Chiropractic: A Modern Paradox
Stephen Barrett, M.D.
Originally Published in September 1983
In 1975, prosecution was begun of a Bethlehem, Pennsylvania, chiropractor who had advertised that "intense, fearful constricting chest pain," "blurred vision," and "numbness, pain or tingling of the arms or hands" are reasons to see a chiropractor. Other ads in the case claimed that "pinched nerves" can cause abnormal blood pressure, hay fever, sinus trouble, arthritis, pleurisy, glandular trouble, goiter, bronchitis and colds, as well as stomach, liver, kidney, and gallbladder problems. At a preliminary hearing, a medical cardiologist testified that severe chest pain could represent a heart attack requiring emergency care, and that delay in getting such care could be fatal. Seven chiropractors supported the advertising claims, one of them testifying as follows:
Q. Sir, if somebody came to you complaining of blurred vision, would you examine the eye?
A. I would examine the spine. I examine everyone's spine.
Q. If someone came to you complaining of goiter, would you examine the goiter?
A. I would examine their spine again.
Q. If someone came to you complaining of intense pain in the chest radiating down the left arm, would you examine, or would you attempt to examine the heart by using an electrocardiogram machine?
A. I only check the spine for vertebral subluxations.
Q. Would you use a stethoscope to check the heart pain at that point if somebody came to you with their complaint?
A. We don't use a stethoscope in checking the pain. We only check the spine for subluxations .
Backed by his state organization, the chiropractor engaged in a series of delaying tactics to prevent adjudication on the merits of the ads. At a subsequent hearing, the chairman of the Pennsylvania Board of Chiropractic Examiners and faculty members of three chiropractic schools endorsed the ads as accurate and representative of what is taught in the schools . The local court ruled that the case should still be tried, but it was not completed. The chiropractor's attorney was elected district attorney, creating a "conflict of interest" which made that office unable to proceed. When the local judge asked state law enforcement authorities to appoint a special prosecutor, the Attorney General's office ignored the request. The judge (no doubt relieved that his county would be spared the expense of a lengthy trial) refused to press the matter, and the case became consigned to legal limbo.
The above case raises many questions: What is chiropractic? What do chiropractors believe? What is taught in their schools? What may they legally do? What do they actually do? Are they qualified to be primary providers? Can the public be protected from its abuses? The answers to these questions are neither simple nor clear-cut.
Chiropractic is based on the beliefs of Daniel David Palmer, an Iowa grocer and "magnetic healer" who con· eluded in 1895 that almost all diseases are the result of misplaced spinal bones. According to his theory, "subluxations" of spinal vertebrae cause disease by interfering with the flow of "nerve energy" from the brain to the rest of the body. Spinal "adjustments," by restoring vertebrae to their proper places, enable the body to heal itself .
Chiropractors today—numbering about 24,000—can be classified into two main groups, "mixers" and "straights." Mixers, the larger group, acknowledge that factors such as germs and hormones play a role in disease, but regard mechanical disturbances of the spine as the major causative factor. In addition to manipulation, mixers use physical therapy modalities and may prescribe food supplements. Straights still cling to Palmer's original doctrines and tend to confine themselves to manual manipulation of the spine. A minority of straights, often referred to as "super straights," believe so strongly in Palmer's philosophy that they "do not diagnose or treat diseases." Like the chiropraetors involved in the case cited above, they merely look for and treat "subluxations." Mixers tend to belong to the American Chiropractic Association (ACA), while straights tend to belong to the International Chiropractors Association (ICA).
Degrees of belief in Palmer's theories actually form a spectrum. In 1975, the ACA's House of Delegates voted to "disaffirm the doctrine that holds to a single approach to the treatment of disease." But a 1980 survey of chiropractors on the ACA mailing list showed that most still believe that mechanical disturbances of the spine are the underlying cause of lowered resistance to disease. Questionnaires were sent to 1,000 chiropractors—presumably all mixers. Of 268 respondents, only 14% said they "do not believe that the chiropractic subluxation is a significant cause of disease." Asked whether "the chiropractic monocausal theory is scientifically supported, 5% said "completely," 75% said "partially," and only 20% said "not at all." 
