although Federal funds are granted to the States. Because Medicaid defines medical assistance as including all medical and remedial care covered under State law, States may choose to cover chiropractic service. The Internal Revenue Service permits income deductions for chiropractic fees and the U. S. Immigration Service admits chiropractic practitioners outside of quotas. Foreign students also are permitted to attend chiropractic schools approved by the Attorney General. These do not have to be accredited schools. Chiropractic services qualify for indemnification under most State Workmen's Compensation Acts and under a great many insurance policies [36].

Chiropractic has failed, however, to receive recognition by some important agencies and programs. The U. S. Office of Education and the National Commission on Accrediting do not list as accredited any of the chiropractic schools [37]. Chiropractic students are not deferred under the selective service system. Chiropractic practitioners are given no special status or rank in the armed forces and their services are not utilized. The U.S. Employee's Compensation Bureau does not reimburse chiropractic practitioners for their services.

State Licensure of Chiropractors

Chiropractors are licensed specifically in 45 States. In 3 States and the District of Columbia, licensing of chiropractors is included under a general "medical practice" or "drugless heating" act. Chiropractors are not licensed in Mississippi and Louisiana. Licensure generally is considered a means of protection for the public, rather than as official recognition of the licensee.

Other than use of drugs or surgery, State licensing laws place no specific restriction on diagnostic methods a chiropractor may use of the illnesses be may treat, except in New York. Certain treatment methods are forbidden in various States, e.g., the administration of drugs is specifically prohibited in 38 States'. surgery in 37 States and the District of Columbia; obstetrics in 37 States; X-ray treatment in 10 States-, physiotherapy in 4 States; electrotherapy in 3 States; dietetic therapy in one State. One State permits the practice of minor surgery and another midwifery. Thirty State laws specify that chiropractors can sign death certificates and 18 do not permit it. Six State laws mention that chiropractors are allowed to sign birth certificates, but in 3 others this is specifically forbidden.

All the States and the District of Columbia require a written examination for licensure. Examinations are judged by various State boards. Thirty-eight State examiner boards are composed entirely of chiropractors and 4 others have a majority of chiropractors. Of the 6 States and the District of Columbia that have a minority of chiropractors on the board, 3 will accept a certificate from the National Board of Chiropractic Examiners in lieu of the written State board examination [37].

Twenty-four States require a basic science certificate in addition to passage of a State board examination [39]. Most States require four years of chiropractic college for licensure; one State requires two years and another three years. Twenty-five States and the District of Columbia require two years of undergraduate college, 3 States require one year of undergraduate college, and 19 States require a high school education [40].

It is apparent, therefore, that State licensing laws do not restrict the scope of chiropractic practice since they do not infringe upon chiropractic philosophy or approach to health and disease. A practitioner operating under the chiropractic philosophy has no interest in the use of major surgery or drugs and therefore a prohibition against these treatments does not alter his mode of practice.

Conclusions and Recommendations

  1. There is a body of basic scientific knowledge related to health, disease, and health care. Chiropractic practitioners ignore or take exception to much of this knowledge despite the fact that they have not undertaken adequate scientific research.
  2. There is no valid evidence that subluxation, if it exists, is a significant factor in disease processes. Therefore, the broad application to health care of a diagnostic procedure such as spinal analysis and a treatment procedure such as spinal adjustment is not justified.
  3. The inadequacies of chiropractic education, coupled with a theory that de-emphasizes proven causative factors in disease processes, proven methods of treatment, and differential diagnosis, make it unlikely that a chiropractor can make an adequate diagnosis and know the appropriate treatment, and subsequently provide the indicated treatment or refer the patient. Lack of these capabilities in independent practitioners is undesirable because: appropriate treatment could be delayed or prevented entirely; appropriate treatment might be interrupted or stopped completely; the treatment offered could be contraindicated; all treatments have some risk involved with their administration, and inappropriate treatment exposes the patient to this risk unnecessarily.
  4. Manipulation (including chiropractic manipulation) may be a valuable technique for relief of pain due to loss of mobility of joints. Research in this area is inadequate; therefore, it is suggested that research that is based upon the scientific method be undertaken with respect to manipulation.

Recommendation

Chiropractic theory and practice are not based upon the body of basic knowledge related to health, disease, and health care that has been widely accepted by the scientific community. Moreover, irrespective of its theory, the scope and quality of chiropractic education do not prepare the practitioner to make an adequate diagnosis and provide appropriate treatment. Therefore, it is recommended that chiropractic service not be covered by the Medicare program.

