Essential Principles of Chiropractic

ESSENTIAL PRINCIPLES OF CHIROPRACTIC

Philosophy

ESSENTIAL PRINCIPLES OF CHIROPRACTIC

Virgil V. Strang, D.C., H.C.D. (Hon.) Dean of Philosophy & Director of Professional Ethics

Philosophy

Palmer College of Chiropractic DAVENPORT

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ACKNOWLEDGMENTS I wish to thank the following individuals for their cooperation and assistance in preparing this book: WILLIAM McDONALD, B.S., D.C. - CONTRIBUTING EDITOR Natalie Burrows, B.S. - Manuscript editor Gregory Borror, B.A., D.C. - Index compilation Douglas Payne, D.C. - Resource material Fred Barge, D.C. - X-rays Burl Pettibon, D.C. - X-rays Glenn Stillwagon, D.C. - X-rays

Copyright C 1984 Virgil V. Strang All rights reserved. No part of this publication may be reproduc� or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission of the copyright holder.

Second Printing First Edition January, 1985

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"The French critic, Remy de Gourmont, observed that 'very simple ideas are within the reach of very complicated minds only. ' This is especially true of philosophy. "

E.W.F Tomlin The Western Philosophers

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CONTENTS

-V� Acknowledgments

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Foreword

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Chapter One THE PURPOSE of CHIROPRACTIC PHILOSOPHY

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Chapter Two THE NATURE OF HEALTH & DISEASE

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Chapter Three THE SCIENTIFIC BASIS of CHIROPRACTIC

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Chapter Four THE CLINICAL RESULTS of CHIROPRACTIC

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Chapter Five THE CHIROPRACTIC APPROACH TO PATIENT 90

CARE Chapter Six PROFESSIONAL & ETHICAL CONCERNS

118

Chapter Seven BEYOND THE SUBLUXATION

146

Appendixes

SELECTED QUOTATIONS of D.O. PALMER A THOUGHT ON HOMEOSTASIS Index

155 166 167

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FOREWORD

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Whenever the word chiropractic is mentioned, an observer would most frequently hear the words D. D. Palmer, Palmer College of Chiropractic and Davenport, Iowa, as well. This association of a pro­ fession, a person, an institution and a community is, of course, not coincidental but is a direct outgrowth of the facts of history. From time to time over the decades since chiropractic was discovered in 1895, books have been authored at Palmer College and elsewhere which contribute to the informational fabric of our pro­ fession. They address many aspects of the chiropractic concept and the development of the philosophy, science and art of this youngest member of the healing arts. Our history has sometimes had stormy episodes, but always our growth and development have been in a positive direction. During a significant portion of the approximately ninety years of our existence, the author of this particular effort has been appropriately classified as an anatomist, a chiropractic philosopher, a practitioner and as a spokesman for professional ethics. Dr. Virgil Strang, a friend and a colleague, is widely known for his views on health in general and chiropractic in particular. He always has seemed to perceive health in terms of its broadest possible meaning and, therefore, has en­ visioned for his students and others a great role for our profession. Dr. Strang, in my opinion, has personified the grasping of the "big idea;" and I feel we are fortunate, indeed, to have his contribution in these pages which comprise the most extensive book on chiropractic philosophy to be published in over fifty years. It is only appropriate that a thirty-three year member of the faculty of Palmer College be the author of this effort. He has been actively involved during both the storm and the calm. I believe everyone associated with chiroprac­ tic, as well as everyone searching for or wishing to maintain their health, should find much food for thought in this book. Jerome F. McAndrews, D.C. President Palmer College of Chiropractic

n THE PURPOSE OF CHIROPRACTIC PHILOSOPHY

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The Purpose of Chiropractic Philosophy

B oth medicine and chiropractic can trace their lineage

to Hip- """"'"

pocrates, the celebrated Greek physician of 400 B. C. l While both professions still retain elements of his philosophy and teachings, the truth is Hippocrates' medications and manipulations lacked the distinc­ tive modus operandi inherent in the practice of contemporary medicine and chiropractic. The birth of medicine as we know it occurred in 1860 when Robert Koch postulated the germ theory. Chiropractic made its real start in 1895 when D. D. Palmer went beyond crude manipulation, boneset­ ting, traction and massage by introducing the specific, short-lever vertebral adjustment. The impact of these developments was profound. In a relatively short time, both professions had been so thoroughly seduced by their new therapeutic concepts that members in both groups openly issued lofty predictions and claims. While giving lip service to the importance of preventive health care, the medical profession put most of its eggs in the germ-theory basket. Microbes were the great cause of disease. Nutritious diet, adequate rest, clean air and water, regular exercise, proper posture and the alleviation of stressful living were of little clinical import. The patient became passive as the doctor became active. The patient was the innocent victim of a "bug"; it was up to the physician to find it and kill it. The German physician Emile von Behring typified many medical doctors who felt, in the words of Rene Dubos, that "all important infections would eventually be controlled by the use of therapeutic serums and prophylactic vaccines specific for each and every type of microbe. "2 Not to be outdone, B. J. Palmer, son of D. O. Palmer (chiroprac­ tic's founder), proclaimed unqualifiedly that the vertebral subluxa­ tion was "the cause of all disease. " The cure, of course, was the chiropractic adjustment. To most early chiropractors, practically all disease was the result of an encumbered nervous system which, in turn, was due to slight misalignments, protrusions and occlusions of the spinal column. Enamored with their clinical results, chiroprac­ tors also went through a period when they played down the patient's need to follow a well-balanced health regimen. The success of medicine and chiropractic put tremendous pressure

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The Purpose of Chiropractic Philosophy on the other three turn-of-the-century health care professions. The naturopaths eventually lost out to the chiropractors,

and the

homeopaths fell in the wake of medicine. Osteopathy, with its roots in medicine, slowly returned to the fold; today, most osteopaths are indistinguishable from medical doctors. Though this is not meant to be a history book, it is impossible to pursue chiropractic philosophy to any length without taking note of certain early developments within the profession. It was almost in­ evitable that the absolutist dictum of "one cause-one cure" could not be made to stick. In addition to the M. D. 's who took up chiroprac­ tic, there were others3 in the profession who did not accept the theory that the vertebral subluxation was the sole cause of disease; even­ tually their position would carry the day. It followed that without the theory of singular cause, there could hardly be a singular cure. The resolution of this issue did not, however, bring calm to the chiropractic profession. The old political and philosophical groupings of broad­ and limited-scope chiropractors (the so-called "mixers" and "straights") have continued to skirmish, primarily over the question of what con­ stitutes the chiropractor's proper scope of clinical services. Nowhere are the old battle scars more evident than in the doc­ trinaire language used by the two factions: chiropractor vs. chiropractic physician; subluxation vs. fixation or lesion; innate intelligence vs. nature or homeostasis; analysis vs. diagnosis; and adjustment vs. manipulative therapy. These are some of the time-worn watch-words that have sparked many an argument. Because of this fact, this book will subscribe to neither vocabulary. For example, at times "innate intelligence" will be used, at other times "nature" or "homeostasis' � .' will be used. If the basic chiropractic principle exists, then words or' terminology can not change it. D. D. Palmer, B. J. Palmer, Willard Carver, John Howard, or A. L. Foster, to name a few early leaders, did not manufacture chiropractic. They simply recognized the ex­ istence of it and spent their lives trying to better understand it. For example, several times B. J. Palmer made radical changes in his think­ ing and practice (meric system, x-ray, neurocalometer, hole-in-one, and then a re-embracement of full-spine adjusting). He wrote, "I have been a constant research student, seeking further light in newer and better explanations of solutions of unknown problems hidden in our new science." The early leaders in chiropractic never allowed their

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The Purpose of Chiropractic Philosophy thinking to become fossilized. So, by de-emphasizing reactionary,

\

polemic terminology of various camps, it is hoped that attention can be focused on the main themes of chiropractic.

As a result of the events of the past 100 years, today's health care consumer is faced with two very different practitioners. The medical doctor, steeped in allopathic4 philosophy, and the chiropractor, guided by the tenets of chiropractic philosophy, offer themselves to a sometimes bewildered public. How can two physicians study the same textbooks for four years, peer through microscopes at the same microbes, and dissect similar cadavers, only to come to such different conclusions as to the nature of health and disease? The answer is found in the particular facts which the two choose to emphasize and in the patterns in which those facts are then arranged. For example, homeostasis and secondary drug resistance are two scientific concepts which, to the chiropractor's mind, provide support for a more cautious, limited use of chemotherapy. It is this activity - the piecing together of facts from the unending encyclopedia of scientific and clinical knowledge - that is the func­ tion of chiropractic philosophy. In short, chiropractic philosophy is concerned with explaining in highly specific terms the art and science of chiropractic. That explanation includes what the chiropractor does and why. Chiropractic philosophy has long been stressed by the chiroprac­ tic profession as a matter of survival. When it comes to making deci­ sions about health and disease, the vast majority of individuals automatically think in terms of traditional allopathic philosophy. Disease to most lay people seems a "thing" that comes from outside the body and "strikes" or "invades" for no recognizable reason; in fact, we frequently hear individuals say that they have been "lucky" not to have contracted a particular disease. Given the above medical model as a common reference point in our culture, chiropractic can not and does not "make sense." Only once the patient understands the "chiropractic model" can the doc­ tor of chiropractic function under optimum conditions. In fact, medical researchers at the University of Utah have found that the chiroprac-

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The Purpose of Chiropractic Philosophy tor's effort to make chiropractic understandable to the patient con­ tributes to effective therapy.5 Not only must chiropractors and their patients have a grasp of chiropractic philosophy, but so must a wider portion of the general population. Many individuals who could benefit from chiropractic ser­ vices have not done so because they viewed the chiropractor through allopathic lenses: "I need something for my asthma - not my back adjusted. " Fortunately, chiropractic is becoming better understood by both the general public and the medical community. Patient refer­ rals to chiropractors by M. D. 's have risen sharply in recent years; in fact, the number of medical physicians who themselves receive chiropractic care seems to be on the increase. The ensuing pages, in addition to providing an explanation of chiropractic, deliniate and underscore those tenets and principles which are considered essential to the chiropractic profession. Where major questions and long-standing points of contention exist within the profession, an attempt is made to suggest answers and solutions. The proposals in these specific situations are made with the hope of fostering unity within the profession while maintaining a consistency to our philosophy. It must be mentioned that chiropractic philosophy, like classic philosophy, should not be chiseled in stone. It must be alive, ever ready to accommodate new, relevant discoveries in science. As the 20th century philosopher C. E. M. Joad wrote, "In philosophy, then, as in daily life, cocksureness is a function of ignorance. "6

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The Purpose of Chiropractic Philosophy

CHAPTER ONE FOOTNOTES ISchafer, ed. , Chiropractic Health Care, 3rd ed. (Washington, D. C. : Foundation for Chiropractic Education and Research, 1978), p. 14. 2Rene Dubos, Mirage of Health (New York: Harper and Row, 1959), p. 152. 30.0. Palmer, The Science, Art and Philosophy of Chiropractic (Portland, Ore. : Portland Printing House Co. , 1910), pp. 75 and 100. For example: Willard Carver, president of several early chiropractic schools, argued that "suggestions" should be considered a cause of disease. Even D. O. Palmer, chiropractic's founder, be­ lieved that the vertebral subluxation was the cause of only 95 per­ cent of the diseases, with the other five percent being due to articular derangements elsewhere in the skeleton. 4� ohn Friel, Dorland's Illustrated Medical Dictionary,

26th ed.

(Philadelphia: Saunders, 1981), p. 50. The allopathic physician seeks to produce a condition incompatible with the condition to be cured. SKane, et al., "Manipulating the Patient

-

A Comparison of the Ef­

fectiveness of Physicians and Chiropractic Care, " The Lancet (June 29, 1974), p. 1336 as quoted in Schafer, op. cit. , p. 93. 6C.E.M. Joad, Philosophy, 3rd, ed. (New York: Fawcett World Library, 1966), p. 10.

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� THE NATURE OF HEALTH AND DISEASE

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The Nature of Health and Disease NOTE TO THE READER: The purpose of this chapter is to examine the distinctions that exist between chiiropractic and medical thinking regarding the concepts of health and disease. Because we seek to delineate differences, this chapter is purposefully polemic and pointed in its observations of medicine's philosophical and practical shortcom­ ings. At no time, however, do we want the reader to think that we are proposing that chiropractic is a substitute for medicine. It is foolish for either discipline to attempt to supercede the strengths of the other. No single healing art can boast of having all the solutions to the myriad ailments besetting mankind.

D

orland's Illustrated Medical Dictionary defines health as "a state of optimal physical, mental, and social well-being, and not merely the absence of disease and infirmitx . " Dorland's defines disease as i1 any deviation from or interruption of the normal structure or func­ tion of any part, organ, or system (or combination thereof) of the body that is manifested by a ch aracteristic set of symptoms and signs and whose etiology, pathology, and prognosis may be known or unknown . " Several observations about the above definitions are in order. While this medical definition of health does succeed in broadening the con­ cept by including "mental and social" aspects, it fails to clearly break with the notion that health is s ther than the "absence of disease . " To say that health i "well-being' (literally being well) is to add little to our understanding of t e concept . Even the modifier "op­ timal" does not make well-being take on any new meaning; it sim­ ply emphasizes that the person is well, as in the expression "very well." In short, this updated medical definition fails to offer a convincing blow to the old notion that health is the absence of disease . Actually, this erroneous view - that health is the absence of disease - meshes perfectly with the way medicine is practiced . Consider for a moment the traditional allopathic doctor-patient relationship . In keeping with the philosophy of allopathy, the doctor seeks to establish conditions within the patient which are incompatible with or antagonistic to the disease . The suspected causative agent is to be driven out, so to speak, by subjecting it to oppressive conditions (e .g., subjecting a streptococcal infection to streptomycin) . Throughout the "battle ," both the doctor and patient adhere to certain tacit assump17

The Nature of Health and Disease tions: 1 ) that the body works like a machine (bioengineering and biomechanics are two representative "buzz" words) , 2) that the disease usually occurs because the body has been overpowered by one or more environmental factors (microorganisms, toxins, etc . ) , 3) that disease is an entity , and as such , it should be the focus of the doc­ tor's attention and ministrations, and 4) that upon banishment of the disease , the patient's health will have been restored . Remember, we are not talking about what the doctor professes to believe , but what the doctor does in the clinic . In practice , allopathy has stressed the importance of the external environment, and in doing so, has failed not only to take into ac­ count the body's ever-changing, adaptive internal environment, but also to fully appreciate the crucial interrelationsr.:ps between those two environments . As a result, allopathy uses as its work-a-day reference, a conceptualization of the human organism which is devoid of any meaningful role for what anatomists and physiologists con­ tend is the essential feature of our biological makeup : homeostasis . When confronted with this charge, medicine issues an emphatic denial , citing both literature and specific diseases where physicians do take into account the body's natural homeostatic mechanisms in ridding the patient of disease . But these evidences are misleading. In the end , medicine must be judged by the customary clinical picture it presents . Too many physicians, for too many years have treated too many symptoms in­ stead of causes. This fact testifies to the allopath's general disregard for the role of homeostasis . The body can and will rid itself of most symptoms, provided the cause is removed . � lIopaths regularly give medications for the express purpose of depressing body temperature . The Merck Manual of Medicine reminds physicians that "Treatment of fever must be directed to its cause . " But instead of addressing the cause of the rising temperatur� the 'L physician too often impulsively treats the symptom - the feve& ain suppression is another prime example of the allopathic tendency to focus on symptoms . It is one thing to offer pain suppressing drugs to a dying 85 year old; it is quite different to administer pain killers to a 20 year old who has fallen on his sacrum . The latter needs to have the irritation and pain removed by a corrective adjustment, not masked by a depressant . The use of corticosteroids is another ex-

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The Nature of Health and Disease ample from the unending list of symptom treatments used by modern­ day allopaths. Corticosteroids do not attempt to get at the cause of inflammation , and, like many medications, there are serious side ef­ fects which can accompany their use . Typical of allopathic thinking is this statement from a medical text: "The rationale for corticosteroid use is that it provides a mechanism which will reverse the inflammatory response and hopefully avoid neural fibrosis. " Why eliminate the inflammatory response? It is not the real problem . The inflammatory response is only a symptom of a deeper problem . Furthermore , why is the emphasis in medicine so one-sidedly on finding a new treatment? Why not a similar in­ terest in finding out how we can keep people from getting inflamed joints. Chiropract'o¥s , some osteopaths, and to a limited extent den­ tists and podiatrists more fully appreciate and utilize preventive health care measures . What is at the very bottom of the philosophical and clinical dispute between chiropractors and allopaths? What is the major point which causes the two professions to diverge? It is this: iropractic views the human being as being continually in flux along a biologic con­ tinuum . Both philosophically and clinically, chir ractic rejects the common notion that a person is either sick or w The adage , "An apple-a-day keeps the doctor away, " shows that we have learned to associate the physician with disease care , not health care . Why? Because the typical practicing physician treats disease after it has made its appearance . Why does the physician treat disease afterwards, but not before it develops? Two reasons. First, patients often wait long after they should before seeking help . But secondly, and most importantly, allopathy is shackled by the belief that a human being is either sick or well . As we noted earlier, their definitions of health and disease do not escape this conclusion . Despite physicians' arguments to the contrary , when we observe them in practice, they give ample evidence that they do believe that people are either sick or well. What would happen if you asked a physician for erythromycin when you were not infected? The doctor would , of course , refuse your request . The same if you asked to have a cast placed on your arm and your arm was not broken . Likewise, if you asked to be placed in traction but your back was not hurting . These examples are not intended to imply that the physician should treat these patients . The

E.h

�

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The Nature of Health and Disease object is to call attention to the fact that the physician, by training, philosophy and particularly by armamentarium , is prepared to treat any patient provided the patient has specific signs and symptoms of a specific disease . In short, you must be sick to get "health care . " e chiropractor, o n the other hand , is desirous of seeing the pa­ tient early in the degenerative process, preferably before symptoms arise . The chiropractor is not looking to treat disease . The chiropractor is looking for interference to the nervous system , a condition which can be cared for before the patient begins to experience serious symp­ toms and disease .

lfh

The chiropractor has a fundamentally different way of assessing a person's condition relative to health and disease . The following is an explanation of the chiropractic approach to assessing the in­ dividual's ever-changing physiological status. This chiropractic con­ struct can be called State of the Organism. "State of the organism" js used instead of "state of health" because the latter carries with it two problems: 1 ) since "health" tends to be thought of in the tradi­ tional and erroneous view1:hat health is the absence of disease!. "state of health" tends to be viewed as simply the degree to which disease is absent, and 2) "state of health" reflects in its syntax and t:ommon usage the attitude that health is an entity and that health (and disease) are visitors who willy-nilly come and go . The implication is that the body is merely a motel which suffers the damages or reaps the prof­ its from these two travelers. State of the organism , on the other hand, is a term which focuses on the amic state of the body as it operates along a biological continuum . �ate of the organism consists of three aspects: 1) the biological spectrum , 2) the state of the organism equa­ tion, and 3) the calisthenic dynamf

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THE BIOLOGICAL SPECTRUM. The human being functions within a biological continuum which extends from what might be called "ideal functional wellness" at one end to "death" at the other end . It is im­ portant that this concept be given full realization in clinical practice . Otherwise, patients are viewed as just sick or well , with little atten­ tion given to that portion of the spectrum between the extremes. In reality, the patient passes through a continuum on the way to ex­ pressing disease . From "ideal functional wellness, " the organism moves to a status which may be termed "departure from wellness , " 20

The Nature of Health and Disease

then to "dis-ease" (lack of ease , coordination , or adaptation) and on to the expression of a specific "disease , " complete with the signs and symptoms which give the particular disease its name . It must be remembered that the organism is continually in flux along the biological spectrum . So not only do we want to know where the patient is on the spectrum at a given time, but we want to know in which direction the state of the organism is moving. Properly seen , a symptom tells us only that change is taking place; it does not tell us in which direction . The direction can be determined only by further evaluation . Given the perspective of the biological spectrum , we begin to put signs, symptoms and disease into their proper place . Instead of see­ ing individuals as being either sick or well , we begin to see them as being in flux, usually somewhere between "ideal functional wellness" and "disease . " We begin to see a need for state of the organism care - not health care (which in our society is disease care) . We begin to see the need for care that addresses patients precisely at their posi­ tion and direction of movement on the biological spectrum . We begin to see that traditional disease care meets the needs of only a small proportion of the population . Disease care has little to offer those millions of individuals who are somewhere between the extremes of "ideal functional wellness" and "disease ." As Joseph Janse, longtime president of National College of Chiropractic, once observed:

LYnless pathology is demonstrable under the microscope,

as in the laboratory or by roentgenograms , to them [al­ lopaths] it does not exist . For years the progressive minds in chiropractic have pointed out this deficiency. With em­ phasis\ fuey [chiropractors] have maintained the fact that prevention is so much more effective than attempts at a cure ! They pioneered the all-important principle that ef­ fective eradication of disease is accomplished only when it is in its functional (beginning) phase rather than its organic (terminal) stage . It has been their contention that in general the doctor, the therapist and the clinician have failed to realize exactly what is meant by disease processes, and have been satisfied to consider damaged organs as disease, and to think in terms of sick organs and not in terms of

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The Nature of Health and Disease sick people. In other words, we have failed to contrast disease with health, and to trace the gradual deteriora­ tion along the downward path, believing almost that mild departures from the physiological normal were of little con­ sequence, until they were replaced by pathological changes...

1.:j

STA TE OF THE ORGANISM EQUATION. In a simple mathematics equation such as x·y= 10, the interacting factors (x·y) form an equilibrium with the resultant (10) . Two examples of this equation would be 2·5=10 or 10·1=10. It is possible to use this elementary equation to approximate the general interrelationship that exists be­ tween the body's external and internal environments. As is commonly known, the body normally maintains an internal temperature of 98.6° F despite ups and downs in the temperature of the environment. This important physiological fact can be represented by the equation Te ·Oi=98.6°F, wherein Te is external temperature and 0i is inter­ nal dynamics (not internal temperature). For example, when Te is 100°F we find that 0i must assume an adjustment factor of only,.986 in order to maintain the normal internal temperature: Te (100°) . 0i(.986) 98.6°F. But when Te drops to 20°F, the 0i increases to 4.93 adaptation factor: Te (200).Oi (4.93) 98.6°F. The purpose of including the foregoing crude equation is to make the point that the body is not merely a static entity acled upon by external conditions. Each individual possesses an intrinsic, biological dynamic that interacts with and greatly modifies the external forces with which it comes in contact. This ever-present interaction of in­ ternal and external forces is evident not only in temperature maintenance, but in such other examples as the digestion of food (body chemistry adaptively interacting with foodstuffs from the en­ vironment) , the circulation of blood (blood pressure and heart rate adaptively interacting with the forces of gravity and atmospheric pressure) , and resistance to disease (neutrophils adaptively interact­ ing with an immune complex) . We can say that an individual's state of the organism is the prod­ uct of the interrelationship of the total internal dynamic and the total external dynamic. The product of this state of the organism equa­ tion determines the position that an individual occupies at any given =

=

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The Nature of Health and Disease time in the biological spectrum. It must be remembered that since the internal and external factors of the equation are constantly and sometimes drastically changing, they do not always produce the desired resultant (Le., Te . Di 105° F!). The state of the organism equation stresses the fact that an organism does not experience a change in the resultant (e.g., malabsorption of food) unless change has occurred in one or more, or all, of the internal and external factors of the equation. It should also be noted that hundreds of external and internal factors may undergo change while the overall condition of the organism remains constant. The concept of the state of the organism being the result of an equation is helpful in illuminating the philosophical and practical differences between allopathic and chiropractic physicians. Chiropractic em­ phasizes the fact that when the patient's state of the organism �ndergoes a departure from the Ideally well state, it is most Iike!y due to an aberration in the internal dynamic - not an external fac­ �. This we know from the statistical fact that wellness is much more common than illness, despite the fact that we live in a continually changing, ever-threatening environment (toxins, traumas, microrganisms, temperature extremes, poor diet, stress, etc.). Because the human organism is blessed with such a powerful homeostatic mechanism, chiropractic focuses its attention on those factors - in­ sults to the neural system and disregard for the common rules of health - which most readily undermine the body's resistance. The goal is to restore resistance before a serious disease can develo . And primary to the body's interna stabilitv is its ability to instantly and acclITately sense itseI=lViF9nmQI=lt Equally important is the body's ability to react to this information in an unfettered, uninterrupted fashion. For these reasons, the vertebral subluxation with its crucial relationship to the> spinal cord and the spinal nerve roots is of utmost concern to the chiropractor. On the whole, allopaths do not deny the importance of such con­ cepts as homeostasis and preventive care. But judging from the way Western medicine has applied its knowledge and technology, it is evident that the predominant focus has been on the external factor in the state of the organism equation. As an article in Preventive Medicine noted, modern medicine "...knows virtually nothing of those positive factors responsible for wellness in individuals and societies." =

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The Nature of Health and Disease The article continues, "There is a need therefore, for attention to early departures from health, not yet expressed as illness, much less as classifiable disease." 2 None of the above is meant to imply that attention should not be given to either the treatment of advanced stages of disease, or to the external factors in the state of the organism equation. Quite obviously the environment can and does supercede internal dynamics, thus producing disease. The error is, and has long been, in the inappropriate reliance upon late-stage heroic measures to "save" the already diseased patient. Why has this grotesque pattern of "health care" developed? It can be traced, in part, to the early influence of the apothecary. Competition between the pharmacist and physician gave way to a new alliance that saw the "druggist" bring to the "doctor" a total fixation on the external world. Given this predilection for external causes and the emphasis on the diagnosis of diseases, one is not surprised at the short shrift given to preventive medicine. After all, preventive care has no external toxins or microbes to neutralize or vanquish and no well-developed signs or symptoms to read. THE CALISTHENIC DYNAMIC. The human organism can adapt to and successfully function within a wide range of external condi­ tions, provided it is given regular exposure to those conditions. The body can, for example, operate efficiently at high altitudes if given the chance to experience those low oxygen conditions for a few weeks. The body can learn to live quite well in very cold regions of the earth, provided there is first a period of acclimation. The body can develop long-term immunity to an otherwise harmful microorganism simply by experiencing an initial exposure which trig­ gers the production of antibodies. When the human body is called upon to function throughout a wide range of conditions, it becomes generally strengthened and en­ joys an enlarged scope of adaptability. So, rather than being victimized by the external world, the body actually increases its survivability by fully experiencing its surroundings. SUMMARY OF THE STA TE OF THE ORGANISM. When think­ ing of an individual's state of the organism (as opposed to state of health) we think in terms of 1) the biological spectrum, 2) the state

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The Nature of Health and Disease of the organism equation, and 3) the calisthenic dynamic. Briefly, the biological spectrum goes beyond the simplistic, erroneous view that the organism is either sick or well. Instead the biological spectrum is seen to extend from ideal functional wellness, through departure from wellness, moving to "dis-ease," continuing on to disease (many types, characterized by their signs and symp­ toms) and ending with death. Instead of health care, which today means disease care, we also need chiropractic or state of the organism care - care that addresses dysfunction at its early stages (departure from wellness and dis-ease). The state of the organism equation stresses that the state of the organism is the result of the interplay of external and internal forces, with the body's internal dynamic being the most important factor most of the time. Therefore, chiropractic concentrates on correcting the vertebral subluxation and restoring a regard for the common rules of health - the two factors which so frequently weaken the body's natural resistance to potentially destructive external factors. The main point of the calisthenic dynamic is that the body learns to adapt to a wide range of external conditions by experiencing a wide range of conditions. The phrase "use it or lose it" is certainly true of the body's homeostatic and defense mechanisms.