Contradiction and doubletalk are actually essential to chiropractic's survival. Literal acceptance of Palmer's delusions is not politically feasible in today's scientific age; but complete abandonment would remove chiropractic's justification as a "separate and distinct branch of the healing arts." Chiropractors disagree among themselves about what to treat, how to treat, when to treat, when to take x-rav films, whether subluxations are visible on x-ray films, and much more. But this current state of confusion is used to political advantage: any embarrassing example of chiropractic belief or practice is immediately dismissed as "nonrepresentative."
Scope of Practice
Although most patients initially consult chiropractors for treatment of backache and other musculoskeletal condi tions, most chiropractors regard themselves qualified as primary physicians with an almost unlimited scope of practice. Charts relating the spine to the full range of illnesses can be found in most chiropractic offices.
In 1979, the Lehigh Valley Committee Against Health Fraud surveyed 35 chiropractic offices in the Allentown/Bethlehem/Easton area of Pennsylvania. The majority had pamphlets suggesting that chiropractic care is appropriate for such things as kidney disease, gallbladder disease, heart disease, and high blood pressure . Recently, students at Loma Linda University visited 55 chiropractic offices in 12 California cities and found a similar pattern of literature .
Additional evidence that chiropractors regard their scope as unlimited comes from advertising. The Committee's collection of newspaper ads includes such statements as:
- "There are very few diseases . . . which are treatable by chiropractic methods."
- "If every person were under regular chiropractic care, the incidence of cancer would be reduced by 50 percent in ten years."
- "There is hardly an illness that does not respond to chiropractic care."
- "Visit a chiropractor before ingesting medication when treating digestive disorders."
- In many cities, ads in the Yellow Pages offer family health care, weight-loss programs, iridology, acupressure, electroacutherapy, colonies, hair and diet analysis, and nutritional counseling. Some chiropractors express special interest in such things as menstrual irregularity, glands, athletic injuries, hypothyroidism, nervous tension, chronic headache, hypoglycemia, and "chronic and difficult cases."
Chiropractors also like to claim that "chiropractic prolongs life." However, the average age at death of 187 chiropractors noted in the A CA journal of Chiropractic from January, 1974 through October, 1981 was only 66 years.
Despite many complaints, including a petition endorsed by three chiropractors, the Federal Trade Commission refuses to take action against flamboyant chiropractic advertising, claiming that the problem is "more appropriately handled at the state level."  However, no state agency seems to care much either.
In 1968, a comprehensive study by the U.S. Department of Health, Education and Welfare  concluded that "chiropractic education does not prepare its practitioners to make adequate diagnoses or to provide appropriate treatment." The chiropractic educational system has upgraded its appearance considerably since that time.
In 1974, the U.S. Office of Education approved the Council on Chiropractic Education (CCE) as the official agency to accredit chiropractic schools. Currently there are 18 schools, 9 of which are fully accredited. Two years of pre-chiropractic education with a minimum C average are required for admission to CCE-accredited schools. To receive the doctor of chiropractic (D.C.) degree, students must complete a minimum of 4,200 hours of study over a four-year period. Courses include anatomy, biochemistry, microbiology, pathology, public health, diagnosis and x-ray examination, related health sciences, and chiropractic principles and practices. Standard medical textbooks are used for most of the nonchiropractic courses.
Chiropractors are fond of charts which purport to compare chiropractic and medical education by listing the number of hours of various courses. But since chiropractic is based on a false premise, neither length of study nor accreditation of its schools can ensure the competence of its practitioners. I will never forget how proudly one of the witnesses in the advertising trial described his curriculum at Palmer College of Chiropractic--which had included 60 hours of "ju-ni-see-ology." Somehow, during those 60 hours, he had not learned how to pronounce the word "gynecology."