Footnotes

  1. International Chiropractors Association, Outline for Study of Services of Practitioner's Performing Health Services in Independent Practice, (Report submitted to the Public Health Service by John Q. Thaxton, Chairman of the Board, International Chiropractors Association, July 30, 1968), p. 11. (Mimeographed)
  2. American Chiropractic Association, A Report on Practitioner Members Performing Health Services in Independent Practice, (Report submitted to the Public Health Service by Harry N. Rosenfield, Counsel, American Chiropractic Association, August 1, 1968), Section II, "Discipline," p. 9. (Mimeographed)
  3. American Chiropractic Association, Transcript of Proceedings, Independent Practitioner Study, Ad Hoc Consultant Group, USPHS, Session on Chiropractic, Thursday, 21 November 1968, A.M. session, pp. 55-56; International Chiropractors Association, Transcript of Proceedings, Independent Practitioner Study, Ad Hoc Consultant Group, USPHS, Session on Chiropractic, Thursday, 21 November 1968, P.M. session, p. 39.
  4. U.S. Department of Health, Education, and Welfare, Public Health Service, National Center for Health Statistics, Characteristics of Patients of Selected Types of Medical Specialists and Practitioners, United States—July 1—63—June 1964, Series 10, Number 28 (Washington, D.C.: Government Printing Office, 1966), pp. 37-40; and U.S. Department of Health. Education, and Welfare, Public Health Service, National Center for Health Statistics, Physician Visits: Interval of Visits and Children's Routine Checkup, United States, July 1963-June 1964, Series 10, Number 19 (Washington, D.C.: Government Printing Office, 1965), pp. 15-33.
  5. D.D. Palmer, The Science, Art and Philosophy of Chiropractic (Portland, Oregon: Portland Printing House Company, 1966), pp. 17-19. (Reprint of 1910 edition)
  6. A.E. Homewood, The Neurodynamics of the Vertebral Subluxation (n.p.: By the Author, 1962), pp. 6, 75. (Submitted to the Public Health Service by the International Chiropractors Association)
  7. Harper, Anything Can Cause Anything (San Antonio, Texas: By the Author, 1964), pp, 146-149.
  8. John M. Mennell, Back Pain (Boston: Little, Brown, and Company, 1960), pp. 18, 23-24.
  9. Batten and Associates, Inc. Chiropractic Survey and Statistical Study (Report to the Board of Directors, National Chiropractic Association, Des Moines, Iowa, [19631), pp. 2-3 (Mimeographed) (This data was compiled from the information presented on these pages)
  10. Henry Higley, D.C., "Preliminary Report on the Keever Research Project," Journal of the National Chiropractic Association, (July, 1963), pp. 1-6; George Haynes, D.C. (Dean, Los Angeles College of Chiropractic), Comments on Keever Project Report, Journal of the National Chiropractic Association, July 1963.
  11. Hugh B. Logan, Logan Basic Methods (St. Louis, Missouri: Vinton F. Logan and Fern M. Murray, 1950), pp. 219-2120. (Submitted to the Public Health Service by the American Chiropractic Association)
  12. Joseph Janse, Chiropractic Principles and Technic (Chicago: National College of Chiropractic, 1947), p. 623.
  13. Otto C. Reinert, Chiropractic Procedures and Practice (2nd ed.; n.p.: By the Author, 1965), p. 213, (Submitted to the Public Health Service by the American Chiropractic Association)
  14. James N. Firth, A Textbook on Chiropractic Diagnosis (Indianapolis, Indiana: J. N. Firth, 1948), p. 225. (Submitted to the Public Health Service by the American Chiropractic Association)
  15. B.J. Palmer Chiropractic Clinic, Neurocalometer, Neurocalograph, Neurotempometer—Research (Davenport, Iowa: By the Author, m.d.), p. 3. (Submitted to the Public Health Service by the International Chiropractors Association)
  16. International Chiropractors Association, Transcript of Proceedings, Independent Practitioner Study, Ad Hoc Consultant Group, USPHS, Session on Chiropractic, Thursday, 21 November 1968, P.M. Session, p. 39.
  17. American Chiropractic Association and International Chiropractors Association, Opportunities in a Chiropractic Career (New York: Vocational Guidance Manuals, Educational Book Division, Universal Publishing and Distributing Corporation, 1967), p. 56.18.
  18. Robinson Verner, The Science and Logic of Chiropractic (Brooklyn, New York: P, J. Cerasol, 1956), p. 229.
  19. J.R. Verner, C.W. Weiant, and R. J. Watkins, Rational Bacteriology (New York: H. Wolff, IW3), p. 1.