In discussing the nature of health and disease it is instructive to look at the ever-present, ever-popular notion that we are on the verge of a "new era" that will bring the ravages of disease under control. In Mirage of Health, Rene Dubos writes: Modern man, probably no wiser but certainly more con­ ceited, now claims that the royal avenue to the control of disease is through scientific knowledge and medical tech­ nology. 'Health is purchasable,' proclaimed one of the leaders of American medicine. Yet, while the modern American boasts of the scientific management of his body and soul, his expectancy of life past the age of forty-five

25

The Nature of Health and Disease is hardly greater today than it was several decades ago and is shorter than that of many European people of the pres­ ent generation. ...He is encouraged to believe that money can create drugs for the cure of heart disease, cancer, and mental disease, but he makes no worth-while effort to rec­ ognize, let alone correct, the mismanagements of his every­ day life that contribute to the high incidence of these con­ ditions . ...One out of every four citizens will have to spend at least some months or years in a mental asylum. One may wonder indeed whether the pretense of superior health is not itself rapidly becoming a mental aberration. Is it not a delusion to proclaim the present state of health as the best in the history of the world, at a time when in­ creasing numbers of persons in our society depend on drugs and on doctors for meeting the ordinary problems of everyday Iife?3 QUite obviously we, as a group, are not experiencing "good health." Likewise, we are not on the verge of a general breakthrough in the control of disease. Cancer, stroke, heart and various arterial diseases, as well as mental illness, form a massive constellation of serious �ff1ic­ tions which are reflective of our "modern way of living." There is no true cure for a lifetime of misgUided, unhealthy living. Air pollu­ tion, impure water, excessive food additives, lack of exercise, over­ use of antibiotics, the masking of problems (emotional and physical) with pain-killers and "uppers" and "downers" (both legal and illegal), faulty diet, alcohol, tobacco, not to mention a gross disregard for the integrity of the musculo-skeletal system (60% of the body) are but a few of the factors which contribute to the onset of today's major "lifestyle" diseases. And just as destructive is the widely-accepted no­ tion that one's health is dependent upon the physician - that somehow the individual is divorced of meaningful responsibility for personal health. The belief that health is mainly dependent upon the right combination of good drugs, good doctors and good hospitals is the driving force behind both increasing medical expenditures and chronic sub-par health. If we learn anything from the history of health care, we should learn that mankind lives with (not apart from) other forms of life. The

26

The Nature of Health and Disease "breakthrough" of antibiotics was seen (IS the beginning of the end for serious infections. Now we suffer the two-fold problem of "resis­ tant strains" and patients who have lost much of their natural defenses because of chronic antibiotic consumption. As long as we entertain the idea that we can overcome nature, we are sure to see our "health care" schemes backfire or disappoint. The Journal of the American Medical Association was obviously distressed to report that despite such innovations as antiarrhythmic therapy, "any contribution of improved medical care to the nationally observed secular decline in mortality from coronary heart disease in the time period studied (1968-1976) was probably restricted to the acute stage of myocardial infarction."4 The list of "breakthroughs" and "miracle" drugs, and of "new" treatments and operations which have appeared on the scene, remained in vogue for a few years, and then were discarded is seemingly endless. We are not talking about modalities that were simply replaced by improved treatment methods. We are talking about new medications or procedures that were later found to lead too frequently to complications and worsened health� Examples range from the tragic extremes of thalidomide and DES (diethylstilbestrol) to the now devalued tonsillectomy and disc­ ectomy. As the spinal surgeon Finneson notes, "The large number of lumbar discectomies performed in this country seems to indicate a wide streak of optimism within the personalities of spine surgeons. At the same time, those of us who tend to see large numbers of surgical failures become increasingly pessimistic and skeptical about the relative value of low back surgery."5 There are two points to be obtained from the last few paragraphs. First, whenever we begin to tamper dramatically with the body, either with drastic intervention or alteration of the body's mechanisms or functions, or through long-range programs of "maintenance" medica­ tion, we run serious risks of weakening the individual's ability to resist disease, to adapt to changing conditions, and to recover the lost health that precipitated the interventi For example, you may through medication cause the blood pressure to read normal, but the body is not producing that blood pressure in a physiologically normal man­ ner. The medication is not a cure or a rehabilitative measure. It is a perpetual masking of the problem. Obviously, the thinking medi­ cal doctor does not relish the idea of using drastic, interventionist

t.

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27

The Nature of Health and Disease methods. The truth is that the patient is often in such depleted con­ dition that only dramatic techniques and treatments will have any chance of staying the degenerative process. When this is the case, then medicine's "heroic" methods are necessary and useful. But this brings us to our second point. 7Since the practice of medicine is concerned more with the treat­ ment of disease than it is with the maintenance of health, it is only natural that it should have developed an armamentarium and clinical methodology which reflects this focus. What must be deplored is not what the medical community does to the diseased patient, but what it does or doesn't do for the not-yet diseased patien For example, the sufferer from headaches is frequently given only pain depressants. The pain is a signal that something is wrong. A chiropractor would immediately suspect nerve interference at one or more locations in the pelvic structure, spine or skull. If this were the case, as it often is, a corrective adjustment would remove the interference, enabling the body to restore proper nerve and artery function and the headache most likely would be gone. The medical physician might offer three defenses in this hypothetical case. One: an examination revealed no abnormality, therefore cor­ rective measures are not indicated. Two: without knowledge of the specific etiology of the headache, it is unwise to guess at a corrective course of action. Three: without indications that the headache is part of an unfolding pathology, the physician should not over-react to this single symptom of headache pain. In other words, until a full­ blown disease or syndrome is expressed, it is acceptable to simply treat the symptom. But whether treating a disease (a collection of signs and symptoms) or � Singular symptom, the physician is still simp­ ly addressing the body's response - not the cause of the response. If the response is fever, the physician breaks the fever; if the response is inflammation, the doctor ices down the inflammation; and if the response is nervousness, the medic sedates the nervous system. It would be wrong to say that medical thinking invariably leads to treating the response; there are many times when the physician does treat the cause. But it is a fact that allopathy is rooted in the ancient notion of treating symptoms with "opposites" (e.g., constipation is treated with a purgative). While medicine is not bound to its early teachings, it is still greatly influenced by an allopathic philosophy that

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28

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has its roots in the disease-fixa ed Cnidian school (circa 400 B. t. of Greece. In the 16 's and 17 's iilll&)�iilths bfjlstered their rather thin J3hiles8JDhy with the seemin� "s@jective-" ®utlCiHik 0f mechimistic think­ ing. Though "mechanism" did not have much practical impact on how the physicians of that day treated their patients, the philosophy of mechanism did allow the allopaths to march under the more re­ spectable banner of science. As will be seen shortly, while mechanism eventually had the effect of propelling medical doctors toward more specific medications, it had the negative effect of segmenting the pa­ tient into smaller and smaller pieces until the whole patient was, for practical purposes, lost. Before examining mechanism's conceptualization of human physiology, it should be noted that just because medical practitioners and chiropractors happen to have different concepts of the meaning of human physiology, this does not imply that they disagree as to the faats of physiology. Both, for example, believe that the sympathetic nerves cause vasoconstriction. Both make use of the same terminology (sodium pump, action potentials, norepinephrine secreting neurons, etc.) What is different is how the totality of the facts - the human - is viewed.

The study and practice of medicine, in general, and symp­ tomatology, etiology, pathology and prognosis, in particular, have been thoroughly dominated by the 17th century mechanistic philosophy of Rene Descartes. As the scholar E.W.F. Tomlin wrote, Descartes' "Discourse on Method is the Charter of scientific humanism. No philosophical or scientific writer has escaped its influence. " The idea was, in part, that everything was potentially measureable, and whatever proved to be immeasureable was unreal. This Cartesian world view has led many health care practitioners into a blind alley. Fritjof Capra, Berkeley-based scientist and author of the best-seller The Tao of PhYSics, has said of the Cartesian philosophy: It is mechanistic and it is also reductionistic. Reductionistic means you look at a complex phenomenon and you think 29

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The Nature of Health and Disease you can explain it by looking at the fundamental elements and explaining the whole in terms of its parts. ...You study the basic building blocks and the mechanism through which these interact, and you think that you can explain the whole phenomenon by doing so. When you talk about clockwork, that's how it works. ... But that's not so with living organisms, they are something very different. ... Also, the attempt to look for single causes in a disease goes back to the clockwork image. In general, you can say that one of the central problems and errors of the biomedical model is that it confuses the origins of illness with the mechanisms through which illness manifests itself. It tries to deal with the biological mechanism at the molecular or biochemical level without taking into account the origins of the illness.6 Capra brilliantly puts his finger on the flaw in the biomedical model when he says "it confuses the origins of illness with the mechanisms through which illness manifests itself." 7 In other words, the molecular changes that accompany a disease are not the cause of the disease, but the result. The molecular changes are simply manifesting the disease - even at the very earliest stages in the disease process. In effect, the clinical diagnostician believes that a patient's signs and symptoms form a trail that can be traced to the cause. It is sim­ ply a matter of gathering and correlating the facts. The philosopher A.C. Ewing has observed in The Fundamental Questions of Philosophy that such Cartesian thinking is flawed in several crucial ways: In its more extreme form it assumes that every change in the physical world could be predicted by a being with suffi­ cient intelligence who knew the position of all the atoms at some previous time simply by applying the laws of mo­ tion. This recognizes only one kind of causation in the physical world and implies that mental events cannot cause or take part in causing any physical changes whatever. ... In its less extreme form the principle of mechanism asserts merely that every effect can be casually explained by resolv­ ing it completely into different factors in the cause. 30

The Nature of Health and Disease ...It makes two assumptions which are by no means true. One is that, if the effect consists of factors a, b, c, and d, its characteristics can be derived simply by summing the factors. But it seems at least very doubtful whether any exhaustive account of the characteristics or states of a liv­ ing organism can be given by merely putting together the characteristics or states of the different living cells which make it up or of the chemical substances of which these cells are wholly composed. ...The other assumption is that the different factors...can be treated as isolable from each other. [In other words] there will always be a law connecting any factor in the cause...with a factor in the effect, [and that law] will hold irrespective of whatever happens to the other factors, or whether they are present at all. This assumption may be doubted without absurdity. The laws may only apply within ' a wider system or whole and be modified according to what happens to the other factors in that whole. 8 The philosopher Joad wrote: Let us suppose that all the different accounts - the physiological, the chemical, the physical, the psychological, the behavioristic, the psychoanalytic, the economic, the statistical, the biological and the anthropological - were rendered complete, collated, supplemented with other ac­ curate but partial accounts and worked up into a compre­ hensive survey; they would still fail to constitute the truth about a man. And they would fail to do this, not because some particular piece of information had been left out, or some particular point of view forgotten - for no matter how complete the collection of scientific accounts might be, the truth would still elude them... True knowledge of a man is not, in other words, the sum-total of the com­ plete and accurate accounts of all his different aspects, even if those accounts could be made exhaustive. True knowl­ edge is, or at least includes, knowledge of the man as a whole.9 31

The Nature of Health and Disease In case the reader is thinking that we are attacking a straw man when we say that medicine concentrates on the parts and not the whole, examine this opening sentence to chapter one of Pathological Basis of Disease, one of the leading pathology texts: Too often the new physician is told 'be concerned with the whole patient.' Sometimes forgotten is the fact that underly­ ing every organic illness there are malfunctioning cells.10 To say that behind every disease one can find dysfunctioning cells is about as enlightening as saying behind every flat tire one will find a leak. The dysfunctioning cells, like the leak, are only an earlier (but not the earliest) expression of the later more obvious problem. (In both the leak and the impaired cells there is a causal "tack".) Matters worsen as the author notes, "...clinical implications of disease cannot be truly understood without deep penetration into the cell." II While it is true that a disease cannot truly be understood without knowledge of certain cellular mechanisms, it is equally true that those bits of knowledge must be correlated with an overall understanding of the whole person. A History of Medicine contains a moving account of how the Nobel prize-winning biochemist, Albert Szent-Gyorgyi came to appreciate what chiropractic calls innate intelligence. Szent-Gyorgyi, after 20 years of preparatory work in biology, felt he was ready to tackle a supremely difficult experiment: the laboratory recreation of "muscle" from isolated molecules of actin and myosin. He explains, "I was convinced that within a matter of weeks we would completely understqnd how muscle generates motion. Then, I worked for 20 years without making prog­ ress. One important point I overlooked was 'organisation.'12 A ma­ jor scientist, after 40 years - 20 on the same project - says he overlooked biological "organization." Then in one of the 20th cen­ tury's most beautiful and to-the-point statements on the nature of living matter, Albert Szent-Gyorgyi wrote: 'Organisation' means that if nature puts two things together in a meaningful way, something new is generated which cannot be described, any more, in terms of the qualities of its constituents. This is true through the whole gamut of complexity, from atomic nuclei and electrons up to 32

The Nature of Health and Disease macromolecules or a complex individual. Nature is not additive. If this is true, then the opposite is also true, and when I take two things apart I have thrown away some­ thing, something which has been the very essence of that system, of that level of organisation." 13 Recently, Boyd and Sheldon, leading medical pathologists, en­ dorsed this emerging wholistic conception of the organism: The most exciting recent developments in human biology are in newer understandings of the interrelationships of various sympathetic amines and their role in the function of the central nervous system, particularly the hypo­ thalamus. These discoveries...promise to explain some of the controls over hormone secretion. This area of new knowledge alone is responsible for a trend away from the atomism of cellular theory and toward a holistic or humoral understanding of h uman health and disease. 14 {our italics]

From the very beginning days of chiropractic, there was the realiza­ tion within the profession that the mechanistic philosophy of the allopaths was obviously missing something; their philosophy simply was unable to account for the fact that all of life seems to possess an organizing, purposeful force. In an attempt to remedy the situa­ tion, D. D . Palmer used the exquisite phrases "Universal Intelligence" and "Innate Intelligence" to speak of the organizing force that per­ vades everything from the vast galaxies to the simple squamous cells of the epithelium. One must remember that D. D. Palmer was writing at a time when important mechanisms of neurology, homeostasis and genetics were still to be discovered. It was the age before scientific thinking was turned on its ear by the development of the concepts of energy and field in electro-magnetism, light, gravitation and the atom. As we will see shortly, there are today solid parallels in science which can allow us to assume with more confidence than ever that there is an overall organization in living matter which can be (and should be) accounted for by chiropractic philosophy. Instead of saying we know that

33

The Nature of Health and Disease "something" is there, but don't ask us to explain it (e.g., "We have no way of knowing whether innate resides in the brain, in the body or outside of the body... " 15 ) , we now can offer an explanation that has a better fit with what science is revealing in the laboratory. The interesting thing about scientific research is that as it has un­ folded over the past 100 years, the findings have invariably supported the major premises of chiropractic. Scientific research has done one thing in the 20th century for chiropractic philosophy: it has enabled us to now present a stronger case for the presence of intelligence (an organizing force) in both the universe and the human organism. The problem which plagued chiropractic philosophy from the earliest days was the same problem that haunted all of the various "vitalistic" philosophies of the day. As the biologist-turned-philosopher Van Nuys notes: ...'Vitalism,' which attempts to conceive of Life [or In­ telligence] as itself an essence. Life is expected to be an entity in its own right, a substance which living things are to contain along with whatever else they contain, and which reveals its presence in them by certain characteristics. There is, of course, no [logical] implication that this Life should be imbedded in matter. Life itself might be a special thing that could exist independently in itself. This use of the term Life leads to the supposition that we have explained some­ thing when we have given a name to a mystery. We im­ agine that we can answer all questions about living phenomena by simply announcing that the mystic essence "Life" [Intelligence] has caused them and made them behave as they do. 16 The above quotation is typical of the error in logic - though not necessarily in fact - that most serious philosophers noted when they read essays by the vitalists. In the 1920's chiropractic attempted to overcome the problem of an inadequate explanation by emphasiz­ ing, as R. W. Stephenson did, the fact that innate intelligence "can­ not change or destroy any Universal Law or matter..." In other words, innate intelligence works within the framework of universal laws whatever they may be. This was the best that could be done given the general state of science in the 1920's.

34

The Nature of Health and Disease The problem with trying to mesh chiropractic philosophy with science was that science at that time was still mainly mechanistic in its conceptualizations. Therefore , scientists were still quick to reject any form of vitalism . It is ironic that chiropractic, itself, saw the human cell as a mechanistic entity , save for the unit of intelligence which its philosophy grafted onto that cell . Beyond this there still were the problems that accompany any dualistic (matter and mind) philosophy, particularly the conflict with the law of conservation of energy and the law of conservation of mass . Scientists and philosophers asked how, if the material realm is accounted for by these laws (as we know it is) , the mental realm (innate intelligence) could cause any material events without unbalancing the equations for material processes, either by adding or subtracting energy . So, mechanistic philosophy con­ tinued to win the day until certain breakthroughs in science finally caused a revolution in scientific thought - a revolution which tips the scales toward chiropractic and its long-standing position that there is something more to life than meaningless mechanism . Three important events in science combined over time to spell the demise of materialistic mechanism . First, the work of Faraday and Clerk-Maxwell in the study of elec­ tricity and magnetism gave us a new equation that described the con­ ditions between the particles, instead of the particles themselves. To­ day we speak of the electromagnetic field that pervades space - an electro-magnetic theory that views the field in a non materialistic "energy" mode. Second , Einstein's Special and General Relativity theories, which gave us the famous E mc2 (mass x square of speed of light energy) , made the point that "matter" and "energy" did not exist separately . They were unified, therefore the law of conservation of mass and the law of conservation of energy were combined: the law of conservation of energy. The upshot is that space-time is considered as a spread-out immaterial unity with a structure or pattern or organiza­ tion controlling the objects and events within it . Astronomers now , for example , see planets as following the curves of the space-time field , rather than being pulled by forces emanating from individual bodies such as the sun . The space between matter becomes more influential and explanatory than does the matter; and, of course, the old notion of matter is not really matter anymore - it is a sort of =

=

35

The Nature of Health and Disease

concentrated energy . Third, mechanism was seriously damaged by the developments in microphysics, particularly by the quantum theory. It was discovered that atomic particles have wavelike properties. Definite allowable orbits of electrons were replaced by a series of "quantized states" which correspond to definite energy levels for electrons (Schrodinger wave equation) . Even the idea of a definite particle electron is replaced by mathematical relations that give the probability that an electron is located in a certain region at a certain time corresponding to a cer­ tain energy state . Now, with considerable help from the philosopher Van Nuys, we can begin to outline an explanation for the organization that we always knew was in the human organism . Drawing on the findings of science as we have just discussed them, we can now realize that it is no longer necessary to indulge in the tortuous, dualistic explanations of how it is that "innate mind" and "matter" are different but still, somehow, inseparable . The body's "matter" is now known to be concentrated energy in patterns . This is an important fact for any philosophy that wants to shake itself free from the various forms of mechanism . Einstein expressed it this way: Starting as a helpful model, the field became more and more real . It helped us to understand old facts and leads us to new ones. The attribution of energy to the field is one step further in the development in which the field con­ cept was stressed more and more and the concepts of sub­ stances, so essential to the mechanical point of view, were more and more suppressed . 1 7 We can now see that since both the body and the brain are concen­ trations of energy in certain patterns of organization, it does not in­ volve any dualistic explanations to envision "mind" too as being an aspect of energy . The key is that the "mind" is not viewed as distinct from the brain or, for that matter, from the body . Thus the law of conservation of energy is not broken . The following is Van Nuys' tight­ ly reasoned argument in support of the position that both a physical force which causes a strain and a mental experience of purposeful, willful thought aimed at resolving that strain are possibly but two sides

36

The Nature of Health and Disease

of the same energy-event coin . A good formulation of the relation between mental exper­ ience and bodily causes is Kohler's . He begins with an analysis of "requiredness," that is, our subjective experience from the inside of meaningful connections between things, of oughtness, rightness, fittingness . We distinguish between harmonious and awkward lines in art, between right and wrong behavior. But behavioristic, mechanistic psychology, confined to the idea of isolated causes enforcing effects, has been unable to find in its theory of causes anything like these phenomenological convictions . Its necessi­ tarianism precludes anything like "oughtness. " But the field theory of physical forces in elastic contact, issuing in vec­ tors and patterns, has at least an isomorphic cor­ respondence to ideas of oughtness. Kohler means by this term that although we cannot establish by empirical method that a feeling of requiredness is actually present inside a physical or nervous process which we observe from the outside , still we can recognize a parallelism in their respec­ tive form and sequence. We experience thoughts combin­ ing together to establish a decision we consider right. In physics and neurology we now discern dynamic self-dis­ tribution , where an aggregate of forces strains toward order­ ly patterns. Kohler asks whether this analogy is not convinc­ ing enough to permit the belief that brain , on the matter side, is after all capable of implementing purposeful mind, on the idea side . Our sense of requiredness would then be the inner feeling of those events that science studies from the outside. Physical forces and mental experiences of pur­ posing, striving and resolving, then , would be two aspects of one series of energy events, isomorphic with each other. 18 Simply put, the above reasoning process is as follows : 1) We subjectively experience "mind" and its convictions of oughtness, rightness and fittingness as we solve problems, 2) We cannot, however, objectively determine if physical and nerv-

37

The Nature of Health and Disease ous forces experience similar feelings of requiredness , 3) But we can objectively observe in physics and neurology examples of forces straining toward order, therefore 4) This isomorphic correspondence to oughtness, rightness and fit­ tingness suggests that the brain can and does implement the pur­ poseful mind that we subjectively experience . The famed philosopher Whitehead had no doubts about what has been presented above . As he wrote , " . . . no act or process is without private , internal tone or without public imprint" (e . g . , the immea­ surable subjective aspect and the measurable objective aspect) . Van Nuys gives universal perspective to our discourse when he writes :

19

The concept of field and radiation proves that all things are indissolubly connected to realities or energies beyond their apparent boundaries. Everything is intertwined with everything else in existence . It is obvious, for instance , that something from every star in the heavens exists at the point where your eye is, simply because you can see it there . Rays from the entire universe must come together where your eye is, or where any eye is, therefore each star and each electron must fill the universe with its radiation . 20 Whitehead punctuates the universe - and the human being with meaning when he postulates : The concrete enduring entities are organisms [in the broad sense] , so that the plan of the whole influences the very characters of the various subordinate organisms which enter into it . In the case of an animal , the mental states enter into the plan of the total organism and thus modify the plans of the successible subordinate organisms until the ulti­ mate organisms, such as electrons, are reached . Thus, an electron within a living body is different from an electron outside it, by reason of the plan of the body . 2 1 As the philosopher Henry A . Murray concluded , "Living is a proc­ ess wherein the organism is continually seeking equilibrium . " 22

38

The Nature of Health and Disease CHAPTER TWO FOOTNOTES lJoseph Janse, "The Wholistic Concept of Health Care Manage­ ment," in Principles and Practice of Chiropractic, ed. R. W . Hildebrandt (Chicago : National College of Chiropractic, 1 976), p . 26 . 2Irvin M . Korr and Charles D . Olgilve, "Health Orientation in Medical Education, United States: The Texas College of Osteopathic MediCine," Preventive Medicine 1 0 ( 1 98 1) , pp . 7 10- 7 18 . 3Rene Dubos, Mirage of Health : Utopias, Progress, and Biological Change (New York : Harper and Row, 1979) , pp . 24-25. 4"Editorials, " Journal of the American Medical Association (Chicago, March 19, 1982), p. 1605 . 5Bernard Finneson, Low Back Pain (2nd ed .) (Philadelphia : Lip­ pincott, 1980) , p. 370 . 6Fritjof Capra, "From Science to Society - Fritjof Capra Makes a Quantum Leap, " interview by Alex Jack, East West Journal, vol . 12, no. 3 (March 1982) , p . 3 1 . 7Jbid . SA . C. Ewing, The Fundamental Questions of Philosophy (New York: Collier Books, 1968), pp . 1 9 1 - 192. 9C . E . M . Joad, Philosophy (New York: Fawcett World Library , 1966) , p . 98 . IOStanley Robbins and Ramzi Cotran, Pathologic Basis of Disease (Philadelphia: Saunders, 1979) , p. 1 . l l Ibid .