Since chiropractors may not prescribe drugs, perform surgery, do invasive diagnostic tests, or care for seriously ill people in hospitals, students cannot graduate from chiropractic school without huge gaps in their knowledge. Yet once they are licensed, they may legally represent themselves as primary practitioners capable of selecting those appropriate for their care and referring the rest elsewhere. No study has been reported of how chiropractors decide whom to treat, but situations like the following are significant:
- In 1979, Mrs. J ., a 32-year-old housewife, experienced a sudden and considerable loss of hearing in one ear. The condition was medically diagnosed as permanent nerve deafness caused by blockage of a tiny artery to the inner ear. The patient accepted the diagnosis, purchased a hearing aid, and was prepared to resign herself to her handicap. The patient's mother, a chiropractic enthusiast, mentioned the case to her chiropractor. When he replied that he might be able to help, Mrs. J .'s mother insisted that Mrs. J. visit the chiropractor. After x-ray examination of the patient's neck, the chiropractor diagnosed a subluxation which he said could have been caused by a fall during childhood. He said that he had seen cases like hers respond favorably to cervical manipulation and that there was no harm in trying it. After one treatment, Mrs. J. concluded that the chiropractor was overselling himself. When she refused to pay her bill, the chiropractor brought suit in magisterial court. Despite medical testimony that spinal manipulation could not possibly help this condition, the magistrate ruled that the chiropractor was entitled to payment for doing what he is licensed to do-and in effect, that he was the sole judge of his scope of practice. Literature from the chiropractor's office suggested that more than 100 diseases—including appendicitis, pneumonia, epilepsy and erysipelas-were within that scope, but the magistrate thought this was irrelevant to the case.
- In 1982, a 65-year-old man arrived at a hospital emergency room close to death from acute pulmonary edema and azotemia. Suffering from severe kidney disease, he had been dialyzed regularly for almost a year until a chiropractor persuaded him to undergo spinal manipulation plus abdominal heat treatments instead. Three days prior to the emergency admission, the chiropractor had ordered blood tests at another hospital which revealed a creatinine of 19 and a potassium of 6.5-but he apparently failed to recognize the dangerousness of these levels.
- In 1977, a 47-year-old man consulted a chiropractor for severe leg pain of three days' duration. The chiropractor did not remove the patient's trousers, shoes or socks. He examined only the patient's back, diagnosed "lurnbalgia," and manipulated his spine. Three days later, when the patient's pain persisted, he consulted a medical doctor who realized that the problem was an occluded artery to the leg. Had the problem been diagnosed earlier, surgery could have removed the blockage. By this time, however, amputation of the leg was required . Most chiropractors would label this as an extreme or isolated example of malpractice-which it may well be-but two things are noteworthy. The fact that the chiropractor examined only the man's spine is consistent with "straight" chiropractic philosophy. Equally curious, the American Chiropractic Association thought the case was important enough to publish in its journal the following statement from its malpractice company:
It has been mentioned in various locations of the country that some chiropractors diagnose and treat patients through their clothing. Following discussion with legal counsel . . . it was determined . . . that legal defense of this kind of case was more difficult and, therefore, more costly to our company. A frequent basis for claims against our insureds is failure to diagose properly the patient's condition. A diagnosis or treatment should not be made through the patient's clothing if this will interfere in any way with giving proper care. We recommend that careful discretion concerning this procedure be exercised by all .
Chiropractic also poses a financial hazard. Many, if not most, chiropractors take courses to help build their practices. One such seminar is given four times a year by Sid. E. Williams, D.C., founder of two chiropractic colleges and current ICA president. Ads for the seminar have stated that its top instructors see 200-400 patients daily. Its major textbook outlines a systematic plan to persuade all comers to have monthly spinal exams .
The largest practice-building firm is the Parker Chiropractic Research Foundation of Fort Worth, Texas, founded by James W. Parker, D.C., the nation's most prominent chiropractor, who also is president of Parker Chiropractic College. A 1982 ad for the Parker School of Professional Success Seminar claimed that 70,000 doctors, spouses, and assistants had attended some 300,000 times, that more than 20 million "extra patients" had been served as a result, and that "increased income for chiropractic was into the billions." First-time chiropractors pay $325 for the four-day course and receive a diploma for completing "the prescribed course of study at the Parker Chiropractic Research Seminar." The first time a chiropractor attends the course, 10 percent of the fee is given to the chiropractic college from which he graduated.