  20. U.S. Department of Health, Education, and Welfare, Public Health Service, National Center for Health Statistics, State Licensing of Health Occupations, Public Health Service Publication Number 1758 (Washington, D.C.: Government Printing Office, [1967]), on page 23 states that in 1965 there were 26,000 State Chiropractic Licenses in effect in 48 States and the District of Columbia. It is believed that some chiropractors hold licenses in more than one State. U.S., Department of Health, Education, and Welfare, Public Health Service, National Center for Health Statistics, Health Resources Statistics: Health Manpower, 1968, states that with the elimination of this factor, it is estimated that there are about 19,000 active and inactive chiropractors in the United States. It is believed that if chiropractic is similar to many professions, approximately 90 percent of its practitioners are active. This means there should be about 17,000 active chiropractors in the country. According to the International Chiropractors Association, Outline for Study of Services of Practitioners, p. 18, there are about 17,000 chiropractors, of whom about 15,000 are active
  21. Batten and Associates, Inc. Chiropractic Survey and Statistical Study, (Report to the Board of Directors, National Chiropractic Association, Des Moines, Iowa, [1963), pp. 2-3. (Submitted to the Public Health Service by the American Chiropractic Association). The ten states with the highest percentage of chiropractors, listed in order of decreasing percentage, are: California, New York, Texas, Missouri, Illinois, Michigan, Pennsylvania, Ohio, Iowa, Florida.
  22. Stanford Research Institute and Southern California Laboratories, Chiropractic in California (Los Angeles: The Haynes Foundation, 1960) on pages 16-23 indicates that in California in 1957 there were 31 chiropractors for each 100,000 population in the State. It was found that in a 5-county rural area the ratio was 33 per 100,000 population. This compares to a physician population ratio of 88 to 100,000, and for the entire state of 149 to 100,000. On the other hand, a study in Canada, Royal Commission on Health Services, Study of Chiropractors, Osteopaths, and Naturopaths in Canada, prepared by Donald L. Mills, (Ottawa: Queen's Printer, 1966) on page 74 revealed a "distinct tendency for these practitioners [osteopaths, chiropractors, naturopaths] to be situated in the larger cities." The report by Batten and Associates, Chiropractic Survey and Statistical Study on page 33 states that 17 percent of chiropractors were in communities of 5,000 or smaller, 71 percent were in communities of 10,000 or greater, 56 percent were in communities less than 50,000 and 30 percent were in communities greater than 100,000. Unfortunately, the term "community" was not defined.
  23. The information discussed in this section on education and research was compiled from the following sources:
    School Catalogs:
    Canadian Memorial Chiropractic College, Calendar, 1962-63.
    Chiropractic Institute of New York, Bulletin 1965-66.
    Cleveland Chiropractic College, Kansas City, Missouri, Catalog (No date)
    Cleveland Chiropractic College, Los Angeles, California, 19621964
    Columbia Institute of Chiropractic Catalog, 1962-64
    Lincoln Chiropractic College, Annual Catalog 67-68
    Logan Basic College of Chiropractic Catalog, 1963-64
    Los Angeles College of Chiropractic Bulletin 67-69
    National College of Chiropractic Bulletin 67-69
    Northwestern College of Chiropractic Catalog, 1964-65
    Palmer College of Chiropractic, Bulletin of Palmer College, Catalog issue 1968-69
    Texas College of Chiropractic Catalog, 1964-65; 1967-68
    Western States College of Chiropractic Educational Section
    Health Research Foundation Catalog, 1961-64|
    Self Surveys:
    American Council on Education, American Chiropractic Association School of Surveys:
       Chiropractic Institute of New York, 4 volumes, 1967
       Lincoln College of Chiropractic, 2 Volumes, 1966
       Logan Chiropractic College, 4 volumes, 1966
       Los Angeles College of Chiropractic, 4 Volumes, 1965
       National College of Chiropractic, 2 volumes, 1966|
       Northwestern College of Chiropractic, 2 volumes, 1966
       Texas College of Chiropractic, 4 volumes, 1966|
       Palmer College of Chiropractic, 1968-69 Self Survey
  24. H. Ronald Frogley, Dean of Academic Affairs, Palmer College of Chiropractic, letter to M.B. Jago, Executive Director, International
  25. American Medical Association, Department of Allied Health Professions and Services, Department of Continuing Medical Education of Graduate Medical Education, Department of Undergraduate Medical Education, and Association of American Medical Colleges, Medical Education in the United States," Journal of the American Medical Association, CCII (November 20, 1967), pp. 763-770\