39

The Nature of Health and Disease

1 2Brian Inglis, A History of Medicine (Cleveland: The World Publishing Co . , 1 965) , p . 143 . 1 3Ibid . 1 4William Boyd and Huntington Sheldon , Introduction to the Study of Disease (8th ed . ) , (Philadelphia: Lea & Febiger, 1980) , p . 52 . 1 5Ralph Stephenson , Chiropractic Text Book (Davenport, IA: Palmer College of Chiropractic , 1 948) , p . 6 . 1 6Kelvin Van Nuys, Is Reality Meaningful? (New York: Philosophical Library, 1 966) , pp . 256- 25 7 . 1 7Einstein and Infield, the Evolution of Physics, p . 148, as quoted in Kelvin Van Nuys, Is Reality Meaningful?, Ibid , p . 164. 1 8Kelvin Van Nuys, Is Reality Meaningfu/?, Ibid, pp . 322-323 . 1 9Whitehead , Modes of Thought, p . 281 , as quoted in Kelvin Van Nuys, Is Reality Meaningful?, Ibid , p . 167 . 2°Kelvin Van Nuys, Is Reality Meaningful?, Ibid , p . 1 9 1 . 21Whitehead , Science and the Modern World (Mentor edition) , pp. 79, as quoted in Kelvin Van Nuys, Is Reality Meaningful?, Ibid , p . 192. 22Henry Murray, Explorations in Personality, as quoted in Kelvin Van Nuys, Is Reality Meaningful?, Ibid , P. 297 .

40

The Nature of Health and Disease

41

� THE SCIENTIFIC BASIS OF CHIROPRACTIC

42

The Scientific Basis of Chiropractic

When asked why he went regularly to a physician, but never to a chiropractor, a layman replied: "M. D.'s are scientific; chiroprac­ tors aren't." That short emphaticism captures the sentiment of all too many individuals. Therefore, it would be fruitless to examine the scientific roots of chiropractic's rationale', without first looking at the popular notion that medicine is somehow a subdivision of science. The media regularly showers us with stories about "medical science. " The popular notion is that medical practice is solidly grounded in scientific research; in short, medicine is a science. While this is the goal of many medical practitioners, it is not the reality. Through no fault of the medical profession, there are some very good reasons why medicine is not, and never will be a pure science. Dorland's Medical Dictionary makes several important distinctions about the use of the word "science": 1) The systematic observation of natural phenomena for the purpose of discovering laws governing those phenomena. 2) The body of knowledge accumulated by such means. Applied Science: . ..the application of discovered laws to the matters of everyday living. Pure Science: ....concerned solely with the discovery of unknown laws relating to particular facts. [Our italics] Clearly, the science which medical proponents allude to is applied science, not pure science. The pure scientist is bent on finding the why of a particular fact. Once discovered, the applied scientist at­ tempts to put the answer to a practical use. In fact, the applied scientist often doesn't even bother with waiting for the why to be answered. Take the case of aspirin. For the better part of a century, medicine has used aspirin without the knowledge of why it worked. This is not to say that a thing must be fully understood before it is used; it simply is offered as an illustration of the fact that medicine is less than purely scientific in its general approach to health care. The episiotomy, pelvic traction, Meperidine (Demerol), and Transcutaneous Electrical Nerve Stimulation (TENS) are four addi­ tional examples (�f many bundreds that (Zould be eited) that show

The Scientific Basis of Chiropractic

the generally non-scientific, pragmatic nature of medical practice. The episiotomy was not the end product of scientific research. It was born in the clinic in response to a practical problem. Pelvic traction is also hardly the product of science. A holdover from the days of Hip­ pocrates, a leading surgeon observes: "Setting placebo effects aside, the mechanical benefits of traction are conjectural." 1 Likewise, the inadequate research which seems to accompany so many prescrip­ tion drugs causes the medical profession to continually make an about­ face: "Meperidine at one time was prescribed by physicians instead of morphine under the mistaken assumption that it was less addictive. Experience has shown that this is not the case and that addiction to meperidine is far less amenable to cure than addiction to morphine."2 As for TENS, medical physicians make use of it even though the af­ fected pain mechanisms "are not fully c1arified. " 3 So, whether it is aspirin, episiotomies, pelvic traction, Meperidine, TENS or hundreds of other techniques and medications, the practice of medicine is hardly a science; it is as the phrase puts it, "the practice of medicine". In other words, the medical practitioner is engaged in an art, hence the phrase "the medical arts". It will be said by some that while the practice of medicine is an art, that art is backed by the findings of science. That is a point which deserves a closer look. First of all, science has no allegiances. Science does not exist for the sake of medicine or dentistry or chiropractic or the government or private enterprise or even scientists. The func­ tion of science is to produce, through the systematic observation of the scientist, the laws which explain facts. Establishing a fact is not a function of science. We have long known, for example, that a par­ ticular cancer exists. That is a fact. The function of science is to establish why the cancer exists, i. e. , the causal conditions and mechanisms. Obviously, everyone in the health arts wants to know the causal conditions and mechanisms for each disease. The assumption is that once we are armed with the knowledge of the specific causal fac­ tors, we will then know how to scientifically combat the disease. But ay, there's the rub. Proving, scientifically, the causation of a disease is one thing. Treating or correcting or curing the condition - in a scientific manner - is quite another. As an example, let us examine how medicine came to treat syphilis with penicillin. In 1905 Schaudinn

44

The Scientific Basis of Chiropractic

discovered that, under certain conditions, the spirochete Treponema paJ/idum could cause the onset of syphilis. Given this scientific prin­

ciple, the applied scientists took over. By 1910 Ehrlich unveiled the long-awaited treatment - arsenic. While we may today smile at the thought of arsenic being a highly regarded, scientific medicine, we must not miss the broader point. Arsenic came on the scene as a cure for syphilis at a time when it was becoming popular to talk of "scientific medicine". Arsenic was hailed and defended as a scien­ tific treatment. Granted, it was effective (though dangerous). But being effective does not make something scientific. What was scientific was the discovery that Treponema paJ/idum could cause syphilis. The subsequent use of arsenic was literally the product of chemical engineering - not science. The same was true later when, in 1928, Heming discovered penicillin. Arsenic was pushed aside for this newer, better and - dare we use the phrase - more scientific discovery. Again, we make the point: the effectiveness of something does not make it scientific. Neither does laboratory experimentation. And the same is true for elaborate testing. All of these things are fine and prop­ er, even necessary. But they do not by themselves constitute science. The enterprise must produce, or at least pursue, the discovery of laws. Then we can speak of science in the root sense. A scientist induces from the specific to the general, whereas an applied scientist deduces from the general to the specific. Scientific methodology tends to en­ sure the accuracy of induction; the same precise methodology does not ensure the accuracy of deduction. Why not? Because the accuracy of deduction is dependent first and foremost upon the correctness of the premises: "Deductive rationalism can be no stronger than the premises it starts with; and if our authority has been mistaken in those, then conclusions can be ever so correctly deduced from them, and ever so logically consistent with one another, and still be mistaken." 4 Any deductive undertaking is only as good as the question it seeks to resolve. If you ask the right question it can be a profitable proc­ ess. If you ask the wrong question, it can be either unfruitful or misleading. For example, if you ask "What is the best way to excise the vertebral lamina?, " you may, by following rigorous scientific methodology, come to a reasonably correct conclusion - for that question. But was that the right question? It is not our desire for the reader to get the notion that medicine does not use careful, exacting

45

The Scientific Basis of Chiropractic

scientific methodology in its research efforts. It does. We are simply concerned that medical research be examined in more precise and realistic terms than is commonly the case. From the foregoing, we can clearly see that a truly scientific discovery (e. g. , that Treponema pal/idum can cause syphilis) does not in any way dictate a treatment for the disease. The development of a treatment usually begins with a guess, a conjecture: "Since we know that Treponema can cause syphilis, let's look for something that will kill the organism, but not the patient. " A bit of chemical engineering and poof! Arsenic, or penicillin. Quite a difference. Yet both parade under the banner of science. The fact is both were the products of individuals who were "winging it" with only a clue to sus­ tain them. The clue was scientific (Treponema can cause syphilis); the careful, precise lab work was not. This is not meant to say that arsenic was not appreciated as a relief for those who were suffering from syphilis; the same can be said for penicillin and the help it brought to the many who suffered from serious infectious diseases. The point being, just because we start with a scientific law, it does not follow that our inferences about that law are also scientific. In fact our in­ ferences, no matter how pragmatic they prove to be, are not the prod­ uct of science unless they too lead to other laws. Dubos, the former Harvard Medical School professor, has written: In practice the drugs discovered either by accident or through a semirational approach must be tested by trial and error in order to establish their practical value. This clumsy and costly way will remain the only one available until a really valid scientific theory of drug action becomes available. 5 As we now know, the results of chemotherapy can be quite unsci­ entific, i. e. , quite unpredictable: In the 1940'5 almost all gonococcal infections responded to 100,000 to 300, 000 units of penicillin G given in one dose. Now many are resistant to 4.8 million units. Moreover, a growing number of gonoccoci have become resistant to the tetracyclines, streptomycin, and sulfonamides. 6

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The Scientific Basis of Chiropractic

Despite the obvious lesson to be learned from the above, the predominant thinking in medicine seems to be captured in this quote from the pathologists Stanley Robbins and Ramzi Cotran: . ..so it has become a race between the ingenuity of man in developing new drugs and the ingenuity of microbes ..7 [our italics] .

How utterly foolish, wasteful and bankrupt to think that we should build a health care system upon an infinite stream of potions, each of which is destined to be quickly discarded. This is not to say, however, that drugs do not have an important role to play in disease care. But instead of using chemotherapy prudently and selectively, we have succumbed to the temptation of using it as a weapon of first resort; thus we now talk of a race between man and microbes - with drugs fueling, in effect, the microbial engine. Putting aside criticisms of chemotherapy, our two main points are these: 1) medicine is an art, not a science. "It is because each clinical decision involves so many judgments of facts and of values that medicine in its highest form will continue to remain an art."B 2) Medicine, like any other endeavor, is not backed by science, except to say that one can look at the findings of science and then conjec­ ture as to how those findings may be applied in a practical way to a real patient. However, that act of conjecture is quite human, even capricious. Even extensive testing programs cannot hope to scientifically "prove" the proposed treatment or medication. For ex­ ample, even when the testing shows the proposed treatment to be relatively safe and effective (forget for a moment the long-term ef­ fects), there is no assurance whatsoever that the proposed treatment is the best or even one of the best that could be proposed. In other words, there is very little, if any, scientific linkage between the dis­ covery of a law (science) and the attempt to make practical use of that law in the care of a patient (art). Philosophers such as P. Duhem and H. Poincare have noted that' a given body of data does not uniquely determine the theory which will interpret it. They reason that there is no "crucial experiment" but always a choice among alternative hypotheses. As they point out, the choice can never be made on evidence alone, but requires a decision or convention gUided

47

The Scientific Basis of Chiropractic

by practical, economic, aesthetic, or other motives. 9 Properly understood, none of the professional health arts are tru­ ly sciences. It is more accurate to say the health arts look to the latest findings of science for clues which may help improve their arts. The major independent health care professions (chiropractic, medicine, optometry, osteopathy, pharmacy, podiatry and clinical psychology) are best described by the term clinical science. While being evermindful of the discoveries of science, the clinical scientist's eye is always on the patient. Ultimately it is by both the systematic and incidental observation of patients that the health professions accept, reject and modify aspects of the technology and art of their particular disciplines. Applied scientists may call their latest substance a "wonder drug", but if patients in the field get worse the medication is given a prompt burial.

In the field of clinical biology there is no such thing as a conclusive. We do not pretend that the principle of chiropractic is the entire or total encompass of the health and disease study. What then is the scientific basis of chiropractic? Simply stated, chiropractiC is a study of prob­ lems of health and disease from a structural point of view with special consideration given to spinal mechanics and neurological relations. 10 � I. HOMEOSTASIS Chiropractic's rationale begins with the law of biology known as homeostasis. Claude Bernard, the famous 18th century French

physiologist, was the first to develop a concept of the constancy of the internal environment as the condition of free and independent life. 1 1 Dorland's I11ustrated Medical Dictionary defines homeostasis as "a tendency to stability in the normal body states (internal environ­ ment) of the organism. It is achieved by a system of control mechanisms activated by negative feedback." Dorland's continues by defining immunologic homeostasis as "the normal state of the adult animal in which it produces antibodies or develops cell-mediated immunity to foreign antigens but not to its own antigens." Gray's

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The Scientific Basis of Chiropractic

Anatomy notes:

Such a preservation of internal constancy, or homeostasis, despite short-term fluctuations in the surroundings, is a cen­ tral feature of the operation of all the principle organ systems, for example, the regulation of temperature, blood pressure, hydration, osmolarity, electrolyte and hydrogen ion concentrations, glucose and oxygen levels, etc. 12

� Homeostasis has special meaning for chiropractic. Like Hippocrates, the doctor of chiropractic prefers to stress the "vis medicatrix naturae" , the healing power of nature. Chiropractic reads in the powerful and sophisticated homeostatic mechanisms an admonition to avoid "elec­ tive" or "precautionary" medication and surgery. "Take this medication just in case" is a phrase which typifies the interventionist tendencies of too many in the health care world. It is as if the body was devoid of all natural recuperative powers. With increasing awareness of the scale of iatrogenic disease, even medicine is beginning to be more vocal regarding the two-edged sword of intervention by physi­ cians. The pathologists Boyd and Sheldon write: In these days when tranquilizers take the place of babysit­ ters, blood transfusions are given indiscriminately and often needlessly, antibiotics are regarded as the cure-all for the most minor infections, and steroid therapy is a panacea, it is small wonder that old maladies are replaced by new, man-made ones. 13 Because homeostasis is essentially a system of mechanisms responding to negative feedback, chiropractors begin their diagnosis of patients with this classic chiropractic question: "What has happened to the homeostatic system?" Notice, the question is not, "What has happened to homeostasis?" Nor is the question "What has happened to the dysfunctioning organ?" - although this may well be asked subsequently. The initial question which characterizes the chiropractic approach to patient care is, "What has happened to the homeostatic system?," i. e. , "What has happened to the sensory, integrative, and effector coordinates upon which homeostasis depends?" This brings

49

).....

The Scientific Basis of Chiropractic

us to our next principle. II. SUPREMACY OF THE NERVOUS SYSTEM

� Chiropractic's rationale draws on the physiological fact that the nerv­ ous system, composed of the encephalon, chorda spinalis and peripheral nerves, controls and coordinates all other organs and struc­

)

tures, and relates the individual to the changing environment

Cunningham's Textbook of Anatomy explains the role of the nerv­

ous system as follows: The nervous system is concerned with controlling and integrating the activity of the various parts of the body, and provides a mechanism by which the individual can react to a changing external environment, while maintaining an internal environment delicately balanced within the nar­ row limits which are necessary for survival. 14 How does the nervous system accomplish this task? Cunningham's explanation is short and to the point: The mechanisms by which the nervous system controls the tissues of the body are at first manifold, but in essence con­ sist of the release of substances which alter the activity of the target organs. This is achieved: 1. By the release of minute quantities of such substances from the terminations of nerve cells on the tissues . . . 2. By the release of substances into the bloodstream, either from the nervous system itself, or from ductless glands directly under its control. 1 5 Concomitant to the supremacy of the nervous system is the fact that the components of the nervous system possess an astounding degree of interrelatedness. This is true on anatomical and functional grounds. Cunningham's summarizes the point: It is usual for descriptive purposes, to divide the nervous system into central and peripheral parts. Nevertheless such a division is quite arbitrary, since the nerves which com­ prise the peripheral part, and the brain and spinal medulla

50

The Scientific Basis of Chiropractic

which make up the central nervous system, are both essen­ tial parts of a functioning unit and cannot be clearly separated from each other on anatomical grounds. 16 .. . It is incorrect, therefore, to think of either system or their parts as though they acted independently. 1 7 On occasion, critics will observe that a spinal adjustment cannot affect certain areas - like the brain - because the spinal nerves do not extend into the encephalon. This kind of statement reveals an incomplete understanding of neural anatomy. Sympathetic nerves arising in the lateral horns of the upper thoracic levels of the spine form the upper cervical ganglion with postganglionic fibers ascend­ ing to supply, among other things, blood vessels of the brain. To gain a cursory appreciation of the breadth, power and com­ plexity of the nervous system, one only has to look at the hypothalamus. Gray's Anatomy makes these observations regarding the hypothalamus: [The hypothalamus is] the 'head ganglion' of the autonomic nervous system (Sherrington 1947). More recently, inten­ sive investigation has not only confirmed in greater detail the controls exerted by the hypothalamus on the endocrine system and the lower autonomic centres, but has also em­ phasized that hypothalamic action depends upon afferent information channels, both nervous and vascular, and that it is interlocked, both structurally and functionally, with higher regions of the nervous system. ... In mammalia, the frontal cortex, limbic system, hypothalamus, and lower regions of the brain stem and spinal cord are conveniently regarded as forming a hierarchy of controls particularly directed towards those homeostatic cycles, which are me­ diated by the autonomic nervous system, the endocrine system, and the locomotor patterns associated with them. 18 The supremacy of the nervous system is clearly established in the minds of physiologists. In their physiology atlas, Agamemnon Despopoulos, M. D. , and Stefan Silbernagl, M.D. , state: Complex organisms are organized to generate an inte­ grated, consistent, and uniform response to a stimulus. The

51

The Scientific Basis of Chiropractic

central nervous system (CNS) is the ultimate integrator. 19 [italics added] III. FAULTY MUSCULOSKELETAL RELATIONSHIPS CAN CAUSE NEUROPATHIES

� Chiropractic's

rationale is grounded in the long-standing clinical

and scientific observation that faulty musculoskeletal relationships can

ii) This concept is demonstrated by the following four (hundreds could be listed) classic examples:

cause nervous system dysfunctio

a. Protruding intervertebral disc can cause sciatica. b. Transverse carpal ligament can cause sensory distur­ bances in the first three fingers (carpal tunnel syndrome) . c. Degenerative arthritis of the cervical spine can cause bony encroachment of the spinal nerve roots, resulting in cervical nerve root compression. d. Cervical rib can cause Klumpke's Paralysis (eighth cer­ vical and first thoractic nerves) with atrophy of hand and wrist. The proposition that musculoskeletal disrelations can cause nerve system dysfunction is fully accepted by the scientific, chiropractic, medical and osteopathic communities. IV. THE SUBLUXATION Given these three scientifically accepted facts -

1. Homeostasis enables the body to stay alive in an ever­ changing environment. 2. The nervous system is the

prime controller of

homeostasis. 3. Faulty musculoskeletal relationships can cause dysfunc­ tions in the nervous system. - chiropractic is able to hypothesize that skeletal disrelations, parti­ cularly in the complex spinal structures, can lead to the loss of nerv-

52

The Scientific Basis of Chiropractic

ous system integrity and, hence, to the loss of health elsewhere in the body. The association of a framework disrelation, lesion or

dysfunction with a nervous system dysfunction is commonly called a subluxation. It is the subluxation which is of utmost concern to the chiropractor, because: Normal integrated neurological conduct equals homeostasis and health, and disturbed neurological conduct results in pathophysiology, disintegration of homeostasis and even­ tually the intrusion of disease. 20 Whenever the term subluxation is used, the chiropractor means: a biomechanical disrelation or dysfunction anywhere in the body, but particularly of the spinal column's contiguous structures or immediate articulations, resulting in aberrant neural function. A most powerful example of how the subluxated spine can impact (via an impinged nervous system) the health of visceral organs was reported in 1958 in the Journal of the American Medical Association: The authors [H. Kamieth, etc. ] made a roentgenologic study of the thoracic spine in 100 patients with roentgeno­ logically proved ulcers of the stomach and duodenum. The group included 83 men and 17 women. Sixty-one men and 11 women had duodenal ulcers; 20 men and 3 women had gastric ulcers; and the other 5 patients had both gastric and duodenal ulcers. ...the convexity of the scoliosis was toward the right side in 60 of the patients and toward the left side in 21, and the remaining 5 patients had an S­ shaped scoliosis. The percentile distribution of right-sided and left-sided scolioses coincided with the percentages of duodenal and gastric ulcers. All the scolioses involved the vertebral segments corresponding to the stomach and duo­ denum, that is, T-6 to T-9. The scolioses were mild, some being so slight that they could hardly be differentiated from variations within the normal range. .. .Moreover, almost 90% of all the patients had pathological changes on the intervertebral disks. . .. Spatial infringement in the in­ tervertebral disk canals [lVF] seems to be of vital impor-

53

The Scientific Basis of Chiropractic

tance, and this contraction of the canals seems to be a complex process, in which morphologic and functional, as well as nerve root, changes may play a part. . . . Morphologic-osteogenic changes seem to be less impor­ tant than functional-dynamic changes. At any rate pro­ cesses in the vertebral column seemed to play a part in 90 of the 100 patients with peptic ulcers. 2 1 The importance of the above quotation cannot be overestimated. The research showed: 1) a small scoliosis was found in the mid-thoracic region of the vast majority (86) of the 100 patients, 2) if the scoliosis veered to the left the ulcer was gastric, if it veered right the ulcer was duodenal, and if it was an "S" scoliosis the patient was found to have both types of ulcer, 3) the scoliosis always involved the vertebral segments T-6 to T-9 which emit the spinal nerves which have sym­ pathetic fibers destined for the stomach and duodenum, 4) the medical researchers believed that infringement of the foramen was the likely culprit, and 5) the most important factor causing the infringement seemed to be functional-dynamic changes as opposed to morphologic­ osteogenic changes. Without saying so, or perhaps without even realizing it, the medical researchers came to a perfectly sound chiropractic conclusion. In any interprofessional discussion of subluxation we face the prob­ lem of definitions. The medical doctor tends to think of a subluxa­ tion as a "partial or incomplete dislocation". Whereas a chiropractor conceives of a subluxation quite differently: The disrelation of a vertebral segment in association with the contiguous vertebra, or vertebrae, is not visualized as a partial dislocation, as the term implies, but, rather, as a disturbance of normal function of a vertebral segment, which would be better expressed by the term "Fixation". . . Thus, the vertebra in question is within its normal range of motion with its facets continuing to articulate... Such a Fixation does not alter the size of the associated inter­ vertebral foramina materially, yet the disrelation, or dis­ turbed kinetic function, does have profound significance for the neuromere and nerve trunk. 22 [our italics] One point must be stressed: In the chiropractic subluxation spinal

54

The Scientific Basis of Chiropractic

nerves are not pinched ("bone on bone") by the closing or narrow­ ing of intervertebral foramina as a result of misaligned vertebral bodies. The "pinched nerve" notion, however, is occasionally offered by M.D. 's as the factual definition of a chiropractic subluxation; once recited, the definition is then promptly ridiculed. It must also be noted, sadly, that sometimes even chiropractors will repeat this simplistic and wrongheaded definition. As A. E. Homewood, the author of The Neurodynamics of the Vertebral Subluxation, explains: On occasion, direct nerve pressure upon a spinal nerve trunk does occur, but this is not an instance of the chiro­ practic subluxation. Rather, this is an example of serious local pathology or trauma. Fracture-dislocation, luxations of cervical vertebrae, pathological destruction of the vertebral body with collapse and displacement of segments, true herniation of the nucleus pulposus of the intervertebral discs, exostoses, etc. , are a few examples of problems that may create direct nerve trunk pressure or impingement. The reader is referred to good, standard orthopaedic texts for the symptomatology of such conditions. Conviction should dawn that any similarity between the symptom pic­ tures of direct nerve pressure from pathology and trauma and the chiropractic subluxation is purely and simply coin­ cidental, if not accidental.23 D. D. Palmer wrote 75 years ago: When we consider that the spinal cord is freely moveable within the spinal canal and that the spinal nerves are af­ forded ample space for their emergence from the inter­ vertebral foramina, we will see that normal movements do not compress either the spinal cord or spinal nerves. "24 Homewood's years of study, lead him to define the chiropractic subluxation in these brief words: . . . not a partial dislocation (less than a luxation), but an alteration of the normal anatomical or physiological rela­ tionships, or dynamics, of contiguous structures.25

55

The Scientific Basis of Chiropractic

Homewood makes the important concomitant point that the chiropractic subluxation most often results in too much nerve sup­ ply, not too little. 26 D. D. Palmer likewise warned chiropractors to remember that too much nervous stimulus was more frequently the patient's problem. 27 This is not to say, however, that he overlooked the potential of diminished nerve supply (" . .. too much or not enough energy is disease" 28). This distinction between hypoexcitation and hyperexcitation cannot be dismissed lightly because the clinical results are entirely different: "Interruption of these [sympathetic] fibers pro­ duces Horner's syndrome, whereas the irritation of these fibers results in manifestations which are directly opposite."29 [our italics] The physiologist Michael Patterson observes, "In a sensitized [cord] seg­ ment, a normal command input would produce an increased outflow from the cord to effector organs and hence an intensified return in­ put. "30 The physiologist Irvin Korr, PhD, while at Michigan State Univer­ sity's College of Osteopathic Medicine, developed a nine-part explana­ tion of how disturbances in afferent and efferent input and in neuronal excitation and conduction alter the function of an affected segment. The explanation makes use of generally accepted facts and observa­ tions from neurophysiology. Unfortunately, too many present-day osteopaths do not seem to grasp the clinical implications of spinal cord dynamics as outlined by Korr. In truth, Korr's elegant construc­ tion of the mechanisms and implications of neural disturbances is much closer to the chiropractor's long-standing conceptualization than it is to that of the allopathic-leaning osteopath. The following is an abridge­ ment of Korr's classic explanation: 3 1

1. EctopiC impulses in afferent fibers, arising as they do somewhere along the axons rather than at the endings, present false sensory information to the cord - situations that have no basis in the peripheral tissues in which the affected fibers end. .. . 2. Similarly, ectopic impulses in efferent fibers are meaningless commands which "join" the real, centrally issued commands, convert them to gibberish, and result in uncoordinated motor and autonomic responses.