In 1981, Mark Brown, a reporter from the Quad-City Times, Davenport, Iowa, attended a Parker seminar and recorded these tips from one of its instructors:
- During consultation with new patients, throw in a few knowing "Mmmmms" and "MmmmHmmms," interspersed with big and small nods. This gives the patient the impression that you understand his problem. When examining the patient, throw in an occasional "Uh-oh." This is good for patient management.
- Enter the room mortician-like when giving a report of findings to a new patient. Pause. Then hold the patient's hand . . . . In a sober voice, tell the patient, "1 'm really glad we took those x-rays."
- Commit the patient to an extended program of care before beginning treatment. If 30 visits will be necessary, schedule all 30 right then.
- Do not give an adjustment on the first visit. Chiropractors who do so become symptom-treating doctors. When the patient's symptoms clear up, he will discontinue treatment .
Peter Fernandez, D.C., of St. Petersburg, Florida, claimed last year that over 1,000 chiropractors were making six-figure incomes by using his "proven New Patient Techniques." He operates an 18-month program of workshops and consultation which costs $250 per month. Ads for the program offer chiropractors the opportunity to "tie together everything you now know about chiropractic care . . . so you can earn well over $1,000 a day regularly . . . and then go on to $2,000 days mixed in with some days when you'll earn over $3,000." Fernandez, elected Chiropractor of the Year by Parker's school (where he often lectures), has written a fascinating book called Secrets of a Practice Consultant: 7001 Ways to Attract New Patients. The following are actual quotes on how to build one's reputation when beginning chiropractic practice:
- Never go anywhere without being paged. This affixes your name in people's minds . . . . Whenever you're not busy, tell your receptionist that you are going to a certain supermarket, and to have you paged at that store, as if for an emergency. This paging procedure can be used 15 to 20 times a day very successfully.
- Your wife and/or receptionist can dial any phone number and say, "Is this Dr. So-and-So's, the chiropractor's office? I hear he is tremendous with treating headaches and I've got a terrible headache." . . . . I know a doctor who employed a woman to make these calls eight hours a day. It was her only function on his staff! He built a large-volume practice in a short time using this technique.
- People do not like to go into an office that is empty. If you act busy, you will become busy! One method of giving an illusion of being busy is to have a friend call your office on cue. Example: Your receptionist sees a patient entering the office. She dials your friend and says, "One is coming," and hangs up. A few minutes later, the friend calls the office and the receptionist talks into the phone, following this script: "Yes, Mrs. Jones, Dr. So-and-so has been very successful with headache cases . . . we'll put you down for tomorrow afternoon at 4:30." Your receptionist then writes down in the appointment book with a different color pen so she will know it is not on actual appointment.
- Have a coat hanging on the rack in the reception room. When the patient is in the reception room, the doctor can open and close doors in the back of the office, giving the impression of being busy.
- Write notes on good chiropractic literature . . . with a red pencil: "John, this man cured my headaches. Go to him!" or "Bob, this is the best doctor in the whole town! He cured the back problem that I have had for the past 15 years!" Then take this literature (with your name and location stamped on it) and lay it all over town.
The number of chiropractors actually using techniques like these is unknown. But two studies suggest that most chiropractors diagnose everybody as sick and suggest regular treatment for life. In one study, 35 Lehigh Valley chiropractors were asked how often patients who feel well should have their spines checked. The majority of chiropractors replied in the range of 4 to 12 times a year. In the other study, three apparently healthy volunteers visited a total of 16 chiropractors for a "check-up." Fifteen of the chiropractors advised treatment-but no two agreed upon what was wrong with any of the patients .
Until 1975, the American Medical Association (AMA) felt a strong responsibility to warn the public about chiropractic. The AMA Department of Investigation maintained an ongoing investigation which enabled physicians, journalists, and legislators to keep informed. This department, along with the AMA Committee on Quackery, were mothballed along with many other AMA components in the organization's financial crisis that year. When the crisis was over, however, neither body was reactivated.