  26. Dewey Anderson, "Memorandum to Delegates, Officers, Committee Members and Officials of the ACA,- unpublished memorandum, June 15, 1964, p. 3. (Mimeographed
  27. M. Lickens, and H. Gillet, Belgian Chiropractic Research Notes (7th ed.-, Brussels: By the Author, 1968). (Submitted to the Public Health Service by the International Chiropractors Association)
  28. B.J. Palmer Chiropractic Clinic, Electrocardiograph Changes Under Specific Chiropractic Adjustment (Davenport, Iowa; By the Author, n.d.), p. 41. (Submitted to the Public Health Service by the International Chiropractors Association)
  29. B.J. Palmer Chiropractic Clinic, Audiometric Changes Under Specific Chiropractic Adjustment (Davenport, Iowa: By the Author, n.d.). (Submitted to the Public Health Service by the International Chiropractors Association)
  30. Henry Higley, "Physiology of a Subluxation," Chirogram, (May, 1968).
  31. American Chiropractic Association, Transcript of Proceedings, Ind.3ependent Practitioner Study, Ad Hoc Consultant Group, USPHS, session on chiropractic, Thursday, 21 November 1968, A.M. session, pp. 37-38.
  32. England v. La. State Bd. of Med. Examiners, 246 F. Supp. 993 (E.D. La. 1965), aff'd mem. 384 U.S. 885 (1966).
  33. Gerard Lacroix, Chiropraxy, Vol. 11 (Quebec: Royal Commission, Chiropraxy and Osteopathy, July 1965).
  34. Royal Commission on Health Services, Vol. 11 (Ottawa, Canada: Queen's Printer and Controller of Stationery, 1965) p. 79.
  35. Stanford Research Institute, Chiropractic in California (Los Angeles, California: The Haynes Foundation, 1960).
  36. National Advisory Commission on Health Manpower, Report of National Advisory Commission on Health Manpower, Vol. 11 (Washington, D.C.: U.S. Government Printing Office, 1967), p. 330.
  37. Department of Health, Education, and Welfare, Office of Education, telephone conversation with Public Health Service Staff.
  38. Department of Health, Education, and Welfare, U.S. Public Health Service, National Center for Health Statistics, State Licensing of Health Occupations, Public Health Service Publication Number 1758 (Washington, D.C.: Government Printing Office, [1967]) pp. 23-29; The National Board of Chiropractic Examiners is explained in Opportunities in a Chiropractic Career, page 107, as follows:
    BESIDES THE STATE boards of examiners, there is also a National Board of Chiropractic Examiners which maintains close relations with the state boards. The National Board periodically conducts examinations in both the basic sciences and the principles and practice of chiropractic. They are held simultaneously in different parts of the country. Candidates who are successful in these examinations are exempt from further examination by state boards in those states which recognize the National Board. At present, the following states come under this category, and others are expected to make similar provisions as soon as the necessary legal technicalities can be complied with: Alabama, Alaska, Arkansas, Colorado, Delaware, Florida, Hawaii, Idaho, Kansas, Kentucky, Maine, Missouri, Nebraska, Nevada, No. Dakota, New Hampshire, Pennsylvania, So. Dakota, Texas, Vermont, Wyoming.
    This is a highly encouraging development. It tends to standardize licensure requirements and, of course, provides a wide range of options to the holder of a National Board certificate. The exemption applies not only to the state boards of chiropractic examiners, but also to the separate science boards in those states which have them.
  39. Department of Health, Education, and Welfare, U.S. Public Health Service, National Center for Health Statistics, State Licensing of Health Occupations, Public Health Service Publication Number 1758 (Washington, D.C.: Government Printing Office, [1967]), pp. 23-29.
  40. State Licensing of Health Occupations, p. 27; American Medical Association, Department of Investigation, Scope of Chiropractic Practice in the United States, (n.p.: American Medical Association, October, 1966) (Mimeographed); Lincoln Chiropractic College Annual Catalog 67-68 (Indianapolis: Lincoln Chiropractic College, n.d.), pp. 9-10; and International Chiropractors Association, "Licensure Information," separate section in Outline for Study of Services of Practitioners Performing Health Services in Independent Practice (Report submitted to the Public Health Service by John Q. Thaxton, Chairman of the Board, International Chiropractors Association, July 30, 1968). Mimeographed.

Appendix A ||| Table of Contents

This page was revised on August 26, 2012.

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