56

The Scientific Basis of Chiropractic

3. Since, under conditions in which "cross-talk" occurs, the direction of lateral transmission is from large fibers to small fibers, excessive activity is provoked in pain fibers and in sympathetic fibers. . . . 4. Since impulses that arise ectopically somewhere along the length of the axon are propagated in both directions (ortho- and antidromically), we need also to consider the effects of the antidromic, or wrong-way, impulses. Those in motor fibers, on reaching the cell bodies in the ventral horn, are known to alter the excitability of those neurons in the inhibitory direction. ... Antidromic impulses in sen­ sory fibers have been shown to produce profound vasodila­ tion and hyperemia (at least in skin). .. 5. The chaos in afferent input and efferent output causes the affected segments and the organs, tissues, processes, and activities that they control to be "out of step", with [a resulting) disruption of the (vertically organized) activi­ ty patterns in which they participate. 6. Somatosympathetic integration, so essential to mus­ culoskeletal function, would also be disrupted. 7. As has been shown for segmental somatic dysfunction, the associated facilitation, for reasons presented above, ex­ tends to sympathetic outflow. ...The clinical impact - the syndromes that may be produced given sufficient time and other contributory factors in the person's life - depends, therefore, on the segmental level, since that determines which organs and tissues may be in the line of fire. . . .it is important to point out that there is a significant sym­ pathetic component in many, possibly most, syndromes and diseases. Therapy directed at silencing or reducing traf­ fic in the affected sympathetic pathways is often ameliorative. ... 8. Since at least several organs and tissues, somatic and visceral, innervated from a given segment or group of segments may be affected by segmental dysfunction, each

57

The Scientific Basis of Chiropractic

becomes, in turn, a source of afferent bombardment. 9. Finally, the effects of somatic insult on nerves and nerve cells are not only on excitation and conduction. To the ex­ tent that deformation of axons impedes axonal transport, the trophic influence of those neurons may be profoundly impaired. . . . As a closing note, we wish to again stress one of the major points of this chapter: the individual health sciences maintain essentially similar relationships to the pure or research sciences. That is, the health sciences look to the pure sciences for clues which can possibly ad­ vance the art of healing. But the act of adapting a newly discovered scientific law to the health arts is always a less than scientific under­ taking. Still, the fact that none of the health care disciplines can be truly scientific in no way relieves them of the duty to found as much of their rationale as is possible on the bedrock of science.

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The Scientific Basis of Chiropractic

CHAPTER THREE FOOTNOTES IBernard Finneson, M. D. , Low Back Pain, 2nd ed. (Philadelphia: Lippincott, 1980), p. 202. 2lbid, p. 213. Jlbid, p. 209. 4Kelvin VanNuys, Is Reality Meaningful? (New York: Philosophical Library, 1966), p. 110. 5Rene Dubos, Mirage of Health: Utopias, Progress, and Biological Change (New York: Harper and Row, 1979), pp. 156-157. 6P. F. Sparling, "Antibiotic Resistance in Neisseria Gonorrhoeae to Penicillin and Other Antibiotics," Med. Clin. North Am. , 56: 1133 (1972), as quoted in Robbins and Cotran, Pathological Basis of Disease, 2nd ed. (Philadelphia: Saunders, 1979), p. 377. %id. 8Rene Dubos, p. 122. 9A. Hofstadter, Principles of Philosophy (Flushing, N.Y.: Data-Guide, Inc. , 1967), a review and study chart. IOJoseph Janse, Principles and Practice of Chiropractic, ed. R. W. Hildebrandt (Chicago: National College of Chiropractic, 1976), p. 47. llWilliam Boyd an� Huntington Sheldon, Introduction to the Study of Disease, 8th edition (Philadelphia: Lea & Febiger, 1980), p. 49. 12Williams and Warwick, eds. , Gray's Anatomy, 36th ed. (London: Saunders, 1980), p. 72.

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The Scientific Basis of Chiropractic

13Boyd and Sheldon, p. 72. 14G. J. Romanes, ed. , Cunningham's Textbook of Anatomy, 12 ed. (Oxford: Oxford University Press, 1981), p. 609. 15Ibid. 1 6Ibid. 17Ibid, p. 740. 1 8Gray's Anatomy, p. 971. 19Despopulos and Silbernagl, Color Atlas of Physiology (Chicago: Year Book Medical Publishers, 1981), pp. 8-9. 2°Joseph Janse as quoted by Lee Selby in "We Control Our Own Destiny," Journal of Chiropractic (Arlington, VA: American Chiropractic Association), January 1983, p. 126. 21H. Kamieth, "Pathogenetic Importance of the Thoracic Portion of the Vertebral Spine," Journal of the American Medical Associa­ tion (Nov. 15, 1958), p. 1586. 22A. E. Homewood, The Neurodynamics of the Vertebral Subluxa­ tion, 3rd ed. (St. Petersburg: Valkyrie Press, 1979), p. 163. 23Ibid. 24D. D. Palmer, The Science, Art and Philosophy of Chiropractic (Portland, Ore.: Portland Printing House Co., 1910), p. 293. 25A. E. Homewood, p. 47. 26A. E. Homewood, p. 42. 27D. D. Palmer, p. 426.

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The Scientific Basis of Chiropractic

28Ibid, p. 36. 29DePaima and Rothman, The Intervertebral Disc (Philadelphia: Saunders, 1970), p. 24. 30Michaei Patterson, "A Model Mechanism for Spinal Segmental Facilitation," Journal of the American Osteopathic Association (September 1976), p. 69. 31Irvin Korr, "The Spinal Cord as Organizer of Disease Processes: Some Preliminary Perspectives," Journal of the American Osteopathic Association (September 1976), pp. 43-45.

61

LD THE CLINICAL RESULTS OF CHIROPRACTIC

62

The Clinical Results of Chiropractic

Wlliam James, the most widely read American philosopher and champion of the pragmatist school of philosophy, once spoke these words to a packed lecture hall at Columbia University: "The whole function of philosophy ought to be to find out what definite difference it will make to you and me, at definite instances of our life, if this world-formula or that world-formula be the true one." 1 If I am present­ ly suffering with vertigo, what difference will it make for me if I ac­ cede to homeopathy? To allopathy? Or, to chiropractic? "Whenever a dispute is serious," said James, "we ought to be able to show some practical difference that must follow from one side or the other's be­ ing right. " 2 "True ideas", noted James, "are those that we can assimilate, validate, corroborate and verify. . .. The truth of an idea is not a stagnant property inherent in it. Truth happens to an idea. It becomes true, is made true by events."3 Chiropractors from the beginning have been pragmatists. They have had to be. With allopathy in the dealer's seat, chiropractic survived the early years by playing, over and over, its long suit: the adjust­ ment. As James noted, the pragmatist keeps returning to ". . . fruits, consequences, facts."4 But lest we deceive ourselves, we must never forget that patients are even more pragmatic than chiropractors. Chiropractic grew in acceptance as one individual after another ex­ perienced the "practical difference" of the adjustment. As chiropractic assumed a larger role on the health care scene and as the times changed, the profession felt the need to state its case in a more precise way than merely pointing to anecdotes and pa­ tient testimonials. At first chiropractic concentrated on compiling statistics. One of the early efforts ( 1934) in this regard was B. J. Palmer's request for the clinical results obtained by those chiroprac­ tors who had studied, under his tutelage, the HIO (hole-in-one) ad­ justing procedures. Of 5,000 cases, spanning abdominal cramps and albuminurea to withered shoulder and wry neck, the 259 chiroprac­ tors - using the relatively new HIO adjustment - reported 3,856 (77. 1%) "Well", 1,0 13 (20.2%) "Improved" and 131 (2.6%) either "No improvement" or the results were not reported for one reason or another. 5 His earlier attempt at gathering statistics concerned chiropractors who used the old "meric system and majors and minors;" the results of this 1910 survey was "only 35% of cases got

63

The Clinical Results of Chiropractic

well." 6 Both of these early studies failed the test of objectivity on several counts. The most that can be said is that they were a beginning. Before turning to recent scientific evidences of chiropractic effec­ tiveness, we need to look at the types of complaints and illnesses for which patients seek chiropractic care. Chester Wilk, D. c., lists the ailments presented by chiropractic patients as being (in their order of frequency) : headache, a variety of spine/back/pelvic/conditions, gastrOintestinal disorders, nervous disorders, neuritis, arthritis, sciatica, extremity trauma (ankle, knee, shoulder, orthopedic conditions), bursitis, respiratory conditions, musculoskeletal conditions (neuromuscular), sprains, common cold, sinusitis, other traumas and strains, cardiovascular conditions, hypertension, plus a number of other less frequent conditions. 7 A survey by the American Chiropractic Association in 1982 revealed that neuro-musculoskeletal problems accounted for 82. 1 percent of a chiropractor's case load, while vis­ ceromotor conditions amounted to 1 1.7 percent, vascular related con­ ditions 4. 8 percent, nutrition 0.7 percent, and "other" 0. 6 percent. 8 Undoubtedly the most important scientific chiropractic research con­ ducted to date was presented at the World Chiropractic Conference in Venice, Italy, in 1982. Eighteen papers were presented, eleven of which involved the cooperative effort of chiropractors and medical doctors. What follows are summaries of ten of the papers. It must be emphasized that there is no substitute for reading these studies in their entirety. A complete reading of each paper will give a more accurate, better balanced and fully reasoned account; for want of space, whole portions of the following papers have been omitted. The reader is urged to obtain a copy of the full texts, published in book form (Chiropractic: InterproiessionaJ Research edited by Maz­ zarelli, D.C.) by Edizioni Minerva Medica of Torino, Italy. 9 Potential purchasers may receive further information by contacting the Inter­ national Chiropractors Association, 190 1 L Street, N.W., Suite 800, Washington, D.C.

A. Rossi, M.D., and G. Martino, M.D., both associated with Ortho­ pedics and Traumatology Hospital in Naples, Italy, and R. Hornbeck, D.C., of Static-Chiropractic Clinic in Naples, report the results of a

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The Clinical Results of Chiropractic

one-year follow-up of patients with lumbar and sciatic, and cer­ vicobrachial pain. 10 Following a variety of examinations, ten patients were selected who demonstated spine alterations, while being free of EEG alterations, muscle pathologies and CNS disease. The pa­ tients abstained from medication and other therapy during the study. In order to remove the possibility of placebo-effect, the patients were studied by way of somatosensory evoked potentials (SEP) before and after chiropractic care. SEP allows an objective evaluation of the passage of sensory impulses. The subjects received an average of 20 chiropractic adjustments. A comparative analysis of the data showed a "significant reduction of peak latencies of 8-9 msec. , indi­ cating decreased suffering". The doctors summarized that "It may thus be supposed that chiropractic has an influence in degenerative, inflammatory, and compressive processes of the peripheral nervous system."

•...•. .

.

Carl Cleveland III, D. c., president of Cleveland Chiropractic Col­ lege (Kansas City) , and Marvin Luttges, Ph.D., associate professor in the Department of Aerospace Engineering Sciences at the University of Colorado, report the effects of differing chiropractic treatments (or no treatments) on the nerve function of 30 patients.

11

The double

blind, multiple control study determined the status of nerve function by having patients perform qualified motor and sensory tasks. All 30 patients presented subluxations as determined by symptoms, neurologic and orthopedic examination, and X-ray analyses (metric line analyses) . Each patient was assigned to one of three groups. The first group consisted of patients who on the first day received a specific chiropractic adjustment at the point of subluxation. Two days later these same patients received a second specific chiropractic adjust­ ment at the point of subluxation. Prior to their first adjustment and following their second adjustment these patients were tested on a variety of motor and sensory tasks. The second group of patients underwent the same regimen, except that they received manipula­ tions instead of chiropractic adjustments. The third group received no treatment; this group was simply tested on the first day and again two days later. The tests involved 1) skin temperature discrimina-

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The Clinical Results of Chiropractic

tion, 2) two-point discrimination, 3) skin temperature (six dispersed measurements were taken to indicate each patient's autonomic nerv­ ous system function) , 4) maximal force (muscular) , and 5) force estimation (subjects attempted to recreate specific target levels of force with the test limb) . The findings were as follows: "The most important consequences of adjustment and manipula­ tions as compared to no treatment appeared in the two-point discrimination and force estimation tasks. There was no apparent con­ sequence of these variables for maximum force production or any of the other tests. These results suggest that peripheral nervous system information carried by large diameter fibers was selectively involved in the mediation of treatment effects. .. . Most of the adjustment and manipulation effects were pronounced in the affected limbs. In fact, manipulation was a relatively ineffective treatment except for the af­ fected limb. Adjustment yielded the largest effects in the affected limbs but produced significant improvements in some functions of the unaf­ fected limb, as well. These observations suggest that subluxations and treatments thereof may influence intraspinal mechanisms. ...Since the patients of all three treatment groups expressed essentially iden­ tical levels of confidence in their force estimation accuracy it seems unlikely that they held different biases which would support different degrees of a 'placebo' effect. ...The overall conclusion of the present experiments is that established chiropractic treatments result in en­ hanced motor and sensory functions in patients diagnosed to have subluxations. The double-blind nature of the experimental design and the multiple control strategies assure the reliability and validity of these conclusions. ..

. "

...v­ � G. Zerillo, a medical doctor with ENT-Hospital at the University of Palermo, and M. Lynch, a doctor of chiropractic at the Static­ Chiropractic Clinic in Palermo, report on the results of chiropractic adjustments for six patients who possessed bilateral Kimmerle's anomaly (ponticulus posticus) in combination with vertebro-basilar insufficiency (VBI). 12 They made use of ontoneurologic examinations, followed by arteriography of the rotation-hyperextensive head movements which clinically are found to frequently trigger the VBI

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The Clinical Results of Chiropractic

and associated symptomatology. They found that while bilateral Kim­ merle's anomaly may be a worsening factor, "it is not an essential factor for the occurrence of symptoms hypothetically related to VBI. " Instead, they found that the C3-C7 vertebrae played an important role - provided the vertebral arteries had not undergone an acquired or congenital structural change. The arterographic study showed that three patients presented vertebral arterial change (mainly hypoplasia) . The other three presented vertebral arteries that were normal mor­ phologically. All six were x-rayed. Each patient exhibited subluxa­ tions and alterations of the lordotic curve in the C3-C7 vertebrae. Each subject then received 15 chiropractic adjustments and was again x-rayed. The group which possessed artery changes did not respond to the regimen. They still complained of the VBI and related symp­ toms. However, the group with morphologically normal vertebral arteries "reported a considerable improvement of symptomatology" (disappearance of vertigo, headache, disappearance or subduing of tinnituses, and resolution of visual disorders) . The authors saw the possibility that in similar cases, " ... Chiropractic could be introduced as an alternative to the routine therapies so far employed."

� � Three medical doctors in Rome recently assessed the quantitative effect of chiropractic on lumbar and sciatic pain. 13 They report, "The effectiveness of Chiropractic in the treatment of lumbosciatalgia is now widely recognized, the single contraindication being the presence of intervertebral disc hernia. " The participating doctors were I. Caruso of Addolorata Hospital (Rome) , M. LoMonaco of Neurologic Hospital, Catholic University of Rome and M. Pizzetli of the Clinic for Physio­ kinesitherapy, University of Rome. They selected 49 sciatic patients that were free from metabolic disease and EMG signs of radicular lesion. Clinical and electrophysiological examinations were carried out before and after treatment. The assessment focused on change in pain and objective parameters (OT reflexes, sensitivity, limitation of flexion, extension, and rotation of the trunk on the pelvis) . After the patients had made 30 visits to the static-chiropractic clinics of Padua, Milan, Palermo and Rome, the M.D.'s found that 8 percent had recovered, 56 percent had improved, and 36 percent exhibited

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The Clinical Results of Chiropractic

no improvement. Significantly, they found that not a single patient had experienced a worsening of their condition. The physicians observed that the clinical evaluations resulted in "a very high percent­ age of improvements and in some cases even of recovery ... " The formal title of their study is EMG and H-Reflex in the Diagnosis and Evaluation of Chiropractic Treatment of Lumbosciatalgia (Preliminary Study) .

Four medical doctors and two chiropractors have found evidence of calcitonin changes in the plasma of patients who received chiroprac­ tic care for cervical arthrosis with Barre's syndrome. 14 Eleven patients with the above conditions received ten manipulations (adjustments) each. None of the patients had been subjected to medical treatments in the days before or during the chiropractic care. The blood was sampled at the beginning and end of the treatment for beta-endorphin and calcitonin (CT) . As the doctors reported, "All the patients benefited from the manipulative therapy and showed a more or less marked improvement of all the tested clinical parameters" (paresthesia, cervicalgia, headache, vertigo, and tinnituses) . While beta-endorphin levels did not become lower after manipulative treat­ ment (insufficient time for pituitary regeneration to occur was offered as one possible explanation) , the CT, dosed by antiserum A, saw a "clear-cut reduction of the plasma level of calcitonin. " The base values of CT did not differ significantly from those found in the reference group. The levels of CT, dosed by antiserum B, remained unchanged. The doctors noted, " ...the fact that only the immunoreac­ tive form of CT [dosed by antiserum AJ present in the pituitary gland, which seems to be influenced by the presence of a painful state, changes after therapy, could induce us to think that the manipulative therapy has modified, though partially, an endocrine asset which could seem to be involved in the modulation of the pain mechanisms. " The participating doctors were: G. Luisetto, M.D., and F. Tagliaro, M.D., of Institute of Medical Semeiotics II, University of Padova, seat of Verona; P. Darling, D.C. , W. Steiner, D.C., and D. Spano, M.D., of the Static-Chiropractic Clinic in Padova; and R. Campacci, M.D., of Service of Recovery and Functional Reeducation of the Polyclinic

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The Clinical Results of Chiropractic

Borgo Roma, Verona.

..v.. w A most interesting study, "Etiopathogensis of Lumbosciatalgia Due to Disc Disease; Chiropractic Treatment (Statistics on 3,136 Patients)" found that a regimen of chiropractic adjustments brought "excellent" or "good" results to 84.8 percent of the patients. IS The study, con­ ducted by S. Fonti, M.D., of Traumatologic and Orthopedic Hospital, Palermo, and M. Lynch, D.C., Static-Chiropractic Clinic, Palermo, concentrated on patients with L5-S 1 vertebral joint lesions where the disc damage could also cause an initial protrusion. They excluded cases of lumbosciatalgias caused by "complete disc hernia," which are more properly surgical cases. It should be noted that "all the pa­ tients reported that they had received pharmacotherapeutic and/ or physiotherapeutic treatments with no appreciable results. " The 3,136 patients each received 15 chiropractic sessions, followed by "mechanical tractions" and then were placed on a maintenance program of 15 chiropractic sessions occurring roughly every two to four weeks. The results: 1,580 (50.4%) patients were rated as showing "ex­ cellent" results based on the fact that "no painful relapses occurred in the two years after the first course of treatment, and the positivity of Laseque's sign disappeared... " Another 1, 080 (34.4%) patients were rated as having "good" results since "the occasional relapses receded only after the subsequent treatment, with no residues or paresthesia and muscular atrophy. " While 476 ( 15. 2%) patients showed no significant remissions of symptomatology, the doctors added the note that most of these subjects "did not comply with the prescriptions. " .. . «e '

. . '

In a study entitled "Static Alterations of the Pelvic, Sacral, Lumbar Area due to Pregnancy; Chiropractic Treatment," a chiropractor and a medical doctor radiologically determined fundamental alterations found at the termination of pregnancy. 16 These included: altered pel­ vic inclination, altered sacrofemoral measurements, altered inclina-

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The Clinical Results of Chiropractic

tion of the sacrum, lumbar hyperlordosis, and retrolisthesis of L5 on the sacrum. The two researchers wrote: "... certain alterations of the physiological curvatures of the spine occurring in the patients during pregnancy last after delivery and that these alterations, if they are not corrected, may be a cause of painful symptomatologies. " The two doctors found that of a group of 200 married women who presented lumbar pains, 60 percent ( 120) "complained of lumbar pains occurring during or immediately after pregnancy. After a while, some of these patients were suffering also from dorsalgic and cervicalgic ascending disturbances, sometimes associated to cephalgias and vertigoes. " Chiropractic treatment was initiated with the 120 women with the goals being to correct articular motion in the spine and to restore the physiological curvatures. After an average of 15 adjustments, these results were observed: 25 percent exhibited a "complete remission" of symptoms, 50 percent "were feeling very well, even if still complain­ ing of pains sometimes.. . ," 15 percent "were feeling better even though they still presented disturbances, " and 10 percent showed "no result." The doctors called attention to the fact that of the 10 percent who did not benefit, most had "as a consequence of childbirth, gynecologic complications (uterine inflammations, fibromas, cysts, etc. ) , that in our opinion were the origin of the reflexed pain in the sacrolumbar area. " The two researchers concluded: ". . . Chiroprac­ tic is by far the most indicated treatment for painful spinal symp­ tomatologies caused by mechanical postural alterations due to pregnancy. . . " The participating chiropractor was L. Crispini, D. C., of the Static-Chiropractic Clinic in Milano, and the physician was E. Mantero, M.D. , of the radiologic department of Milano's Fornaroli Hospital of Magenta.

� W In another study, the proposition that chiropractic care of the cervi­ cal spine would relieve oto-vestibular symptomatology was put to the test. 17 The study was based on 80 patients who presented arthrosis and static-dynamic cervical changes, as well as symptoms such as vertigo, tinnitus, and·hypoacousis. The study was carried out by M. Lynch, D.C., of Palermo's Static-Chiropractic Clinic and G. Zerillo,

70

The Clinical Results of Chiropractic M.D., of the Ear, Nose and Throat Hospital of the University of Palermo. Tonal audiometry, impedancemetry, automatic audiometry (when necessary), electronystagmographic recordings, eye tracking tests and visual suppression tests were conducted before and after the treat­

ment period. Initially the patients' cervical spines were examined by x-ray; cerebral rheography was also used to detect the presence of vascular disorders of the posterior circulation. The patients received an unspecified number of chiropractic treatments, supplemented by cervical traction. The results appeared to be quite encouraging. In regard to problems with oto-vestibular balance, "Virtually all the patients [80] reported a benefit from the treatment." Of the 59 patients with hypoacousis the symptomatology disappeared or decreased in only 19. All 80 patients exhibited headaches prior to treatment. Afterwards, the headaches had disap­ peared in 60, decreased in 12 and were unchanged in 8. As for the 68 with tinnitus, it disappeared in 31 cases, decreased in 22 and was unchanged for 15 patients. Vestibular reflexia became normalized for 19 of the 34 hyporeflexia patients and normalized for 16 of the 34 hyperreflexia cases. Of the 65 patients with qualitative changes in nystagmic response, 37 experienced if not a complete normaliza­ tion, at least a minor decrease. Of the 46 who experienced spon­ taneous nystagmus, there was a complete disappearance for 19 and a decrease for 24. Of the 77 suffering from cervical nystagmus, 28 were fully relieved of the problem, while 28 experienced a decrease. The neurologic tests revealed that of the 60 patients with eye track­ ing test dysfunction, 28 became normalized and 12 showed improve­ ment. With the 49 patients showing dysfunctional problems in the visual suppression test, the chiropractic sessions led to a normaliza­ tion in 24 cases and improvement in 14. In their concluding remarks Lynch and Zerillo noted, "We found that the vertiginous stimulation, present in all patients we examined, was favourably influenced by chiropractic treatment. Indeed, it disap­ peared in 64 cases and decreased in the remaining 16 cases. This value per se could not have a real importance, if it were not cor­ roborated by the electronystagmographic findings." They went on to call their results with spontaneous cervical nystagmus a "particularly important objective finding." Furthermore, they explained that the

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The Clinical Results of Chiropractic

changes in the eye tracking test and visual suppression test "express a state of distress of the vestibular ways in the brain stem. Since this distress, of hypoxic type, is susceptible of regression (at least partial­ ly) , when the causal factors are removed, the repeated control of the above mentioned tests enables [us] to have an objective finding. . . " As for the results with tinnitus, they note, "a remarkable improve­ ment was afforded by chiropractic. "

...v. � A study entitled, "Cardiovascular Changes in Degenerative Cervico­ pathy; Chiropractic Treatment," cannot help but stimulate further interest in chiropractic's beneficial influence on the vascular system. 18 P. Darling, D.C. , and D. Spano, M.D., both associated with the Static­ Chiropractic Clinic in Padova investigated the relationship of degenerative cervical spine disease and cerebrovascular changes (23 patients) , upper limb vascular alterations (63 patients) and heart activ­ ity changes (11 patients) . Diagnostic procedures included EEG, ECG, arterial rheography, phonocardiography and cervical spine x-ray. The investigators illustrated the potential importance of their findings with cerebrovascular cases by relating the case history of a 54-year-old who had suffered a whiplash injury with resultant paresthesia in the left upper extremity and headache. EEG depicted deep ischemia. Chiropractic care resulted in the disappearance of the subjective symp­ toms. An EEG during therapy revealed attenuation of the anoxia. An EEG given after the 20 chiropractic sessions showed disappearance of the ischemic signs. The doctors wrote, "This case deserves compari­ son with a larger series, and offers a working hypothesis for a team of researchers. " It was found that the 1 1 patients with heart activity changes ex­ hibited normal resting ECG results. But cervical tests (left and right torsion, forced flexion and extension of the head) produced A-V block, tachycardia and extrasystole. The same tests when given to healthy subjects showed "no changes worthy of note." Because cer­ vical manipulation "may sometimes" be responsible for sympathetic stimulation (exhibiting hypotension, extrasystole) at the "commence­ ment of a course of treatment," the researchers recommend (in the case of positive cervical tests) "a pharmacological prophylaxis of the

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The Clinical Results of Chiropractic

sympathetic system with an antidystonic drug two or three days prior to chiropractic adjustment. .. " They noted that the cervical tests "became negative after the chiropractic course. " As for the 63 cases of upper limb vascular alterations, arterial vaso­ spasms were the most commonly observed rheographic changes. Three representative sets of rheographic tracings were presented. A 52-year-old patient (presenting cervical arthrosis with cervical pain and paresthesias in the left superior limb) experienced a normalizing of the tracing after 15 chiropractic sessions. A 44-year-old (with cer­ vical arthrosis, brachialgia and bilateral paresthesia) showed a nor­ mal ARG after 10 chiropractic treatments, and the paresthesia had disappeared. And a 62-year-old patient, suffering similarly to the previous case, responded much the same after 10 chiropractic sessions.

& � Another important kind of evidence of the effectiveness of chiro­ practic care is found in public health records. While numerous such studies are available, it will suffice to briefly quote these two examples: The state of Oregon's Workmen's Compensation records show that in a sample of patients reviewed, 82% of the patients treated chiropractically returned to work after one week as compared to 4 1% treated medically. The study was conducted by Rolland Martin, M. D., Oregon Work­ men's Compensation Board, March, 197 1.