In 1976, chiropractors began a series of lawsuits, charging that the AMA, other prominent professional organizations, and several individual critics, had conspired to de· prive chiropractors of their legal rights. Because chiropractors are licensed, the litigants reasoned, conspiring against them was a violation of antitrust laws. When the key trial was held, the jury ruled decisively against the chiropractors. The appeal process is still under way, however, and the suits have discouraged medical organizations from engaging in antichiropractic activity. Many medical leaders no longer feel that Medicine has a special responsibility to protect the public against quackery. As a result, many physicians who want information about chiropractors are finding it difficult to obtain.
Coping with Chiropractors
Chiropractors have made it clear that they want most of the privileges of medical doctors without the accompanying responsibilities. While some are content to practice modestly and conservatively in their offices, others are campaigning for hospital privileges. Pathologists and radiologists are being asked to perform tests or send reports ordered by chiropractors, and other physicians are being asked to accept referrals and to share their findings. When faced with these requests, doctors feel uneasy: if they do not cooperate, will they be sued?
In my opinion, the answer is no. There is no law which says that physicians must take orders from chiropractors. Until the antitrust suits are finally resolved, there may be legal risks for medical organizations to engage in antichiropractlc activities. However, independent action by an individual physician cannot create grounds for an antitrust suit. Despite the belligerent reputation of chiropractors, lawsuits against individual physicians are extremely rare; and, as far as I know, none has ever been successful.
The key principle for dealing with chiropractors is to do what is best for the patient:
- If a chiropractor asks you to perform a laboratory test or x-ray examination, unless you have personal knowledge that the chiropractor is qualified to interpret this information correctly, the request should be ignored. There is little reason to believe that giving medical information to a misguided practitioner will enhance a patient's chances of getting appropriate care.
- Referrals for treatment should be accepted. There is no reason to deny medical care to anyone simply because he has been referred by a chiropractor. However, if an acknowledgement is given, it should be done by telephone. Correspondence from physicians can be misused by chiropractors to boost their prestige.
- If a patient asks that existing reports be sent to a chiropractor, the reports should be offered to the patient. Patients have a legal right to see their records. Seeing a medical report-particularly a normal one-may even protect the patient from a chiropractor who wishes to treat nonexistent spinal problems.
- If a chiropractor wishes to discuss an x-ray film he has taken, such consultation should be provided only if the chiropractor agrees in advance that a report be sent to the patient's medical doctor if medical care is indicated.
- DeMartino JM. Testimony in Barrett vs. LaBarre, Northampton County Magisterial District 1-1, Dec. 17, 1975, pp. 13-134.
- Fitterer, BP, Flescia J, Smith WM, Clum GW. Testimony in LaBarre vs. Gallagher, Northampton Court of Common Pleas, No. 23 Oct. Term, 1976, Feb. 17, 1977.
- Palmer DD. Text-Book of the Science, Art and Philosophy of Chiropractic. Portland, Oregon: 1910, Portland Printing House Company, p. 20.
- Quigley WH. Chiropractic's monocausal theory of disease, ACA Journal of Chiropractic, June, 1981, pp 52-60.
- Barrett S. The Spine Salesman. In Barrett, S.: The Health Robbers, 2nd Ed. Philadelphia: George F. Stickley Co., 1980.
- Jarvis WT. Personal communication to Dr. Barrett, 1982.
- Federal Trade Commission. Letter to Dr. Barrett, March 9, 1979.
- Cohen W. Independent Practitioners under Medicare, A Report to Congress. Washington, D.C.: U.S. Dept. of Health, Education and Welfare, 1968.
- Modde P. Malpractice is an inevitable result of chiropractic philosophy and training. Legal Aspects of Medical Practice, Feb. 1979, pp. 20-23.
- Dallas H. NCMIC clarifies its requirements for malpractice insurance coverage. ACA Journal of Chiropractic 16:27,32, 1979.
- Williams SE. Dynamic Essentials of the Chiropractic Principle, Practice and Procedure ("Blue Senior Textbook"). Marietta, GA: Si-Nel Publishing Co. (undated).
- Brow, M. Chiropractic: How much healing? How much flim-flam? Quad-City Times, Davenport, Iowa, Dec. 13, 1981, p. 3.
This article was posted on November 6, 2019.