19

In the state of California 1,000 employees with industrial injuries were questioned about time loss and residual pain from their injuries. Responses obtained from 629 cases, half of which were treated chiropractically and the other half medically, showed the following: Loss of time under chiropractic care 15.6 days; under medical care 32 days. Loss of time in excess of 30 days under chiropractic care was 6.7% compared to 13.2% treated medically. The in­ cidence of no time loss under chiropractic care was 47 .9% compared to 2 1% for those treated medically. The author of the study was C. Richard Wolf, M.D. , 1972. 20

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SEVEN SELECT CASES

CASE NUMBER ONE. This 32-year-old male construction worker presented low back pain radiating into both legs following a fall from a trailer at a construction site. He was adjusted for both a bilateral posterior-inferior pelvis and an ASLA atlas. The "post" x-ray was taken three days after the "pre" x-ray. He returned to work within one week with no restrictions on his activities. The attending chiroprac­ tor was Dr. Glenn Stillwagon of Monongahela, Pennsylvania.

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CASE NUMBER TWO. This 45-year-old male heavy equipment operator suffered a job-related fall 11/2 years prior to seeking chiroprac­ tic care. He had not been able to work for four months prior to the chiropractor's examination. Previously an orthopedic specialist had told him he had a "slipped disc and pinched nerves". The orthopedist had advised a myelogram with the likelihood of surgery. The patient presented lumbo-sacral pain radiating into the left hip; he also had right shoulder pain. The pelvis, C5 and atlas were adjusted. Three months elapsed between the "pre" and "post" x-rays. The patient was able to return to his normal duties at the end of the three months. The attending chiropractor was Dr. Glenn Stillwagon of Monongahela, Pennsylvania.

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CASE NUMBER THREE. This 40-year-old housewife presented with chronic leukorrhea discharge, headaches, and low back pain radiating into the left leg. She had previous medical treatment consisting of heat applications and muscle relaxers; she most recently was on the painkiller Darvon. Seven days elapsed between the "pre" and "post" x-rays, during which time she received axis and pelvic adjustments. She showed a marked improvement, though there is still an occasional recurrence of the leg pain. There was also a "90 percent improve­ ment in leukorrhea discharge". The attending chiropractor was Dr. Glenn Stillwagon of Monongahela, Pennsylvania.

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The Clinical Results of Chiropractic

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CASE NUMBER FOUR. This 14-year-old female student presented a scoliosis. After examination and x-ray analysis, the chiropractor determined that the causal subluxation was a "disc block subluxa­ tion of L3." Approximately one year passed between the "pre" and "post" x-rays; during that time a regimen of adjustments were ad­ ministered. The response was good as can readily be seen. The at­ tending chiropractor was Dr. Fred Barge of LaCrosse, Wisconsin.

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The Clinical Results of Chiropractic

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CASE NUMBER FIVE. This male patient presented with an "acute lateral 4th lumbar tortipelvis. " The patient received two adjustments of the L4 vertebra. This was followed with the addition of a left 1/4" heel lift; the "post" x-ray was taken with the lift in place. The two x-rays were taken eight days apart. After the second adjustment the patient assumed a normal posture and was able to function again. The attending chiropractor was Dr. Fred Barge of LaCrosse, Wisconsin.

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CASE NUMBER SIX. This 24-year-old male presented severe neck pain. The patient could not turn his head to the left. In addition, he was experiencing stiffness in the low back region. The "pre" and "post" x-rays were taken eight days apart. The neck pain diminished and the cervical range of motion returned to normal. Also, the low back became symptom free. The attending chiropractor was Dr. Burl Pet­ tibon of Vancouver, Washington.

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The Clinical Results of Chiropractic

....-

� ---- -. -

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CASE NUMBER SEVEN: This 45-year-old female had trouble sleep­ ing, and pain in the left shoulder, arm, hand, and fingers. She also experienced a loss of strength in the left arm. An adjustment was made at atlas using the chiropractor's cervical adjusting instrument. The "post" x-ray was taken 15 days after the "pre" x-ray. The pa­ tient was feeling good as a result of the adjustment, but subsequent­ ly reaggravated the injury. This required another adjustment which, again, restored the patient to symptom-free functioning. The attend­ ing chiropractor was Dr. Burl Pettibon of Vancouver, Washington.

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The Clinical Results of Chiropractic

CHAPTER FOUR FOOTNOTES lWilliam James, Pragmatism and Other Essays (New York: Simon and Schuster, 1963) , p. 25. 2Ibid, p. 23. 3Ibid, pp. 88-89. 4lbid, p. 27. 5B. J. Palmer, The Subluxation Specific: The Adjustment Specific (Davenport: Palmer College of Chiropractic, 1934) , p. 858. 6Ibid, pp. 857-858. 7Chester Wilk, Everything You Should Know About Chiropractic (Park Ridge, lIIinois: Wilk Publishing, 1980) , p. 16. 8Matthew Brennan Ill, "Department of Statistics Completes 1982 Survey," Journal of Chiropractic (Arlington, VA: American Chiropractic Association) February 1983, p. 56. 9Joseph Mazzarelli, ed., Chiropractic: Interprofessional Research (based on reports presented to the World Chiropractic Conference April 30-May 2, 1982, Venice, Italy) (Torino, Italy: Edizioni Minerva Medica, 1983) . 1°lbid, pp. 1-6. Illbid, pp. 2 1-31. 12lbid, pp. 33-35. 13lbid, pp. 37-40.

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14Jbid, pp. 47-51. 15Ibid, pp. 53-57. 16Jbid, pp. 59-68. l%id, pp. 69-75. 18Jbid, pp. 77-87. 19Chester Wilk, p. 31. 2°Ibid, p. 31.

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[0 THE CHIROPRACTIC APPROACH TO PATIENT CARE-

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The Chiropractic Approach to Patient Care

A History of Medicine observes: "Osteopathic and chiropractic train­ ing colleges were opened, with curricula of their own; and in spite of some savage persecution by orthodoxy, both survived and flour­ ished, taking over many of the functions of the old family doctor." 1 Two factors led to the rise of chiropractors as general practitioners. First, medicine and, later, osteopathy began to specialize. This often caused doctors to take a myopic view of the patient: The cardiologist is concerned with the patient's heart, the endocrinologist with the patient's hormones, the gastro­ enterologist with the gastrointestinal tract. The whole pa­ tient is lost in the mass of component parts, like the loose pieces of a jigsaw puzzle. 2 Over the years millions of patients arrived at chiropractic's doorstep, tired of the "referral merry-go-round" and still sick. In time the most obvious indicator that a soured relationship. had developed between the medical physician and patient was the "exponential rise in the number of malpractice suits."3 The second factor that caused chiropractors to assume the role of general practitioners was the simple fact that patients were able to get relief from such a wide array of illnesses and conditions. Ac­ tually, from the very beginning chiropractors did not consider themselves to be "back doctors" anymore than M.D.'s considered themselves to be "blood doctors" just because they put medications into the vascular systems of their patients. As documented in the previous chapter, chiropractic with its impact on the nervous system is able to influence biochemical and functional mechanisms throughout the body. In orthodox circles, it is sometimes said that the chiropractor's suc­ cesses have been due to placebo effect. 4 Well, this is true to some extent - just as it is true in any branch of the health arts. The clinical psychologist, the physician, and the surgeon have all been party to the placebo. In fact, it is in the medical world that we read of the sugar pill, the water injection, and the incision-only surgery. 5 When one seriously compares the placebo delivery potential of the medical doctor against that of the chiropractor, the M.D. wins hands

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The Chiropractic Approach to Patient Care

down. The physician has the advantage of 1} orthodoxy (In many minds an M.D. is a "real doctor" against which all others are measured) , 2} science (Television portrays the physician's world as one of "molecular disease", "wonder drugs", and "computerized tomography") and 3} prestige (From a purely sociological standpoint, the medical physician ranks at the top of the health care pyramid in terms of social respectability). The medical physician truly brings a powerful and weighty presence to the doctor-patient relationship. On the other hand, chiropractors have been frequently faced with patients who all but tell them, "Look, I've never been to a chiroprac­ tor, I don't believe in chiropractic, and I'm only here because my son and daughter-in-law have insisted that I see you." Then there is the patient who goes to the chiropractor on his or her own, but as a last resort. This patient has already exhausted the medical therapy ap­ proach and still has the affliction. This patient has put the chiroprac­ tor last for one very obvious reason: the patient has little confidence that chiropractic is what is needed. It is under these less than op­ timal conditions that chiropractors have often had to practice their science and art. Yet, chiropractic has continued to grow in populari­ ty. An article in the May 30, 1 983 issue of Medical Economics expresses alarm over the increasing "defection" from medical care and cites chiropractors as the leading choice of patients who go to non-medical health care providers. Chiropractors ranked ahead of podiatrists (second) and other non-medical doctors such as op­ tometrists and psychologists. Chiropractic's growth is rooted in the fact that literally millions of patients - despite their initial doubts have enjoyed improved health following the correction of malposi­ tioned spinal vertebrae. Some roentgenographic examples of this com­ monplace clinical occurrence were presented in the previous chapter.

>f-

The Hippocratic Oath, as translated by William Jones, requires the young physician to swear, "I will abstain from all intentional wrong­ doing and harm."6 Dorland's translation, in part, reads, "I will prescribe regimen for the good of my patients according to my abili­ ty and my judgment and never do harm to anyone." 7 Nineteenth­ century historian Edward Theodore Washington interpreted Hip-

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The Chiropractic Approach to Patient Care

pocrates as meaning, "The great objective of the physician should be to benefit his patient, or at least do him no harm. ."8 Obviously, all chiropractors, medical physicians and osteopaths are in agreement that they should at least "do no harm" to the patient. But because chiropractors eschew the use of drugs and surgery, thereby avoiding the mishaps that go with them, the profession has been able to justly claim, relative to other primary care providers, that chiropractic is exceptionally safe. The New Zealand Report on Chiropractic (a nearly two year study by a Royal Commission of In­ quiry) concluded their hearings and investigations by finding: .

"They [chiropractors] carry out spinal diagnosis and therapy at a sophisticated and refined level. Chiropractors are the only health practitioners who are necessarily equipped by their educational training to carry out spinal manual therapy. . .. Spinal therapy in the hands of a registered chiropractor is safe. The education and training of a registered chiropractor are sufficient to enable him to deter­ mine whether there are contra-indications to spinal manual therapy in a particular case, and whether the patient should have medical care instead of or as well as chiropractic care."9 One of the most pragmatic measures of patient risk is to examine the cost of malpractice insurance. Chiropractors pay low malprac­ tice rates for one reason - they simply do not get sued for malprac­ tice as often as do other practitioners. Chester Wilk, D.C., writes, "Since malpractice rates are judged by actuarial studies which observe cold hard facts free from bias or emotion, they represent the best standard of comparison as to the safety of a profession. In some states a medical physician's insurance may be 50 or more times greater for the same insurance coverage as a doctor of chiropractic." 10 Simply put, chiropractic is the safest health care procedure known to the Western world. Stanley Robbins and Ramzi Cotran, both M.D.'s and co-authors of the textbook Pathological Basis of Disease, have written: "As many as 5 % of medical hospital admissions are due to iatrogenic [doctor­ caused] disease."ll One can easily imagine the hue and cry that would

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The Chiropractic Approach to Patient Care

be raised by political medicine, specifically the AMA, if 5 percent of all hospital beds were filled with chiropractic-caused injuries. It has always been chiropractic's position that the patient should be given the opportunity to recover from illness with as little interven­ tion as possible. The attending doctor should seek to remove impedi­ ments to recovery, but little more. It is widely accepted that most ailments are self-limiting. This alone should impel health professionals toward a conservative approach. There is a tendency in allopathic thinking to assume that to "do nothing" is to risk that the patient may actually get worse. This is, of course, true. But to intervene with medication, surgery, or both, is also to subject the patient to risk. Since both approaches are poten­ tially risky, intervention should not be the automatic response of the thinking doctor . To again quote Robins and Cotran: Man's ingenuity in the quest for better control of illness has led to ever more potent therapeutic agents which regret­ tably are simultaneously more potent in their potential for cellular damage. ... The range of implicated agents and their reactions is limited only by the size of our pharmacopeia. . ..No antibiotic is incapable of causing damage. 12 Surgical intervention is likewise hazardous: The incidence of failed back surgery cases following initial surgery is estimated to be as high as 1 0 % to 40 % ; in re­ cent studies, a 37 % rate has been reported following sur­ gery without fUSion, and a 30 % rate following surgery with fusion. Repeat surgeries are often m ultiple, with 50% of

patients requiring from two to seven repeat surgical pro­ cedures, according to one source.

13

[Italics added. )

The author of the above quote, Bernard Finneson, M. D. , wrote in Low Back Pain, "Foremost is my persuasion that the largest group of treatment failures results from improper evaluation or from an in­ adequate trial of conservative management." 14 By "conservative management" he meant not only medically conservative therapies, but also chiropractic adjustments; in fact, Low Back Pain contains

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The Chiropractic Approach to Patient Care

a chapter written by Scott Haldeman, D.C., M.D., and Ph.D. , on the subject of manipulative and adjustic techniques. The tragedy of so much of the surgery, particularly in the low back region, is that it often is unneeded. Again we quote Finneson: The most common cause of surgical failures [in low back cases] is an error in judgment with regard to the indica­ tion for initial surgery. I recently reviewed 94 postsurgical patients with failed low back syndromes; most of them had undergone multiple spinal operative procedures. In this series, the original surgery was not indicated in 76 of the 94 cases (8 1 % ) assessed. 15 The point of all of the above is not to argue that drugs and surgery are unwarranted. The point is that when used with selectivity, they can play a most constructive and important role in the overall health care picture. But the watchword must be selectivity. As Hippocrates wrote, "Extreme remedies are very appropriate for extreme diseases." 16 It is an easy thing for chiropractic to warn the medical and osteopathic communities on the issue of overutilization of drugs and surgery. It is quite another thing when chiropractic is asked to ex­ amine its own practices. What obligations are imposed upon the chiropractor who wishes to "do no harm"? Those who are familiar with the clinical side of chiropractic can immediately raise a number of obligations or questions which must be addressed by each chiroprac­ tor. The following five fundamental questions should be asked and answered - by all chiropractors with all patients. I. IS THIS A CHIROPRACTIC CASE? Historically chiropractors have considered the classic chiropractic patient to possess two distinc­ tive characteristics: a) a spinal subluxation, and b) a physiological status which, though pathologically altered, could reasonably be expected to return to homeostasis following the removal of the neural disturb­ ance inherent in the subluxation. If the case does not qualify on the first count (subluxation), the patient is referred to a more appropri­ ate health care provider. Or, should a subluxation be discovered in a patient wherein the disease is so advanced that the removal of nerve

95

-<­

The Chiropractic Approach to Patient Care

interference alone will not likely lead to recovery, the case is given concurrent care. That is, the chiropractor concentrates on removing the subluxation, while the patient is referred to an appropriate physi­ cian who can focus on treating the advanced manifestations of the disease. To adequately answer the question "Is this a chiropractic patient?" the chiropractor must ascertain the status of not only the spinal col­ umn and its associated structures, but the whole person as well. For just as a hearing loss may be due to a spinal subluxation affecting nerve fibers destined for blood vessels in the ear, 17 it may also be due, for example, to a wax plug in the external ear canal. The occasionally expressed notion that a chiropractor need only examine for abnormal juxtapositionings of vertebrae is a dangerous disservice to patients. Suspected valve defects in the heart, various occupational poisonings, and fractures, are just a few of the condi­ tions which should be recognized as requiring the attention of a medical specialist. To fail as a chiropractor to obtain a good case history, to give a reasonably broad examination, and to differentially diagnose is to run certain risk, legal and otherwise. As the International Chiropractors Association noted: The purpose, then, for diagnosis in the chiropractic office is to eliminate peril. This applies to the chiropractor and the patient. Tradition holds that some diseases are in the medical field. If this tradition is broken by the chiroprac­ tor, he becomes something of an insurer of the patient's well being. In some of this, there is no logic nor justice. We must say with some cynicism that the chiropractor who speedily refers a cancer patient to the medics where the patient will worsen and die is a good chiropractor. If the D.C. chooses to provide the patient terminal relief through chiropractic, he or she may face financial consequences by legal action on the part of the heirs. In time, this in­ equity may vanish, but at present we must be mindful of it. 18 Some doctrinaire practitioners of the health arts say that only

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The Chiropractic Approach to Patient Care

"natural" procedures should be used in the care of the sick - that we should not use the "unnatural" interventions of toxic medications and traumatic surgery. This is true, up to a point. The trouble with the word natural is that the meaning changes with the context. Dur­ ing normal times, it is natural for monkeys to drink directly from a stream by simply placing their lips in the water and sipping. But dur­ ing extreme drought when traditional water sources have disappeared, monkeys have been observed to fold leaves into dipper-like utensils in order to scoop water out of the lower recesses of tree stumps. The use of tools is considered an unnatural act for monkeys - except when natural adaptive measures have been exhausted. Then, and only then, the seemingly unnatural becomes the natural. Indeed it would appear most unnatural should a thirsting, dying monkey refuse to save his own life simply because of his allegiance to a doctrine that said that a folded leaf was a tool, and that tools were unnatural interventions into the natural ways of monkey business. II. ARE THERE CONTRAINDICATIONS FOR ADJUSTING THE SPINE? While the patient may be subluxated and the illness at a stage which would respond to the removal of the neural disturbance, there may exist serious contraindications to delivering the spinal adjustment. Spinal cord tumors, primary bone tumors, and unstable fractures are examples of conditions which may, depending upon specific findings, contraindicate the chiropractic adjustment. X-rays, as well as other lab and clinical tests, have played an important role in enabling the chiropractor to not only assess the potential subluxation, but to check for contraindications. III. WHAT IS THE PLAN OF CARE? To schedule all patients for the same visit frequency, and then administer the same adjustment regimen is to have no plan. For example, a chiropractor who would deliver the same "rack'em-stack'em" adjustment sequence to each patient, each visit, has abandoned the exercise of profeSSional judg­ ment regarding the individuality of each case. The various chiropractic adjustments were developed for the express purpose of correcting specific joint malpositionings/maifunctionings which commonly put stress on the nervous sytem. To routinely subject all patients to the same adjustment or sequence of adjustments without first having some indication that the joint (s) to be adjusted is malpositioned or malfunctioning is to subject the patient to unjustified microtrauma and

97

The Chiropractic Approach to Patient Care

is, of course, engaging in quackery. It should go without saying that any adj�stment ca�able of correcting � biomechanically i� d� � t /. � neuro oglc problem IS also capable of causing on qefore a � j',.�, 1. '. jOiRtisadjusted, there should be one or more indications (x-ray, palpation, instrumentation, leg checks, or ortho-neural tests, to name a few) showing that on that day the joint is malpositioned or malfunc­ tioning in such a way as to be capable of causing the nerve interference that the chiropractor is proposing to remove. In short, the chiropractor is expected each visit to a) examine the pa ent (briefly in some cases, extendedly in others), b) formulate a clinical impression, and c) undertake a course of corresponding corrective action action that reflects the examination and clinical impression J Beyond. the specific course of action to be implemented that day, the chiropractor is expected to formulate a tentative long-range plan of care for each patient ome patients may require a program aimed at long-term restoration of the full spinal column (e.g., scoliosis), some may need a single motor unit corrected (e.g., atlas misalignment), and others may be more suited to periodic maintenance care The object of any long-range plan of care is to ultimately make the patient less dependent on not only medical physicians and surgeons, but on chiropractors as well! Are patients really more healthy (Le., more adaptive, resilient, and self-dependent) if they must go every week to the chiropractor for the rest of their lives? Where is the correction that leads to a normally functioning nervous system and, thereby, homeostasis? Obviously there is a minority of patients who for certain congenital or acquired conditions cannot be fully restored to an independent status; these cases need continual sup­ portive care. Having noted these exceptions, a distinction must now be made between a true maintenance program and what only can be called a long-term adjustment program. Maintenance care em­ phaSizes patient monitoring:

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Maintenance Care: Many employers, patients and chiropractors consider a program of preventive health care services to be in the best interests of the patient or employee. This may consist of periodic examinations of the patient for the purpose of determining whether the pa­ tient will be benefited by chiropractic adjustments for the

98

The Chir."rectic A""r..ach to Patient Care

elimination of subluxations, regardless of whether there have been any complaints of symptoms. In this sense, the maintenance care is preventive care. The examination or analysis may or may not reveal the need for chiropractic adjustments. Adjustments given under such circumstances would be preventive and without an awareness on the part of the patient of adverse symptoms. [4/24/8 1 ICA posi­ tion paper.J A long-term adjustment program stresses frequent visits which invari­ ably result in the patient getting one or more adjustments much like some allopathic physicians prescribe medication for high blood pres­ sure; the patient is not expected �o get better, to become free of the need for the "fix" of the adjustment (or medication). The all too fre­ quent adjustments keep the patient's spine in a perpetual state of hypermobility, causing the patient to continually "slip into subluxa­ tion," and thereby creating anew the need for more adjustments. IV. IS THE PATIENT'S PROGRESS BEING MONITORED? The patient's progress should be monitored and recorded at each visit. Without planned, regular monitoring the chiropractor is sometimes unable to detect significant gradual changes in the patient's health. Also, monitoring provides an opportunity for the chiropractor to docu­ ment the course of the patient's progress. This provides an ongoing measurement of the chiropractor's results, as well as a useful tool for patient education. Regular monitoring enables the chiropractor· to more quickly recognize the case which is not responding properly and, therefore, requires a reassessment of the patient's condition and the regimen of care. Patients too do not sometimes recognize the physiological changes they are experiencing - particularly beneficial changes. Commonly patients do not know that blood pressure has lowered since starting chiropractic care, or that a "short leg" (physiologically speaking) is now even with the other leg, or that a "military neck" has been restored to a more normal lordotic curva­ ture. Only by monitoring the patient's progress can the chiropractor apprise the patient of the progress being made. This, in turn, gives the patient an incentive to continue the program until full correction is achieved. Since the early days of the profession, chiropractors have sought 99

The Chiropractic Approach to Patient Care

to use objective measures of patient progress. To the standard signs, symptoms and palpatory findings, chiropractors have pioneered distinctive techniques in such evaluative modalities as x-ray, thermo­ graphy, thermometry (particularly in relation to spinal misalignments and subluxations), plumb line, weight distribution scales, and various methods for checking and interpreting bilateral differences in leg lengths. To these must be added various standard clinical and laboratory procedures such as urinalysis, blood analysis, the measure­ ment of blood pressure, and the incorporation of selected orthopedic and neurologic tests. V. IS THE PATIENT PROPERLY INFORMED? Patients have a right to be informed of certain basic facts so that they may be better able to make intelligent decisions about their health care. First, the patient should be told as plainly as possible that chiropractic has a distinctive point d'appui or basis. Put briefly: Problems in the spine can trigger problems in the nervous system. And when the nervous system is not working prop­ erly, the body's tissues and organs can begin to dysfunc­ tion. We correct the spine in order to restore normal nerve activity throughout the body. (author) The above explanation can be used even with the most uneducated patient. It is oversimplified, but it gets the point across. It is helpful to use a model of the spine or a wall chart as you make this basic explanation. A more sophisticated interpretation can be used with those patients who show the aptitude and interest. Public opinion surveys in the past have shown that a majority of the public thinks that chiropractors are bone doctors instead of nerve doctors. Why? Because as practitioners we too often fail to make a simple explanation, such as given above, to each and every patient. Never assume that new patients (or old patients) understand that chiropractors are most concerned with the nervous system. Even medical doctors who refer patients to D.C.'s sometimes think we are bone doctors. A chiropractor in Illinois reported recently that a pa­ tient came to him at the suggestion of a physician. The M.D. had commented to the patient, "The chiropractor might be able to crack that shoulder to get it loose." An examination revealed cervical spine

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The Chiropractic Approach to Patient Care

involvement. After two specific adjustments in the mid-cervicals, the shoulder regained its full range of motion. Once nerve function was restored to the shoulder, joint function followed. As long as a portion of the public does not know that we restore nerve function, they can only view as preposterous the reports of our successes with visceral and non-joint-Iocated illnesses. Second, patients must be told that their symptoms - as painful and unpleasant as they may be are n ot the real problem. The pa­ tient must be told that the symptoms are only signs of an underlying problem - rooted quite often in the nervous system. This explana­ tion can be made as a natural follow-up to the first point. Third, patients should be informed as to the nature and extent of their problem. They should be given enough detail so as to grasp the meaning of the problem. "You have a sacral misalignment" is not enough. For example, you may want to make sure the patient knows where the sacrum is, what it looks like, what its function is, what nerves are associated with it, whether the problem appears to be chronic or acute, how much it is misaligned, what other visceral and osseous structures and nerves might be influenced by its position­ ing, and how serious the problem is for both the short- and long-term. Fourth, patients should be informed of the prognosis. What is the extent of correction, if any, that may be expected? Here the chiroprac­ tor speaks in terms of past experience. The emphasis is on the tenta­ tive nature of the prognosis. Promises of correction are never made. Yet, all patients have a right to know the likelihood of recovery vis­ a-vis other similar cases. Also, explain the risks in each case. Fifth, patients should be informed of the plan of care. What does the chiropractor plan to do? How many visits are tentatively en­ -

visioned? When and how will the patient's progress be evaluated or reviewed? How will the chiropractor determine that the patient's prob­ lem has been corrected and that the case should be terminated. Is maintenance care envisioned? Is there a recommendation for concur­ rent evaluation by another doctor? What are the alternative methods of care? These questions should be addressed forthrightly by the chiropractor prior to starting patient care. Sixth, patients should be informed of the schedule of fees and charges, as well as the policy for payment. The use of a brief written

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The Chiropractic Approach to Patient Care

schedule of the fees and payment stipulations may avoid confusion. ... . * .

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The chiropractor offers one service - only one - which is not duplicated by any other branch of the healing arts. That most distinc­ tive, valuable and potent service is the detection and removal of subluxations which are causing abnormal functioning of the nervous system. Yes, there are osteopaths, a few orthopedists, and some physiotherapists who "manipulate" the body, including the spine. But because of their general dirth of training, because of their tendency to non-specificity in their manipulations, because they see manipula­ tion limited to musculoskeletal problems, and because they tend to lack a meaningful, practical grasp of the hierarchical arrangement of the body's systems, their manipulations are unable to approach the clinical results of chiropractors. That of course could change in time. But it is doubtful. Medical doctors, and medical schools, are not going to drop centuries of reliance on drugs and surgery to make way for the chiropractic adjustment. At most, they would teach it as an ac­ cessory to their traditional treatments. Even then, it would most likely be of limited value because it would be used in the allopathic tradi­ tion of symptom chasing. The tendency would be to look only to the site of the pain or at most to the proximal vertebrae. The con­ cept of analyzing and correcting the full spine, as a functional unit, would not rest well with allopathic thinking. So, the adjustments would cease when the patient's immediate problem (pain) went away. For both the philosophical and practical reasons cited above, most manipulators are unwilling and unable - clinically - to apply a corrective strategy that is based on the integrative role of the nerv­ ous system. Because of their background, they do not realize (intel­ lectually yes, clinically no) the meaning of Irvin Korr's classic article on "The Spinal Cord as Organizer of Disease Processes . . . " 19 Much of what passes under the rubric of "manipulation" is little more than aggressive loosening-up movements. Joints are forceful­ ly freed of restrictions. The question of why the body saw fit to put restrictions (adhesions) there is often not asked. To ask such a ques­ tion is to immediately realize that the restrictions are not the cause

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The Chiropractic Approach to Patient Care

of the problem, but the result of 1) the body's natural attempt to stabilize a misalignment or malfunction that exists in the joint, or 2) abnormal nerve activity expressed at the joint but due to an impinge­ ment or disturbance elsewhere (commonly the spine). The osteopathic concept of taking a joint through its full range of motion does not address either the misalignment at that joint or the disturbed neural activity at that joint which has emanated from another misaligned or malfunctioning joint (e.g., from a cervical joint to the shoulder). -7. In short, the chiropractor fills a distinctive and highly beneficial role in the health care system. The chiropractor is the only member of the health care team to offer the identification and specific correc­ tion of subluxated vertebrae for the purpose of restoring normal neural function as a means of achieving homeostasi Take away the chiropractor's adjustment, particularly in the context in which it is tradi­ tionally used, and you have a practitioner who at best can only at­ tempt to mimic the other health professionals. The chiropractor can imitate, but rarely best the nutritionist when it comes to matters of nutrition. The chiropractor can imitate, but rarely best the physical therapist when it comes to matters of classical physical therapy. The chiropractor can imitate, but rarely best the orthopedist and neurologist in the nuances of those specialties. In the whole scheme of things, it is safe to say that the chiropractor stands and falls by the vertebral subluxation, much like the dentist and oral hygiene. Take away the morbid tooth and the need for the dentist quickly vanishes.

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...v. w It is not the purpose of this philosophy book to choose one theory of subluxation over another. The truth is, all of the major theories of subluxation have their strengths and weaknesses! The problem with any theory is that it cannot account for all the varying conditions which can surround and engage the thing or event that it is attempting to explain. A theory is static while the actuality is dynamic. But still, we do need theories. A theory is an explanation of how an unknown works. If a theory becomes proven to the satisfaction of all concerned experts, then it is elevated to the status of a law. Many times chiropractic students express the desire to do away with "all of the conflicting theories" of chiropractic and simply, via

1 3

The Chiropractic Approach to Patient Care

research, "prove which one is reaJJy correct. " Well, there are prob­ lems with this approach. First of all, under the right circumstances, each of the major subluxation theories is probably correct. Each presents a portion of the whole picture; several theories are needed in order to see the subluxation in all its living forms. When we speak of the subluxation we must remember that it occurs in a dynamic spine in a dynamic and complex body. The variables are astronomi­ cal. To say that subluxations occur only by way of swollen discs, or proprioceptive insult, or rotational narrowing of the IVF, or whatever, is to needlessly weaken the considerable case for the subluxation. Secondly, students (who are understandably anxious to erase all uncertainty before entering practice) must remember that conflicting theories abound in all the hard sciences and health arts. Physiologists have disagreed for some time over the events responsible for the first heart sound. That disagreement has not kept M.D.'s from treating a discordant "Iub!" when they hear it. Similarly there are four theories of hearing. Page 843 of Krusen 's Handbook of Physical Medicine and Rehabilitation discusses the "place theory, " "frequency theory," "volley theory, " and "traveling wave theory. " 20 The author notes, "the fact that four different explanations persist indicates the com­ plexity of the process. The rehabilitator can use this perspective in approaching hearing impairment." The same notion could be applied to subluxation theories. Their very plurality bespeaks the myriad nature of the subluxation. Likewise, the chiropractor can use this perspec­ tive in approaching neuroarticular impairment.

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The chiropractic approach to patient care focuses on the subluxa­ tion. Clinically the subluxation requires the chiropractor to always be aware of two factors: the neurological and the biomechanical. There are nine leading models of the neurological dysfunction associated with the subluxation. Presented in no preferential order, they are: Nerve Compression Hypothesis Proprioceptive Insult Hypothesis Somatosympathetic Reflex Hypothesis Somato-somatic Reflex Hypothesis

104 .

The Chiropractic Approach to Patient Care

Viscerosomatic Reflex Hypothesis Somatopsychic Hypothesis Neurodystrophic Hypothesis Dentate Ligament- Cord Distortion Hypothesis Psychogenic Hypothesis Janse presents a good review (with sources) of the first seven of the nine hypotheses in Principles and Practice of Chiropractic. 21 The book is recommended reading. For our purposes, a quick sketch of the neurological models will suffice. The nerve compression hypothesis has been with chiropractic from the very early days. It is frequently used in patient education even though the chiropractor may in actual practice make use of several of the models. The concept of neural disturbance (hyper- or hypoactiv­ ity) arising from intervertebral foraminal compression is readily grasped by the patient. One problem, however, is that patients often tend to visualize the nerve impulses as being "shut off" by the impinge­ ment. Many authorities, ranging from D. D. Palmer to A. E. Homewood, call attention to the fact that we are more likely clinical­ ly to see an o veractive neural condition associated with the subluxa­ tion. But regardless of this side point, it does not take much imagina­ tion to look at the lumbars and realize the potential for spinal nerve impingement. As Rothman, M.D., Ph.D., and Simeone, M.D., report in The Spine, impingement is a genuine clinical possibility. They cite A. W. Larmon's study: However ample the overall dimensions of the intervertebral foramen may be, it is its eliptical nature that is responsible for many of its relational problems. In the lumbar region the vertical diameter of the foramen varies from 1 2 to 1 9 mm. This undoubtedly accounts for the fact that a com­ plete collapse of the disc may produce little or no evidence of nerve compression. However, the transverse diameter, from ligamentum flavum to the vertebral body and disc, may be as little as 7 mm. Since the diameter of the fourth lumbar nerve can be just slightly less than 7 mm., the tolerance for pathologic alteration of the bony or connec­ tive tissue relations is very restricted. 2 2 [Italics added. ]

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The Chiropractic Approach to Patient Care

The proprioceptive insult hypothesis emphasizes that articular altera­ tions can cause hyperactivity of proprioceptive nerves leading to distor­ tions of equilibrium, as well as aberrant reflex activity in visceral, somatic and encephalonic tissues. Guyton's Medical Physiology, for example, notes the important physiological role of cervical proprioceptors: By far the most important proprioceptive information needed for the maintenance of equilibration is that derived from the joint receptors of the neck . . . 23 The somatosympathetic reflex hypothesis has been with chiropractic since the early days of the "meric system". Irvin Korr's model (see chapter 3) illustrates somatosympathetic reflex pathways. An excellent article by Akio Sato, M.D., entitled "Physiological Studies of the Somatoautonomic Reflexes", is found in Scott Haldeman's Modern Developments in the Principles and Practice of Chiropractic. Sato concludes: If a suitable kind of stimulation of the [animal's] skin or muscle at the proper spinal segmental level is selected, all these visceral organ [heart, stomach and bladder] func­ tions can be reflexly affected by cutaneous or muscle stimulation. 24 The somato-somatic reflex hypothesis simply postulates that af­ ferent impulses from one body area can result in reflex activity in other body areas. Guyton observes one such example: Another important landmark in the saga of pain control was the discovery that stimulation of large sensory fibers from the peripheral tactile receptors depresses the transmis­ sion of pain signals either from the same area of the body or even from areas sometimes located many segments away. 25 The viscerosomatic reflex hypothesis is concerned with visceral afferent fibers which reflexly cause somatic problems. In The

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The Chiropractic Approach to Patient Care Neurodynamics of the Vertebral Subluxation, Homewood outlines

a common chiropractic observation: Any irritant introduced into a viscus, such as the lung or stomach, adequate to stimulate the receptor nerve endings, sends impulses back over the splanchnic afferent fibers to the spinal segments... Synaptic connection is effected with the anterior horn cells, resulting in somatic muscle hypertension, especially signficant to the doctor of chiro­ practic, since postvertebral muscle fibers are involved.26 It is the above hypothesis which enabled D. D. Palmer to contend that in some cases the toxins within food, drink and medication could lead reflexly to spinal subluxations.27 The somatopsychic hypothesis is an outgrowth of what chiroprac­ tors over the years have seen in the clinic: that subluxations sometimes are a causative factor in cases that a non-chiropractic physician might label purely "psychosomatic". As Janse explains, this hypothesis looks to the effects that subluxations have upon the ascending paths of the reticular activating system, calling attention to such conditions as insomnia and restlessness.28 The neurodystrophic hypothesis focuses on the lowered tissue re­ sistance that results from abnormal innervation. As Pasteur put it, "The bacterium is nothing, the soil is everything."29 As the pathologists Boyd and Sheldon note: When a microorganism invades tissues or a host, 1 of 3 things may happen: 1. The bacterial invader may die, which is most likely. 2. The microorganism may survive without giving rise to disease, but may cause an immune reaction in the host... 3. Exceptionally, the microorganism survives, multiples, and produces clinically apparent disease... 30 [Italics added.] Because the body is effective over 99 percent of the time in warding off potentially harmful organisms, the chiropractor does not accept the popular notion that normally healthy tissue is susceptible to be­ ing overpowered by, say, the streptococcus pneumoniae. When Boyd

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The Chiropractic Approach to Patient Care

and Sheldon write that there are exceptions wherein the microorganism produces clinically apparent disease, they have left out an important qualification: the condition of the host. As chiroprac­ tors have traditionally stressed, pathogenic infections are most likely the result of a predisposing weakness in the host's defense system. Janse refers to studies on the role of the nervous system in phagocytosis (Speransky, 1 943), physiological alterations in nerves as a result of antigenic stimulation of the skin (Freidrich, 196 1), and the control of immunogenesis by the nervous system (Gordienko, 1 958). Korr, the osteopathic profession's leading physiologist, writes that neuronal proteins transported via the axon are most important to the maintenance of healthy tissue: This basic mechanism seems to be involved in a variety of neurotrophic influences, the best known of which is the maintenance of structural, functional, and biochemical in­ tegrity of muscles, certain sensory organs, and other tissues. Interruption of this mechanism leads to atrophy and degeneration. It seems to be involved, also, in the regula­ tion of growth, prenatal and postnatal development, regeneration, and healing; and in the regulation of the abili­ ty to respond to hormones and other circulating substances. Of special scientific and clinical import is the fact that the same kind of mechanism seems to be responsible for the neural regulation of the activity and expression of the genes in skeletal muscle and possibly other tissues. Hence, any factor which for a protracted time ... impedes axonal transport could block the neural influence on the innervated structures or cause it to become adverse and detrimental, thereby contributing to disease. Among the most probable factors are the compressive forces and mechanical stresses occurring in the myofascial tissues and channels through which the nerves pass, the accompany­ ing chemical changes in these tissues, and their aberrant sensory input. 31 Homewood's text contains a six-page section filled with excellent scien­ tific sources regarding the importance of host resistance in pathogenic

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The Chiropractic Approach to Patient Care

infections.32 Homewood puts the findings into a perspective which clearly explains the relationship between the vertebral subluxation and lowered tissue resistance. For example, after citing Selye's research which points to the importance of the adrenals in resisting various stresses including infections, Homewood rightly reminds the clinician that the suprarenals, like all organs, enjoy a crucial relationship to the nervous system: A kinetic aberration in the area of the sixth to ninth thoracic region through fatigue or central inhibitory effects may decrease the neural stimulation of the adrenals with resul­ tant decrease of 'resistance'. 33 The dentate ligament-cord distortion hypothesis , developed by John Grostic, D.C., focuses on the fact that upper cervical misalignments can cause the dentate ligaments to place stress on the cord, especially the lateral corticospinal tracts. The resultant cord distortion, particularly in the lateral white columns, can cause, among other things, disturbed function in the extremities. The psychogenic hypothesis concludes the list of potential causes for the subluxation. While Homewood cautions against trying to pin­ point a specific subluxation that is caused by emotions alone, he notes: ... generalized muscular tension of a psychogenic nature superimposed upon the insult of irritation caused by other, previously discussed forms of stress, could be conceived to be the 'straw that broke the camel's back', creating local­ ized subluxations in the regions of the spine under greatest total strain. 34 (The psychogenic hypothesis is also discussed later in chapter seven.) It must be repeated that these nine models of the subluxation are not exclusive of each other. There is not just one true model. Most practitioners have seen all nine types of subluxation walk through their clinic doors. But regardless of the various models, most subluxations present themselves with some very recognizable, down-to-earth characteris­ tics. Scott Haldeman lists five such features of the subluxation: 1)

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The Chiropractic Approach to Patient Care

vertebral malposition, 2) abnormal vertebral motion, 3) lack of joint play, 4) palpable soft tissue changes, and 5) muscle contraction or imbalance. 35 Many would add temperature variation as a sixth sign. Depending on several factors, including the acute or chronic status of the subluxation, the temperature over the subluxated area would be relatively warmer or cooler than other regions of the spine. Also, most would concur that local tenderness frequently constitutes a seventh finding. Careful examination and consideration of all areas of the spine are necessary - even regions which to the patient are symptom free. Staff doctors at the Gonstead Clinic in Mt. Horeb, Wisconsin, offer this instructive estimate: ...up to ninety percent of patients have areas of the spine involved other than the level of major complaint. In 65 to 75 percent of these, the other areas are of critical im­ portance to spinal correction. A large number of cases that had previous care, did not get results because they did not receive correction in the proper area of the spine.36 [Italics added.]

& W Two major styles of technique emerge from the history of chiroprac­ tic and osteopathy: the adjustment and the manipulation. The adjust­ ment is more indicative of the chiropractor and the manipulation is more indicative of the typical osteopath. While there are many types of manipulations, two examples are sufficient to characterize the basic nature of manipulation. The physi­ cian Robert Maigne of France has offered the classic lumbar roll as representative of the "indirect" manipulation. With the lumbars rotated to tension, the doctor "abruptly exaggerates pressure over the ischion, thus imparting to it an additional thrust." 37 The "semi-indirect" manipulation can be readily understood by considering what John Mennell, M.D., calls the knee-in-the-back technique. With the pa­ tient seated and hands clasped behind the head, the doctor places a knee in the patient's back while sliding his arms under the patient's arms so as to be able to grasp the patient's forearms. While the pa1 10

The Chiropractic Approach to Patient Care

tient draws his elbows toward his sides, the physician lifts the patient upward. "This method produces the movement of joint play, open­ ing up the superior aspect of the interlaminar intervertebral joints at one level, in this instance the sixth thoracic junction."38 Many manipulators, like Mennell, commonly think of vertebral dysfunction as involving subtle "joint lock"39 (demonstrable as the loss of involuntary joint movement) , with the clinical object being sim­ ply to restore the lost movement. This limited view, accurate as far as it goes, causes the doctor to miss the significance of the physiological interrelationship between the cord and spine. And since the goal tends to be thought of in terms of simply restoring movement (which in­ deed is deSirable) , the manipulator gravitates toward the long-lever techniques as described above. These techniques do produce move­ ment and without a lot of fuss on the manipulator's part. The criticism, however, is that this type of maneuver is not very specific in that the force is directed into a region of the spine. ''The vertebral level which receives most of the mobilization is often the one which is already hypermobile rather than the one at which motion is restricted." 40 This involves some increased risk to the patient. Because the chiropractor has tended to be concerned with the restoration of proper relationship between vertebrae (in addition to the restoration of movement) there has been a continual search in the profession for new ways to be more and more specific in the delivery of the adjustment. In fact, if there is one word which cap­ tures the spirit of the chiropractic adjustment it is specificity. Not that all chiropractic adjustments are specific, but that certainly is the desire of most practitioners. One current example of the search for specificity is seen in the "activator" system of adjusting with a small spring-driven instrument. This is mentioned, not as an endorsement of a technique or as a comment on the merits of the system, but as an indication of the chiropractor's concern for exactitude. The classic chiropractic adjustment - for which the profession is most often known - can be described as one of several maneuvers that is characterized by the phrases short-lever , high-velocity , short­ amplitude, and specific-Iine-of-correction. Obviously there are numerous well-known, successful techniques (Logan Basic, Grostic, S.O.T. , to name just a few) that do not fully fit this description. But for the sake of understanding the generic adjustment, and particularly 111

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to gain a sense of the pithiness that accents its reputation, we must examine the more traditional adjusting thrust. By short-lever it is meant that the adjustor makes a direct contact against some aspect of the vertebra to be corrected. The segmental contact may be a spinous process, transverse process, or lamina. By high-velocity it is meant that the thrust is delivered with "snap" and speed, as opposed to a shove. By short-amplitude it is meant that the thrust is of a controlled depth, depending on the exact malpositioning and the bulk of the surround­ ing tissue. By specific-line-of-correction it is meant that the thrust follows such a path as to account for the various directional malpositionings of the vertebra. For example, atlas may have gone anterior, inferior, right and rotated as well. All four misalignments would be accounted for in the specific-line-of-correction. Richard Burns, chairman of the technique department at Palmer College of Chiropractic, has observed that a variety of chiropractic adjustments frequently have two similar elements: the practitioner is positioned on the balls of the feet and delivers a short, quick thrust with the triceps muscle. Dr. Alex Cox, an expert in the Gonstead technique, has expressed two notions about spinal adjusting which reflect the attitude of many, though not all, chiropractors: There are two major concerns for vertebral correction: to correct the specific vertebral position related to the patient's symptoms, and [to give] . . . consideration for the correction of the entire spine.41

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CHAPTER FIVE FOOTNOTES I Brian Inglis, A History of Medicine (Cleveland: World, 1 965), p. 139. 2 Boyd and Sheldon, Introduction to the Study of Disease, 8th ed. (Philadelphia: Lea & Febiger, 1 980), p. 623. 3 Ibid., p. 622. 4Brian Inglis, p. 138. 5Bernard Finneson, M.D., Low Back Pain, 2nd ed . (Philadelphia : Lippincott, 1980), pp. 187- 188. 6Christopher Morley, Familiar Quotations: John Bartlett (Boston: Little, Brown and Co., 1 940), p. 97 1 . 7John Friel, Dorland's Illustrated Medical Dictionary, 26th ed. (Philadelphia: Saunders, 198 1), p. 609. 8 Brian Inglis, p. 28. 9Fraser, Inglis (Chairman) and Penfold, Chiropractic in New Zealand (Report of the Commission of Inquiry, 1979; presented to the House of Representatives by the Governor-General) (Wellington, New Zealand: The Government Printer, 1979), p. 3. IOChester Wilk, Everything You Should Kno w A bout Chiropractic (Park Ridge, Illinois: Wilk Publishing, 1980), p. 48. l 1Robbins and Cotran, Pathological Basis of Disease, 2nd ed. (Philadelphia: Saunders, 1979), p. 540. 12 Ibid.

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l 3Bernard Finneson, p. 1 70. l4Ibid. , p. XV. l 5Ibid., p. 363. l6 Christopher Morley, p. 9 7 1 . l7Joseph Janse, Principles and Practice of Chiropractic, ed., R. W. Hildebrandt (Chicago: National College of Chiropractic, 1976), pp. 7 7 -78. Janse quotes from Spinal Manipulation by the British or­ thopedic surgeon J. F. Bourdillon wherein the medical doctor reports that he adjusted the spine at T4-5, restoring a deaf patient's hearing. The surgeon makes reference to D. D. Palmer having done the same feat; further, he states the belief that the adjustment had a favorable impact on the ascending sympathetic fibers to the head - the same reasoning as used by D. D. Palmer . l8Malpractice Alert, Vol. IV, No. 3, (Washington, D . C . : International

Chiropractors Association), November 1983. 19Irvin Korr, "The Spinal Cord as Organizer of the Disease Processes," Journal of the American Osteopathic Association , Vol. 80, No. 7, March 1981, pp. 45 1/5 1-459/59. 2°Kottke, Stillwell and Lehmann, Krusen 's Handbook of Physical Medicine and Rehabilitation (Philadelphia: Saunders, 1982), pp. 843-844. 2 l Joseph Janse, pp. 3 10-3 1 1. 22A. W. Larmon, "An Anatomic Study of the Lumbosacral Region in Relation to Low Back Pain and Sciatica," Annals of Surgery (vol. 1 1 9; 1944), p. 892, as cited in Wesley Parke, "Applied Anatomy of the Spine," The Spine (vol. 1), 2nd ed., Rothman and Simeone, eds. (Philadelphia: Saunders, 1982), p. 35.

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23 Guyton, Textbook of Medical Physiology (Philadelphia: Saunders, 198 1 ), p. 646. 24Akio Sato, M. D. , "Physiological Studies of the Somatoautonomic Reflexes [in Animals]," in Modern Developments in the Principles and Practice of Chiropractic, ed. Scott Haldeman (New York: Appleton-Century-Crofts, 1980), p. 1 04. 25Guyton, p. 6 16. 26A. E. Homewood, The Neurodynamics of the Vertebral Subluxa­ tion, 3rd ed. (St. Petersburg: Valkyrie Press, 1979), p. 279. 270. O. Palmer, The Science, Art and Philosophy of Chiropractic (Portland, Ore.: Portland Printing House Co.), pp. 296 and 832. 2BJoseph Janse, p. 3 1 1. 2 9Boyd and Sheldon, p. 1 66. 3 0Ibid. 3 1Irvin Korr, "Andrew Taylor Still Memorial Lecture: Research and Practice - a Century Later," Journal of the American Osteopathic Association , January 1974, p. 365. 3 2A. E. Homewood, pp. 292-297. 33 Ibid., p. 294. 34Ibid., p. 94. 3 5Finneson, pp. 252-256. 36 Joseph Mazzarelli, ed., Chiropractic: In terprofessional Research (based on reports presented to the World Chiropractic Conference April 30-May 2, 1982, Venice, Italy) (Torino, Italy: Edizioni Minerva

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Medica, 1 983), p. 42. 3 7Maigne, Orthopedic Medicine: A New Approach to Vertebral Manipulations (Springfield, IL: Thomas, 1979) 3rd printing, pp. 1 28- 129. 3 8Mennell, Back Pain: Diagnosis and Treatment Using Manipulative Techniques (Boston: Little, Brown and Co., 1960), p. 1 1 8 (see caption). 39Ibid. , pp. 24-25. 4°Haldeman, "Spinal Manipulative Therapy in the Management of Low Back Pain" in Low Back Pain, 2nd ed., Finneson (Philadelphia: Lippincott, 1 980), p. 260. 41Joseph Mazzarelli, ed., p. 43.

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117

CD PROFESSIONAL AND ETHICAL CONCERNS

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Professional and Ethical Concerns

A

ll professions expect the individual members to conduct themselves as professionals. That is, each engineer (or attorney or psychiatrist or chiropractor) is expected to follow a course of action and conduct that is deemed by the general membership to be most appropriate for the special circumstances of that profession . This general expec­ tation within the ranks of the profession gives rise to the various codes of ethics which are adopted by the profession's major state, national, and international organizations. There are compelling reasons why the members of a profession are concerned with the questions of ethics and ethical conduct. Some of these reasons become clear when we look at the basic nature of a profession . Historically a profession has been thought of as a group of individuals characterized by at least three factors: 1 . The members of a profession provide a highly specialized skill, knowledge, service or ability - usually based on rigorous formal education and training . 2 . The members of a profession hold and exercise a public trust. 3 . The members of a profession, to a large extent, define and regulate their own profession . This definition is of course at odds with the popular notion that a football player is a professional if he gets money for playing the game. The football player may be paid an astronomical salary and score 30 touchdowns a year, but he fails to meet the qualifications as defined in items two and three above . About the only trust involved is that he is supposed to give the fans his best effort, but in the end it is only a game. While the players exercise financial power at contract time, they do not have much say concerning the rules, the schedule, the practice conditions, the travel arrangements, or the selection of the coaching staff . And ultimately players are fired or "let go, " not by their colleagues, but by the owner. In other words, the players do not define and regulate in a meaningful way their "profeSSion . " Because a profession is a group of individuals with a self-interest in preserving the quality and, hence, the desirability and effectiveness

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of the skill that it offers, it is beneficial to the profession that ques­ tions of ethics, practice and conduct be not only considered, but be resolved ; and the obvious sequel is that the resolutions must then be enforced . For a profession to not follow this course is for that pro­ fession to condemn itself ipso facto to weakness from within and en­ croachment from without . That is, if ethical questions are not aired, not resolved, or if resolved are not enforced, two things will hap­ pen . First, various conflicting, dubious, and nefarious practices will arise within the profession; the upshot will be increasing public stigma, internal disharmony and an erosion of the individual member's desire to identify with the membership as a whole. As John D. Grostic, D . C . , explains, "The research shows that rather than identify with his stigmatized colleagues, the individual is more likely to attempt to rise above them . "l Second, when questions of ethics go unresolved, ex­ ternal forces (government, consumer groups, or other professions) soon move in to resolve the questions . The greater the public's trust in a profession, the greater the pro­ fession's freedom to define and regulate its own affairs . Should the public not completely trust a profession, or should the profession abuse the trust it enjoys, the public not only withdraws its trust but Simultaneously reduces the profession's latitude for arbitrary action . For example, the public and the insurance companies begin to ask for second opinions prior to surgery. The psychiatrist's arbitrary com­ mitment of an individual to a mental asylum must now meet with the approval of a judge . And attorneys are no longer allowed to restrict competition by banning members of the bar from advertising . While most would agree that it would be good if the major profes­ sions did a better job of policing themselves, the practical question always arises as to how that can be done best. The first step is to educate the membership to the fact that all professions, chiropractic included, have an inherent tendency to degenerate into little more than petty, myopic, regressive, financially-oriented, interest groups. Note, the word is tendency. A constant effort must be made to keep a profession centered on its ideals and in pursuit of its founding pur­ pose . As Brian Inglis writes in A History of Medicine: The story of the development of a professional [medical] ethic ought to be inspiring; but its most obvious

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characteristics were envy, malice and uncharitableness and it was not only heretical individuals who suffered . From medieval times, the different clinical groupings and factions had fought each other with remarkable consistent ferocity and malice . 2 If the reader questions whether Inglis is really serious in his criticism of professions, particularly the medical fraternity, please read the following: . . . it is an inevitable tendency of any group of men practic­ ing medicine, whether priests, sorcerers, medicine men or physicians, to form a closed corporation and begin to develop a closed corporate mind . Such groups are under powerful pressures, for the sake both of their prestige and of their pocket, to make themselves indispensable. Any Egyptian schoolboy, presumably, knew that castor oil was a purgative ; there was consequently no point in bothering the sorcerer if a purgative was all that was needed . But if it was accepted that any drug, to work properly, should have a spell attached, then the sorcerer's services would be required . And as he considered himself, a priest of the gods, to be a superior personage, he did not like his rights to be infringed by outsiders - or even by general practi­ tioners ; his attitude to them was probably very m uch the same as most doctors' is today to chiropractors . Even if he did not consciously try to squeeze the general practi­ tioners out of business, he would do his best to persuade patients that it was always wise to consult their sorcerer, just in case . 3 As we go to press, the chiropractic profession is engaged in a legal suit (Wilk et. al. vs. AMA et. al. ) against the closed corporation and the closed corporate mind of political medicine . But lest chiroprac­ tors assume that they are eternally destined to be the good guys and medical physicians the villains, let us examine just one example of how easily chiropractic too can unwittingly slip into the closed cor­ porate mode of thought: "The chiropractic adjustment is not in the common domain, because it was established exclUSively by the rights

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earned by our profession and , more importantly, it is a procedure that is specifically and scientifically designed to correct vertebral misalignments . Terminology related to the adjustment procedure is also exclusively chiropractic . Chiropractors should take legal action to protect this all important domain and understand that it is our reason for being in chiropractic" . 4 To say that the adjustment belongs exclu­ sively to today's chiropractors because yesteryear's chiropractors developed it is to argue, among other things, that lineage and heritage are valid criteria for determining who should and should not perform an activity . A sounder argument for chiropractic having exclusive right to the adjustment would be this : only chiropractors have sufficient education , training and internship to safely, skillfully, and appropriately deliver the adjustment. But let us assume for a moment that an M.D. shows that he or she 1) has an appreciation of vis medicatrix naturae, 2) has com­ pleted additional courses at medical school in neurology , myology, osteology and arthrology (areas in which chiropractors have more instruction) , 3) has attended numerous chiropractic seminars (con­ cerned with adjusting) and chiropractic technique courses at accredited chiropractic colleges, and 4) has spent a year of adjusting in a chiropractor's clinic under the supervision of a licensed chiroprac­ tor. Aren't we hard pressed to say that such a practitioner should be forbidden to deliver an adjustment? It is a bit like saying that despite our extensive training in x-ray , chiropractors should not be allowed to take x-rays because M . D . 's worked with x-rays first, i . e . , x-rays belong to medicine . The point of the above paragraph is that we should not base our professional thinking on selfish reasoning . Instead , it should be our position that the adjustment (or any other name it may be given) should be restricted to those individuals who have earned a D . C . degree or who have experienced a similar level of chiropractically recognized instruction and internship in adjusting and case manage­ ment. Instead of basing our thinking on our pocketbooks, we should base it on what is best for the patient . In other words, if an M . D . were desirous of becoming properly qualified to deliver competent adjustments for the benefit of patients, that should not stir our pro­ fession to anger. Actually , we should be mature enough to see it for

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what it is: a victory for the chiropractic method. As D.O. Palmer wrote: I am more than pleased to know that our cousins, the Osteopaths, are adopting Chiropractic methods and ad­ vancing along scientific and philosophical lines . . . . It is also a pleasure for me to observe that the medical profession [is] absorbing Chiropractic ideas, using its methods, as shown by their books and practice . 5 None of this is to say that we should not object to physicians who want to learn chiropractic methods merely by attending week-end seminars or a single course offered by a medical school in which the professor also lacks adequate schooling in the sophisticated methodologies associated with chiropractic spinal care . Simply put, we should make our stand for quality , not quarantine . As a general rule, the chiropractic profession would be wise in all questions of ethics and convention to ask, "What is best for the pa­ tient's health?" Not what is best for the chiropractor . Not what is best for the chiropractor's corporation. Not what is best for the chiroprac­ tic profeSSion . Not even what is best for the patient's pocketbook. For just as it is unethical to perform a clinical service simply for pecuniary gain , it is likewise unethical to not perform a prudent ser­ vice solely because the patient might look disfavorably at the addi­ tional cost . While many factors must be considered in questions of right and wrong, the major consideration must be the patient's health . This is true not only in the doctor-patient relationship , but also in the codes, policies and positions adopted by the chiropractic profession .

..v.. w Trust. Unless the patient trusts the motives, knowledge , skills and behavior of the practitioner, little can be accomplished to restore the patient's health . Health care rests on the patient's willingness to cooperate with the practitioner. It is the chiropractor's duty and respon­ sibility as a professional to make every effort to act in such a way that patients are justified in placing their trust in his or her abilities . Winning and holding the patient's trust is more than a matter of merely acting trustworthily. The chiropractor's trustworthiness should flow

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from the deep wellsprings of educational and clinical competence. This means that the chiropractor m ust be engaged in an ongoing ef­ fort to learn more about the art and science of chiropractic as well as those findings in other disciplines which relate to chiropractic . The chiropractor must not only stay abreast of the scientific and technical developments within the profession , but also should maintain an awareness of the major changes that occur in related health care fields. Further, the chiropractor must couple the unending acquisition of knowledge with the equally important task of improving the prac­ tical skills and abilities used in the clinic . This is an activity that in­ volves more than just "practicing" on many patients. It involves at­ tending seminars, reading, thinking and just plain after-hours doing. So by learning new knowledge and by achieving better clinical skills, the chiropractor builds the sound foundation required to sustain the patient's trust . Confidentiality. Any information pertaining to the patient's case history, examination , findings, prognosis, regimen of care, or prog­ ress is considered privileged information . To divulge such informa­ tion without the patient's consent (or without a legal imperative) is a breech of ethics and , in some cases, law . In the course of caring for a patient, the chiropractor also frequently learns of the person's financial dealings, social habits, personality quirks, family relations, and political , religious and philosophical beliefs. Often these bits of information are not related to the patient's case . However , such information should be considered confidential communication . It simply is nobody's business to know that patient XYZ is footing the bill for his mother-in-Iaw's nursing home care . When a patient relates her belief in Zen Buddhism or Methodism or pure capitalism , she expects it to go no further than the chiroprac­ tor. Similarly , it should not be passed to others that a certain patient tells off-color jokes . In short, "mum is the word . " The same is true for the receptionist and the chiropractic technician or assistant. Promiscuity. Barbara Bates, M. D . , has written frankly and succinctly on this important topic : Practitioners of both sexes may occasionally find themselves attracted to their patients. If you become aware of such feelings, accept them as normal human responses but pre­ vent them from affecting your behavior . Keep your rela-

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tionship with the patient within professional bounds. Occasionally patients may be frankly seductive or make sexual advances. Calmly, but firmly, you should make clear that your relationship is professional , not personal . You may also want to review your own image . 6 Religion and Politics. The chiropractor should avoid mixing religion

or politics with patient care . Nothing makes a patient feel more in­ secure than to realize 30 seconds before their neck is to be adjusted that the chiropractor disagrees with their political views. Like everyone else , chiropractors will hold viewpoints on religion and politics, but these should not be worn on their sleeves . To use the chiropractic office as a pulpit or soap box is to take advantage of the patient's illness. To preach religion or spout politics in the office is to force some patients to "put up with" what they consider an affront to. their beliefs in order to get the health care they require . Others may sim­ ply be driven away , never to get the care they need . Malpractice. The simplest definition of malpractice is: negligence . There are several considerations associated with malpractice . To begin , it is unethical and illegal to undertake the care of a patient without first telling that individual " . . . what you plan to do and why, what results you expect, what risks are present, what side effects are in the offing, all the alternatives - and get their O . K . Otherwise , you are assaulting your patients - and assault is relatively easy for them to prove!"7 It must be stressed that it is not enough to get a patient's O . K . ; the patient's approval must be based on adequate knowledge . Only then does the chiropractor have the informed con­ sent required in a court of law. "Compare your practice with those of others in your locality, for that is how a court goes about defining your duty to your patients. " 8 Do other chiropractors in the area require x-rays after a fall? Do they require lab work following an unexplained weight loss? The answers to questions such as these cause patients to expect, and courts to insist upon , particular standards of care to be upheld in your practice . Not only must you attempt to follow local standards, but you m ust be careful. 9 No patient consents to the chiropractor confusing his or her x-rays with those of another patient . Furthermore , you must perform well. 1 0 That is , you must perform

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the patient care in a competent manner. It does not matter how many exculpatory agreements you have the patient sign . If you do not per­ form the chiropractic examination , adjustments, and all other related care in a competent fashion , you are guilty of malpractice . Naturally, if the patient did not follow the chiropractor's instruc­ tions in some relevant way, or if the patient acted so as to directly contribute to his or her own injury the chiropractor may have grounds to have a malpractice case dismissed . Such a case involves ques­ tions of the patient's contributory negligence. The plaintiff in any malpractice case must show that the chiroprac­ tor's action or inaction was the "direct and proximate" cause of the damage. Please note , it is occasionally possible for a plaintiff to be able to show cause , but fail to show damage . Without proof of damage , there cannot be compensation . Claims and Promises. In all efforts to inform patients and the public about the nature and benefits of chiropractic , the chiropractor must guard against making cliams that are false , misleading, or unsubstan­ tiated . Likewise , promises are strictly verboten. Nobody in his right mind claims to have the cure for any ailment. Nothing is a certainty in the health care field . Furthermore , nothing could be more misleading than to talk or write about chiropractic as though it were capable of being targeted at specific diseases. It is wrong to suggest directly or indirectly to patients that there is a headache adjustment, a diarrhea adjustment or a menstrual cramp adjustment. Often what results in a correction for one patient, requires a different approach for the next . Chiropractic does not stimulate or suppress the nervous system as does medicine . Chiropractic normalizes the nervous system. To do thiS, the chiropractor must consider much more than the symp­ tom; the chiropractor m ust consider what biomechanical problem is involved in causing or perpetuating the problem . Since any of several reflex patterns can cause a particular symptom , a variety of biomechanical problems must be considered in any given case. While we can readily identify the final common pathway that is contributing to the dysfunction, we cannot with certainty surmise the reflex route that is the source of the problem . This realization (that the disturbing subluxation may or may not be located at the level of the final com­ mon pathway) explains why the simplistic meric system of analysis was finally abandoned by its champion , B. J . Palmer. Headaches,

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Professional and Ethical Concerns

for example, have been eliminated by adjustments at atlas, axis, the upper thoracics, and sacrum to name but a few causal sites . So what can a chiropractor honestly say or write about the ser­ vices offered to patients? First, it can be said that the chiropractor seeks to normalize the nervous system by finding and removing subluxations that are disturbing neurophysiological function . Second, it can be noted that patients frequently report that after receiving chiropractic care for a subluxation, various symptoms diminish or disappear. Third, it can be related that some of the more common symptoms which historically have brought patients to chiropractic of­ fices include : pain (neck, back, arm, hand, leg), numbness, burning and tingling (arm, hand, leg) , headaches, menstrual cramps, abnor­ mal length of menstrual cycle, gastritis, diarrhea, constipation, bed wetting, hypertension, nervousness, asthma, and vertigo . Fourth, chiropractic is not a panacea; therefore, in some cases patients will be referred to appropriate specialists. Whether it is in conversations with new patients, in brochures in the office literature rack, in public lectures, or in mass media adver­ tising, the chiropractor should avoid giving the impression that the adjustment corrects the disease. In truth, the adjustment corrects the subluxation. While this may clear the way fOr the nervous system ' � and the associated homeostatic processes to restore health, the ad­ justment does not have a direct relation to the banishment of a disease. To be forthright on this matter does not weaken the case for the chiropractic adjustment . In fact, it calls attention to the broad attributes of the adjustment. The adjustment, by normaliZing the body's nerv­ ous system, restores coordination to the body's far-reaching system of homeostasis. Few subjects generate such contention as advertising by health care professionals . The Bates judicial decision gave all professionals the right to advertise, provided the advertising was not misleading or un­ true . Dr. Murray E. Dennis, optometrist, has observed, "I guess what does bother me is the poor control over advertising . It bothers me that there are so many misleading ads. In my own profession, for example, you may see an optometrist advertising contact lenses for $29 a pair. Well, that $29 turns out to be $ 1 29 by the time the per­ son walks out of the place . "!! Dr . William T. DeFeo, podiatrist, cautions, "We are talking about

127

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) \

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Professional and Ethical Concerns

taking care of the body . . . 1 think you have to be very careful about what you put in an ad, and in what types of ads you utilize. You can't look like Sears in the Sunday supplement. You have to ex­ press the thought, 'Here I am . I want you to know I'm here so that I can help you . ' But you have to be careful; you don't want to run a laundry list of things that you can do for the patient."12 And Dr. Tamar Earnest, M . D . , notes, "Chiropractors are very busy now liv­ ing down what some members of the profession have claimed to be able to do. These doctors have said 'We can treat anything.' " 13 Nothing is as distasteful nor smacks more of pure shysterism than advertisements which offer something-for-nothing. These baited traps include such promises as no-out-of-pocket-expenses, free consulta­ tion , free "contour" analysis, free x-rays, free examination , free scoliosis screening, etc . Of course someone ultimately pays. In the case of no-out-of-pocket-expenses, a common tactic is to maximize the bills to the insurance companies to make up for those patients who do not have coverage . Such advertising schemes give the distinct impression that the doctor is out to make a fast dollar, ethical restric­ tions notwithstanding. Would you put yourself in the hands of a spinal surgeon who used the come-on , "Get your laminectomy during this special 30-day offer and I'll give you the myelogram free . " For a n excellent discussion of the question of whether or not adver­ tising is for you , plus some guidelines on how to tastefully advertise should you decide to do so , see the March-April 1983 issue (vol. 3 7 , no . 1) of ICA International Review of Chiropractic. Another valuable resource is the profeSSional associations . Other Ethical Considerations. I t i s unethical and illegal i n many situations to engage· in what is known as "fee-splitting." That is, a practitioner cannot refer a patient to another chiropractor or physi­ cian and then get a "kickback" from the doctor who received the pa­ tient. A chiropractor can however charge the patient an extre fee that is clearly designated to cover the cost of work performed by a con ­ sulting radiologist or laboratory c1inician.l yo' ..( � It is unethical for a chiropractor to rna ign or belittle other chiropractors publicly or to their patients . likewise, it is unethical to malign or belittle practitioners in other health care professions. If a practic­ ing chiropractor has knowledge of corruption or improper conduct by a member of the chiropractic profession , the proper procedure

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is to bring the matter to the attention of the state board of chiropractors. . It is of course illegal for any health care practitioner to tam�r with patient records. The doctor cannot expunge, omit, wrongly alter, destroy or falsify information or records regarding a patient . A chiropractor cannot "go along with" a patient's request that the prac­ titioner help obtain benefits or money by way of illegal, unethical or wrongful means or methods . Despite the patient's wishes, the chiropractor cannot provide deceptive or fraudulent information, records, or opinions to schools, government bodies, branches of the military service, insurance agencies, employers, or anyone else . Scope of Practice. It is obvious that the doctor of chiropractic should not (indeed legally cannot) exceed the scope of practice for which he or she is licensed . The scope of practice is defined by both state law and the court decisions which have made interpretations of that law . The various states within the United States and the various na­ tions of the world have passed "scope of practice" laws which vary one from the other. In some jurisdictions a chiropractor is defined simply as one who is licensed to examine the patient for the purpose of detecting spinal subluxations which then can be corrected by the chiropractor's adjustments. In other locales the chiropractor is de­ fined as one who is licensed to not only detect and adjust spinal sublux­ ations, but to perform a variety of services and treatments, including such items as physiotherapy, vitamin therapy, and in a limited number of jursidictions, bone casting, minor surgery, colonic lavage, and psychological counseling . Except for restrictions against performing surgery and the prescribing of medicine, a few jurisdictions are quite liberal in the scope of practice legislated for chiropractors . The mat­ ter of determining an appropriate scope of practice has long been a point of contention in the chiropractic profession. If one starts with this notion - "A chiropractor should be legally '! allowed to practice the science, art and philosophy of chiropractic" - you are likely to come to a certain conclusion as to the appropriate scope of practice . But if one starts with this notion - "A chiroprac­ tor should be legally allowed to practice any science, art and philosophy which is not expressly forbidden by law" - you are likely to come to a different conclusion as to the appropriate scope of practice . The former assumption leads many t o conclude that chiroprac-

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tors should concentrate on the detection and correction of structural problems (particularly the subluxation) which are causing (via the nerv­ ous system) functional problems. Although this group prefers a more n arrow scope of practice , these practitioners tend to see the adjust­ ment as having both a prophylactic and rehabilitative impact on a wide range of illnesses and conditions. So while they call for a limited scope of practice, they do not see themselves narrowly limited in terms of providing efficacious care for the patient. The contrasting assumption leads many to conclude that chiroprac­ tors should be able to do more for their patients than "just adjust . " As a n Illinois chiropractor charges, " . . . we exclude and withhold treat­ ment from our patients that is needed for the cure , treatment, and alleviation of pain and disease . " 14 He writes further, " . . . we must ac­ cept scientific knowledge as it is in the twentieth century and recognize that if we are truly to function as physicians in more than name only, it will be necessary for us to expand our prerogatives to include medicine , and at least, office surgery . " 15 At this point the reader should know that the following pages will first offer some observations about these two opposing positions within the profeSSion , and then follow with a suggested position which may foster some degree of unity on this matter. To call for the right of chiropractors to give medicine is to call for the reinvention of the wheel. The osteopathic profession has manipulated spines and prescribed medications for well over 100 years. Osteopathy - not chiropractic - is the proper profession for the practitioner who wishes to prescribe medication with his ad­ justments. Can you imagine the response by other osteopaths if one of their own called for the abolition of drug therapy . They might polite­ ly suggest that he become a chiropractor. Now , despite the teachings of a small minority of purists, there are obviously numerous situations which call for the use of surgery or drug therapy. But to contend that these selected situations demand that chiropractors should be permitted to make incisions or prescribe medicine is to argue for the self-serving and expedient . Carried to its logical completion this line of reasoning implies that all doctors of all fields should provide whatever services and specialties might be called for in a particular case . Not only is this dangerous from the standpOint of providing quality health care , the fact of the matter is

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that this is not the modus operandi in any recognized health care profession in the world. A few examples from other health profes­ sions will suffice . Optometrists often diagnose eye conditions which require surgery. Yet this fact does not move optometrists to demand that surgery be added to their scope of practice. When the need for eye surgery arises, the optometrist simply refers the patient to an ophthomologist . Similar­ ly, psychologists sometimes come across patients who have acute symptoms requiring sedation . This recurring clinical event does not drive psychologists to call for the right to prescribe medications. When there is a need for sedation , the psychologist sends the patient to a psychiatrist . But an even better example is found among medical doctors who have unlimited licenses. The general practitioner is per­ mitted , by law, to perform brain surgery . Instead , the G . P . refers. The brain surgeon , upon discovering that the patient is hyperten­ sive , could not only perform the surgery but retain the patient for a long-term program of pharmacotherapy. Instead , the surgeon defers to the G . P . who has handled thousands of cases of hypertension . And so it goes. Eye-ear-nose-and-throat doctors do not feel a need to pull teeth, even though diseased teeth have a direct clinical rela­ tionship to some of the conditions treated by this specialty. Likewise , there are growing numbers of medical physicians who are referring patients to chiropractors . It seems hypocritical for any chiropractor to publicly call for increased cooperation among M . D . 's and D . C . 's , only t o turn around and agitate within the profession for chiroprac­ tors to take over a significant portion of the medical practitioner's historic scope of practice . It is a wise public that is leery of the pharmacist who surreptitious­ ly prescribes medications. It is a wise public that is leery of the M . D . who dabbles in manipulation . And it is a wise public that is leery of the chiropractor who treats specific diseases and symptoms by prescribing specific dietary supplements . All three have entered the murky waters beyond the edges of their chosen professions . Without full and appropriate professional backgroun d , education and train­ ing, the pharmacist is attempting to practice as a diagnostic physi­ cian , the medical doctor as an osteopath , and the chiropractor as a medical doctor. None of this is meant to imply that the chiropractor should not

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evaluate a patient's general diet, particularly when there are clinical indications of deficiencies. Nor does it mean , for example, that diather­ my may not be desirable in some cases . The point is this: chiroprac­ tic's collective expertise is in the restoration of normal nerve activity - not the use of stimulants (e.g. dietary cathartics, diathermy) or depressants (e.g. certain acupressure techniques, cryotherapy) to mask the problems of under- or over-active nerve tissue . Chiroprac­ tic methodology prepares the chiropractor to remove the structural lesion in hopes of effecting a lasting functional improvement; this is quite different from the stimulation/depression approach which tends to focus on the sympto m . I f a patient i s i n need of ultraviolet treatments i n order t o destroy motile bacteria in a chronic ulcer of the skin , the treatment should be provided by a licensed physiotherapist or physiatrist (M .D . ) . Why? The primary aim of such treatment is unrelated to the removal of nerve interference . The proposed treatment in this case is obviously more in keeping with the expertise and orientation of an allopath . It can be reasonably argued that whenever the aim of the physiotherapy is other than the restoration of normal nervous activi­ ty , such cases appropriately reside in the realm of the medical physi­ cian and the physiotherapist. In January of 1984, the Board of Direc­ tors of the Council on Chiropractic Education and the presidents of the 15 chiropractic colleges of the United States and Canada unanimously approved the following definition of chiropractic science: Chiropractic is the science which concerns itself with the relationship between structure , primarily the spine , and function , primarily the nervous system , of the human body as the relationship may affect the restoration and preser­ vation of health. It can be inferred that to simply use various physiotherapy modalities as temporary "symptom chasers" is to practice something other than chiropractic . As noted above , chiropractic involves 1) the relation­ ship of structure and functio n , for the sake of 2) restoring health or 3) preserving health . To apply, for example, heat and transcutaneous electrical nerve stimulation (TENS) to a patient as a treatment for pain is contrary to any reasonable definition of chiropractic . How so? Such practices do not effectively alter the structure-function relation­ ship so as to restore the health that has been lost. Heat and TENS

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may raise the patient's pain threshold, but only temporarily . To raise a patient's pain threshold through the use of TENS or heat means in reality that the dysfunction (signaled by the pain) has been masked, but not corrected . White and Panjabi write , "We are not aware at the present time of any studies that convincingly demonstrate the usefulness of these [TENS] techniques. " 16 And as Krusen's Hand­ book explains concerning heat therapy, "It should be noted that neither in the application of shortwaves nor in superficial heating agents is the underlying pathology such as disc protrusion affected at all . The treatment is symptomatic . . . " 1 7 What then is the role, if any, of physiotherapy in chiropractic? If one defines physiotherapy to mean those traditional practices of phYSiotherapists, then the answer to the question is : Physiotherapy as traditionally practiced has little if any role to play in chiropractic . This rather strict answer is dependent on the phrase "as traditionally practiced . " The history of physiotherapy has been dominated by various practices, techniques and modalities aimed at providing symp­ tomatic relief. Therefore , physiotherapy is really much more at home in the allopathic and naturopathic clinics . As Dorland's reminds us, allopathy is "that system of therapeutics in which diseases are treated by producing a condition incompatible with or antagonistic to the con­ dition to be cured or alleviated . "1 8 Thus, if a patient experiences mus­ cle pain , the allopath or the allopath's physiotherapist may use heat to raise the pain threshold or cold to numb the sensory nerves . In either case the physiotherapist produces a condition (functional hypoalgesia) incompatible to the condition to be alleviated (pain ) . In short, physiotherapy meshes perfectly with the aspirin-mentality of much of allopathic care . Likewise, physiotherapy is important to the Doctor of Naturopathy who is practicing "a drugless system of therapy, making use of physical forces such as air, light, water, heat, massage , etc . " While naturopathy espouses a reliance upon the natural curative powers of the body, the clinical approach is surprisingly allopathic: vitamins are frequently used as though they were drugs and symptoms are often the focus for various forms of physiotherapy . On the other hand, traditional physiotherapy works against the goals of the homeopath and the chiropractor. Homeopathy is "a system of therapeutics . . . in which diseases are treated by drugs [minute por-

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Professional and Ethical Concerns

tionsj which are capable of producing in healthy persons , symptoms like those of the disease to be treated . . . "20 In other words if the pa­ tient is hot, you do not artificially cool the patient. Instead , the homeopath introduces a minute amount of drug that would - in a healthy person - cause a fever. The object is to arouse the body's homeostatic processes. Because homeopathy may be likened to driv­ ing an allopathic ambulance in reverse gear, it is easy to see that tradi­ tional physiotherapy would never fit with homeopathy . Just when the traditional allopath would exclaim , "Ice that patient down! ," the homeopath would cry out, "No! Heat that patient up!" So while it is readily conceivable that a homeopath could use various physiotherapeutic modalities, they would be used in an unorthodox manner. Orthodoxy's indications for stimulation would be homeopathy's indications for depression and vice versa. To use traditional physiotheraphy with chiropractic would often cause the patient's physiology to be pulled in opposing directions . For example, a chiropractor who is caring for a patient with facet syndrome can choose one of three primary ways of seeking a cor­ rection to this subluxation and accompanying afferent-efferent reflex cycle . One, the vertebral subluxation can be adjusted . Two , the af­ ferent nerve fibers can be flooded with increased stimulation (e.g. pressure point therapy, deep heat) . Or three , the efferent and af­ ferent nerve fibers can be treated, say by massage or ultrasound the object being to break up any neurofasciomuscular adhesions con­ tributing to the syndrome and to relax the soft tissue environment, thereby reducing the generation of ectopic impulses . One and two above conflict. The adjustment seeks to allow the body to normalize nerve activity by removing the subluxation and its irritation (i . e . hyperactivity) of both afferent and efferent fibers . On the other hand, the flooding of afferent fibers with stimulation indirectly speeds up the body's sympathetic activity - just the op­ posite of what is best for the patient's health . As Korr noted earlier: . . . it is important to point out that there is a significant sym­ pathetic component in many, possibly most, syndromes and diseases. Therapy directed at silencing or reducing traf­ fic in the affected sympathetic pathways is often ameliorative . 21

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Professional and Ethical Concerns

The above point must not be overlooked . Certainly, the use of diather­ my may silence the nociceptor afferent traffic , but at what cost? Once the deep tissue is warmed sufficiently, sudomotor and vasodilator functions in the skin can be triggered by way of increased sympathetic activity, a process which can contribute to the facilitation of the in­ volved spinal cord segment(s) . So , instead of normalizing the neural activity of the involved segment, the diathermy depresses nocicep­ tor traffic only to stimulate unwanted sympathetic activity. The picture is somewhat the same when pressure point therapy is substituted for diathermy. As Hagbarth , Torebjork and Wallin report in Peripheral Neuropathy (Dyck, Thomas, Lambert and Bunge, eds . ) , "Any unexpected arousal stimulus , such as . . . a sudden pain stimulus anywhere on the skin surface evokes a single burst of [skin sympathetic activity (SSA) ] impulses. " They explain, " . . . arousal reflexes usually involve simultaneous activation of sudomotor and vasoconstrictor fibers . "22 The adjustment alone will more than likely trigger some sym­ pathetic activity without the need to induce excitation of the autonomic system by the certain pain that can accompany pressure point therapy. � As for alternative course three above , ultrasound is not indicated as a useful modality in neuropathies . G . Keith Stillwell, professor of physical medicine and rehabilitation at Mayo Medical School, explains, "Ultrasound is an efficient form of deep heating but is rarely indicated for patients with neuropathies . " As he notes, "Heat and cold are not frequently indicated for peripheral neuropathies and must be used with caution ."23 And as is typical of so many physiotherapy modalities, ultrasound does not normalize nerve activity . J ust the opposite . In the case of ultrasound , "An increase in vascularity and skin temperature can be produced by ultrasonic radiation applied to the sympathetic nerves. "24 Even if the patient is suffering from a lack of vascular activity , the best way to achieve a lasting, healthy result is to enable the person's own body to generate the needed vascularity by way of properly functioning homeostatic mechanisms - not by way of the whip of ultrasound . Massage was also suggested in alternative three above . Again , massage does not produce normal nerve activity; therefore , we do not get normal physiology . Massage causes both "dilation and con­ striction of arterioles" according to Miland E. Knapp , M . D . , of the University of Minnesota Medical Schoo l . 25 Depending on the con-

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Professional and Ethical Concerns

text, massage tends to stimulate or depress nerve activity. Either way, it counteracts the goal of chiropractic which is simply to remove the point of structural stress to the nervous system so that the nervous system - by itself - can restore homeostasis. The arguments for and against physiotherapy being used by chiropractors are essentially these : Against: 1) physiotherapy is based on the practice of disturbing the nervous system (i . e . stimulating or suppressing nerves) and hence is in opposition to the chiropractic concept of removing disturbances to the nervous system , 2) physiotherapy is not curative , but is basically a masking activity which temporarily makes the patient appear to be pain-free and supple , 3) physiotherapy is in millions of cases a needless waste of the pa­ tient's money, and 4) physiotherapy is basically an allopathic preserve which should not be raided by chiropractors (who by history and legal precedent are considered limited practitioners) . In Favor: 1) physiotherapy can reduce spasms, swelling and pain , thus making the adjustment a more pleasant and productive experience for both patient and chiropractor, 2) even if the soothing effects are only tem­ porary, many patients like the physiotherapy treatments and look forward to this aspect of the visit, 3) chiropractors are legally permit­ ted to use physiotherapy in most states and, in fact, have in several ways made pioneering contributions to physiotherapy, and 4) in cases where physiotherapy is warranted , the patient should be able to be serviced in the chiropractor's office instead of making a trip to another practitioner . The argument against physiotherapy concludes with the salty ques­ tion , "Why would a chiropractor want to steal from the medical gar­ bage can?" Physiatry, the branch of medicine using heat, cold , light, water, electricity, and mechanical devices, is held in such low esteem according to some medical authorities26 that only one out of 200 medical graduates chooses to practice in this specialty . In fact physiotherapy is considered by the medical community to be so menial that 99 percent of the PT cases are farmed out to the lower-status, non-doctors - the physiotherapists. Then why the scramble by many chiropractors to use physiotherapy? Some chiropractors assert that the real reason is money. Physiotherapy is a money maker, pure and simple . Others say that PT appeals to those chiropractors who feel clinically inadequate and so try to bolster their position by borrowing

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Professional and Ethical Concerns

as much as they can from the allopathic camp. Yet others contend that physiotherapy found its way into chiropractic because so few chiropractors have a full understanding of the chiropractic rationale . Yes, most chiropractors know a few philosophical "catch" phrases, but many never learned to think chiropractically . To these practi­ tioners, symptoms are still something you treat, not something you monitor to see if homeostasis is being restored . Nerves are something you turn on or turn off, not something you allow to normalize by merely removing structural stress . Disease is something external , an entity that must be fought, rather than the result of the body's response to a situation . So, never having learned to think like chiropractors , it is unrealistic to expect them to act like chiropractors . Despite all that has been said above, there are those chiropractors who contend that while they do not believe that health comes from treating symptoms and diseases, they still choose to use physiotherapy modalities and techniques . They argue that they do so not to get the patient well, but mainly to provide some measure of relief until the adjustments have enabled the body to begin recovery. And some chiropractors of this persuasion underline their sincerity by not charging a fee for physiotherapy services. What can we finally conclude regarding the issue of physiotherapy? While physiotherapy is not a part of the art, science or philosophy of chiropractic , it does not follow that the acid test for a chiropractor is whether he or she abstains from the use of physiotherapy or similar practices of fringe medicine . It is quite conceivable that a doctor of chiropractic could refuse to use physiotherapy modalities and still not practice according to the principles of chiropractic. Therefore , the acid test for any chiropractor is found in this question : Is the chiroprac­ tor's primary clinical concern the detection, removal, and preven­ tion of spinal subluxations? If the answer is "yes, " it can be said that

the physiologic therapeutics are playing an auxiliary, supportive role , and that the patient is receiving chiropractic care - that is , the at­ tending chiropractor's basic frame of reference is chiropractic . If the answer is "no," then the physiotherapy or other fringe medical prac­ tices have ipso facto assumed a primary role and the patient is no longer receiving chiropractic care . In such a situation , the patient is receiving allopathic, naturopathic, homeopathic, or possibly Chinese medicine , from a practitioner who does not hold a doctor's degree

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Professional and Ethical Concerns

in any of these disciplines. When patients go to a dentist they expect the DDS to 1) use an allopathic perspective in assessing and han­ dling their cases, and 2) refrain from administering chiropractic ad­ justments, homeopathic remedies, and acupuncture - disciplines in which the dentist has not earned a degree . In short, when a doctor of any type abandons the basic frame of reference of his or her discipline , and when that doctor proceeds to administer care which is for the most part borrowed from another discipline in which the doctor is unlettered , that doctor can no longer in good faith claim to be a practitioner of the discipline in which he or she holds a doctor's degree . And the corollary is that when a doc­ tor of any type adheres to the basic frame of reference of his or her discipline , and when that doctor administers care which is mainly drawn from that same disciplin e , that doctor can in good faith claim to be a practitioner of the discipline in which he or she holds a doc­ tor's degree . So to claim to be a practitioner of a specific health field , one must exhibit in a prevailing manner that discipline's basic think­ ing (i . e . , that discipline's diagnostic and analytical methods) and art (i. e . , that discipline's distinctive skill or service) . Note that the word "prevailing" was used in the previous sentence, as opposed to the word "exclusive" which would be preferred by some strict constructionists . The purpose of this line of reasoning and word­ ing is to get at the all-important central reality which is : subluxation­ oriented chiropractors (roughly 80 percent of the field) should not be divided by a heat lamp . As long as the primary concern is with the subluxation , these practitioners have more to unite them than to cause division . To put it in outdated language, the majority of "mix­ ers" (the subluxation-oriented ones) and the majority of "straights" (the subluxation-oriented ones) should be able to move toward the development of a profession which is united around a common defini­ tion which expresses the clinical need for both limitations and freedoms. (It must be assumed from the outset that no common defini­ tion will ever satisfy the would-be MD's or purge-minded purists who occupy the fringe ends of the chiropractic spectrum ; this fact should not deter the profession from making the effort to seek a greater unity based on common concern for the subluxation . )

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Professional and Ethical Concerns

Each passing year sees an ever-widening circle of acceptance for chiropractic . With the first chiropractic colleges achieving full accredita­ tion , with chiropractors making their first appearances in hospitals, and with chiropractic being included in a broad range of federal health programs, the profession must give consideration to chiropractic's place on the interprofessional health care team . As touched upon early in the book, chiropractic is best equipped to care for those cases which are still reversible once normal nerve function is restored . As a generality , late-stage diseases which are life-threatening require heroic measures more appropriate to the medical profession . In such cases, chiropractic care may still be desirable as an adjunct to medical procedures, but it would be only to assist and support - not to cure what may well be beyond the curative stage . As chiropractors become more of a presence in hospitals, it should be expected and insisted upon that they have the right of admitting and caring for patients under conditions and policies that place chiropractors on an equal footing with other doctors who enjoy privileges at the same hospital . At no time should a chiropractor par­ ticipate in working arrangements which undermine the chiropractor's plan of care for the patient. And at no time should the chiropractor be put into the situation of being the medical staff's "glorified physiotherapist . " That is, the doctor of chiropractic never allows another doctor to determine if a patient needs a spinal adjustment, let alone at which spinal level . As Chiropractic in New Zealand (aka "The New Zealand Report") stressed , " . . . no doctor has the training or experience to tell them [chiropractors] how to diagnose a vertebral malfunction or how to manipulate it . "27 On the other hand, chiropractors must expect to forego some prac­ tices which they previously may have performed themselves. Urinalysis would be carried out by the hospital laboratory , x-ray by the x-ray department, and any physiotherapy by the hospital physiotherapist. This chapter will end with three pertinent quotations from Chiropractic in New Zealand, the nearly two-year official study con­

ducted by a New Zealand Commission of Inquiry.

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Professional and Ethical Concerns

On the matter of access by hospitalized patients to a chiropractor: The only limitation , in our view , m ust be that chiropractic treatment should not be given where there are medical contra-indications. By this we mean some solid and soundly-based medical reason. We do not mean that a hospitalized patient should be prevented from receiving chiropractic treatment simply because the doctor in charge of the case believes that chiropractic treatment would be ineffective , or because there is some imagined philosophical difference . In a case where there could be some risk at­ tached to manual therapy we see no reason why doctor and chiropractor should not consult together on the prob­ lem so that the doctor is made to understand precisely what treatment and result the chiropractor has in mind, with due recognition given to the fact that the chiropractor can nor­ mally be expected to have a knowledge of biomechanics and training and skill in manual therapy beyond that of most medical practitioners. 28 On the matter of the potential for conflict between chiropractic philosophy and allopathic philosophy : There cannot b e any fundamental objection t o a n attitude to health care which restricts drugs to cases where they are shown to be a matter of necessity rather than a matter of mere convenience . Nor can it seriously be suggested that anyone is unreasonable to believe that it is better for the body's disorders to be relieved , if possible , by natural , rather than artificial or chemical means . 29 And on the matter of chiropractors as partners to medical doctors, not as auxiliaries : It is clear that the chiropractor m ust come into the health care team as a partner, not as an auxiliary . He must not be required to give up his independent professional status. That is because he has training and expertise in an area where most medical practitioners have no special training or expertise . In that respect the doctor must defer to the

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Professional and Ethical Concerns

chiropractor. So also m ust the chiropractor defer to the doctor in the much more extensive areas where specifically medical training is demanded . 30

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CHAPTER SIX FOOTNOTES 1 1983 lecture , Palmer College of Chiropractic . 2 Brian Inglis, A History of Medicine (Cleveland : World, 1965) , p . 133 . 3Ibid , p . 18 . 4S . E . Williams, International Review of Chiropractic (Washington , D . c . : International Chiropractors Association , Autumn/Winter issue 1982) , p . 14. 50 . 0 . Palmer, The Science, Art and Philosophy of Chiropractic

(Portland , Ore . : Portland Printing House Co . , 1910), p . 16 . 6Barbara Bates, A Guide to Physical Examination, 3rd ed . (Philadelphia : Lippincott, 1983) , p . 23. 7Marc Lan e, The Doctor's Law Guide (Philadelphia : Saunders, 1979) , p. 54. 8 Ibid , pp . 54-55 . 9Ibid , p . 55. I°Ibid . l lMurray Dennis, 0 . 0 . (optometrist) , Journal of Chiropractic (Arl­ ington , VA: American Chiropractic Association , July 1983), p. 30. 1 2Ibid , William DeFeo, D . P . M . (podiatrist) , p . 23. 1 3Ibid , Tamar Earnest, M . D . , p . 18 . 14D . P . Mammano , D . C . , Journal of Chiropractic (June 1982) , p . 9.

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15Ibid . 16White and Panjabi, Clinical Biomechanics of the Spine (Philadelphia: Lippincott, 1978) , p. 327 . l 7Article by Lehmann and DeLateur as quoted in Kottke , Stillwell and Lehman n , Krusen 's Handbook of Physical Medicine and Rehabilitation (Philadelphia: Saunders, 1982) , p . 333 . 1 8John Friel , Dorland's Illustrated Medical Dictionary, 26th ed . (Philadelphia: Saunders, 1 98 1 ) , p . 50. 1 9Ibid, p . 869 . 2°Ibid , p. 6 14 . 21 Irvin Korr, "The Spinal Cord as Organizer of Disease Processes : Some Preliminary Prospectives , " Journal o f the American Osteopathic Association (September 1 976) , pp . 43-45. 22Hagbarth , Torebjork and Wallin , "Microelectrode Recordings from Human Skin and Muscle Nerves , " Peripheral Neuropathy, Vol . I (Philadelphia : Saunders, 1 984) , p . 1 024. 23Stillwell, "Rehabilitative Procedures , " Peripheral Neuropathy, Vol. II (Philadelphia : Saunders, 1 984) , p. 2303 . 24Schroeder, "Effect of Ultrasound on the Lumbar Sympathetic Nerves, " Arch. Phys. Med. Rehabilitation ( 1962) , 43 : 182- 185 as quoted in Krusen's Handbook of Physical Medicine and Rehabilita­ tion (Philadelphia : Saunders, 1982) , p . 3 1 9 . 25Ibid (Krusen's) , p . 386 . 26Ibid , p. xiii . 27Fraser, Inglis (Chairman) and Penfold, Chiropractic in New Zealand

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(Report of the Commission of Inquiry, 1979; presented to the House of Representatives by the Governor-General) (Wellington , New Zealand : The Government Printer, 1979) , p . 305 . 28 Ibid , p . 302 . 2 9Ibid , pp . 303-304 . 30Ibid , p . 305.

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Professional and Ethical Concerns

145

ZI BEYOND THE SUBLUXATION

146

Beyond the Subluxation

The subluxation is an effect. Chiropractors sometimes forget this fact. D.O. Palmer's writings remind the practitioner that, "Poisons just as

surely act upon and cause contraction of nerves and muscles, draw­ ing bones out of alignment."l D.O. also argued that subluxations could even more readily be traced to trauma,

or sometimes even

autosuggestions. Because the subluxation is an effect, it behooves the chiropractor to not only remove subluxations, but also to prevent their occurrence. To prevent subluxations from happening, there must first be an understanding of how subluxations commonly occur. What follows is a discussion of how D.O. Palmer's "auto-suggestion" directly or indirectly produces thousands of subluxations every day. The body works on what may be called an energy-balance equa­ tion. That is, every bit of energy generated is expended - one way or another. Energy is expended when we talk, walk, think, eat, sleep and swim. As long as we produce the appropriate amount of energy for our activities, little goes wrong. The problem arises when we pro­ duce too much energy for a particular situation. The extreme exam­ ple is when adrenalin courses through a bystander's arteries at the scene of an auto accident, only to leave the onlooker shivering and shaking minutes later. The adrenalin that prepared the body to lift a car or pry open a battered door demands a physical release; the unused muscles work off the excess energy in fitful shudders. It is not uncommon for many, if not most, individuals to produce a continuous, low-level of "nervous energy." They can be seen biting their nails, tapping their toes, drumming their fingers, clenching their fists, tensing their jaws and - importantly - tensing their paraspinal muscles. In fact, millions of individuals exhibit the unconscious act of perpetually tensing the spinal musculature. In effect, these in­ dividuals have generated more energy than is appropriate. The central nervous system's efficient solution is to simply route this excess energy to those muscle masses most proximal to the brain and spinal cord, i.e. the muscles of mastication, and the muscles of the suboccipital and paraspinal regions. Not only does this excess muscle tensing along the axial skeleton contribute to misalignments and subluxations, but the additional and continuous nerve traffic tends to facilitate the various spinal cord segments, leading to hyperactivi-

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Beyond the Subluxation

ty of other tissues and organs related neurologically to those segments. The great challenge to any chiropractor is not merely to spend one's life removing subluxations, but rather to help patients to remove the causes of their subluxations. The original meaning of the word doc­ tor was one who possessed the qualifications to teach. Every chiropractor has a responsibility to teach. Obviously, not every pa­ tient will accept teaching. And obviously, some cases present more opportunities to impart knowledge than do other cases. What is to be taught? The supreme health care concept that all individuals should understand is this: the conscious and unconscious mind cannot be disturbed without dire physical consequences. If the emotions are continually in shambles, there will eventually be serious physiological consequences. A most trying task for a chiropractor is to attempt to correct the spine of a genuinely distraught individual. The subluxations are apt to return again and again. The nervous energy that accompanies conscious or unconscious mental conflict wracks both smooth and striated muscles,

not only initiating

physiological dysfunction, but perpetuating it through the resultant subluxations. How does one go about teaching the healthy interrelationship of mind and body? The place to begin is with oneself. The ancient ex­ pression "Physician, heal thyself" is appropriate. The doctor of chiropractic must enjoy some measure of inner repose before expect­ ing to be of help to a patient with the same problem. Does the chiropractor's body language express tension, conflict, hostility or unhappiness? Living is an art. For the person who has not learned that art, liv­ ing can be most painful. The art of living begins with birth, but not birth from the womb. True birth into the art of living occurs when the individual realizes and accepts the responsibility for being (physical, emotional, spiritual, sexual, social and intellectual). As one scholar stressed: We have a responsibility to be well. There are a few who seem to realize there is such a thing as physical morality. [Italics added.J2 The idea is this: it is immoral to attempt to make others responsible

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for our health. To not accept responsibility for our own health is to act like a child. Too many doctors of all types (and too many of their patients) refuse to take care of themselves physically. They drop their health problems in the lap of another doctor or their spouse or their parents. They refuse to say, "I am going to get myself well and I am going to keep myself well." Certainly, another doctor may be needed, but only to diagnose and render care - not to shoulder the emo­ tional burden. What has been said about being responsible for one's physical well being can also be said about one's emotional, spiritual, sexual, social and intellectual well being. As long as an individual refuses to take responsibility for each of these important aspects of selfhood, that individual operates on a childish, immature level - slavishly follow­ ing the ideas, beliefs, goals and "do's and don't's" of others. The unhealthy or destined-to-be unhealthy person has often forfeited all decision making to others. They wait until the doctor tells them to lose weight. They depend on the clergy to provide them with religious thought. They ask the counselor to give them career ideas. They let Motor Trend magazine steer them to the right car. They keep pace with the latest fads to insure a "fun" social life. And in search of securi­ ty, they chase the dollar until they die. What people really want is to feel as worthwhile and happy as they are capable. They pursue money and things only because they think it will give them the feeling of self-worth. However, this feeling is only possible as the result of deciding and doing what one is talented or gifted at doing. When we live out our real and unique abilities, we naturally feel right inside. The point here is not that Motor Trend or fads are worthless, but that when people let others run their lives they are setting themselves up for emotional conflict and ill health. Until individuals decide to take responsibility for all of their own development, recognizing that all external authorities are only advisors, they in fact have not been fully born. In this immature condition, an individual's quest for health will be shallow indeed. Chained to a self-defeating reliance on others, he or she cannot break the debilitating habit of doctors and doctor­ ing (or chiropractors and chiropractoring). The self-perception is: "Yes, I need my health, therefore I really need my doctor." This individual values health, but does not value healthy self-reliance. This individual

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does not value (trust) his or her ability to rise to the challenge of Spencer's "responsibility to be well." Karen Horney, one of the giants in psychiatry and author of Our Inner Conflicts, wrote: "Inconsistencies are as definite an indication of the presence of conflicts as a rise in body temperature is of physical disturbance."3 The chiropractor who preaches healthful habits but does not practice them has a serious internal conflict. The practitioner who says, "Chiropractic has given me a whole new outlook on health and living, " and then insists on having "a weekly adjustment" in perpetuity is still caught in the old conflict of wanting the independence of health, but getting a regular "fix" instead. It is just as essential to have one's life adjusted as it is to have one's spine adjusted. The starting place for such a task is with one's true thoughts, feelings and desires. As the Oracle at Delphi commanded: "Know thyself." Each person must ask, "What do I really think? value? believe? want?" Not, "What does my mother want for me." Not, "What does the minister want?" Not even, "What do my patients want?" None of this means the individual is supposed to automatically react in opposition to mother, clergy or patients. But it does mean a person should be doing only that which he or she honestly feels is right. This compels the individual to sift through the hodge-podge of conflicting shalls-and-shall-nots handed to us from various authorities. The goal is to piece together a life that is consistent, truthful, and satisfying to oneself. This requires that we examine all that we have been taught, including our deepest habits, our most fevered prejudices and surest assumptions. As Socrates argued, "The unexamined life is not worth living. "4 How does the mature and healthy practitioner assist patients in moving toward a more responsible attitude about their health? Kahlil Gibran in The Prophet wrote of the teacher: If he is indeed wise he does not bid you enter the house of his wisdom, but rather leads you to the threshold of your own mind.5 Slogans, sermons and signs on the wall are probably not the way to go with patients. Practical, simple advice may help. Oftentimes, a straight forward question such as "Do you really like your work?"

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Beyond the Subluxation

or "Is there something in your life you would really like to change?" can spark a patient to begin to face up to an unhealthy conflict situation. Beyond these suggested approaches, the chiropractor's own ac­ tions and patient care procedures are a most useful teaching tool. If the practitioner provides the patient with ways to take an active role in the recovery process, if the chiropractor seeks to correct the nerve problem instead .of chasing symptoms, and if the doctor of chiropractic demonstrates respect for the innate recuperative powers of the patient's body instead of overwhelming it with a barrage of treatments and traumas, then and only then, will the patient have a chance to develop a sound, responsible attitude toward personal health.

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Beyond the Subluxation

CHAPTER SEVEN FOOTNOTES 10.0. Palmer, The Science, Art and Philosophy of Chiropractic

(Portland, Ore.: Portland Printing House Co., 1910), p. 832. 2Attributed to Herbert Spencer (1829-1903 A. D.). 3Karen Horney, Our Inner Conflicts (New York: Norton, 1945), p. 35. 4James Feibleman, Understanding Philosophy (New York: Dell, 1973), p. 40. 5Gibran, The Prophet (New York, Knopf, 78th printing 1966), p. 56.

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Beyond the Subluxation

153

APPENDIXES

154

Appendixes

SELECTED QUOTATIONS OF D.D. PALMER The following 90 quotations are from D.O. Palmer's classic work,

The Science, Art and Philosophy of Chiropractic, a 1007 page text published in 1910. The quotations were selected not only to present some of the main ideas of chiropractic's founder, but also to sketch some of his qualities as a man. A thoroughgoing intellectual, he also was argumentative and egotistical. He engaged in bitter squabbles with his equally strong­ willed son and chiropractic leader, B. J. Palmer, over various issues regarding chiropractic theory, practice, education and professional ethics. Throughout his life, D.O. Palmer bedeviled his enemies and charmed his supporters with a sizzling wit. Despite the fact that Palmer's writings are from the mind of a 19th century man, much of what he wrote is still relevant and edifying.

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. . . . This question had worried thousands for centuries and was answered in September, 1895. Harvey Lillard, a janitor, in the Ryan Block, where I had my of­ fice, had been so deaf for 17 years that he could not hear the racket of a wagon on the street or the ticking of a watch. 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. With this object in view, a half-hour 's talk persuaded Mr. Lillard to allow me to replace it. I racked it into position by using the spinous process as a lever and soon the man could hear as before.

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...Shortly after this relief from deafness, I had a case of heart trouble which was not improving. I examined the spine and found a displaced vertebra pressing against the nerves which innervate the heart. I ad­ justed the vertebra and gave immediate relief. .. Then I began to reason if two diseases, so dissimilar as deafness and heart trouble, came from impingement, a pressure on nerves, were not other diseases due to a similar cause? Thus the science (knowledge) and art (adjusting) of Chiropractic were formed at that time. I then began a systematic in­ vestigation for the cause of all diseases and have been amply re­ warded. (pp. 18-19) In disease, mental impulses are not impeded, hindered, stopped or cut off - they are modified. An impingement does not obstruct; it is either an excitor or a depressor. (p. 57) The real, primary cause of disease is tension; the cause of tension is pressure; the cause of pressure in 95 per cent of diseased condi­ tions, is luxated [subluxated] vertebrae. The cause of the remaining 5 per cent is the luxation of other bones than those in the vertebral column. (p. 57) Most diseases are the result of too much instead of too little func­ tioning. (p. 70) Pressure on nerves usually excites, irritates, thereby creating too much, an excess of nerve force at the peripheral nerve endings. (p. 72) Chiropractic has no room for Miss Treatment, neither has Adjust­ ment any need of being hampered by Miss Remedy. These girls of fashion change their clothing to suit every suitor; they would only annoy my kids. Chiropractic and Adjustment are inseperable; they desire no other company. (p. 81) ...the rules of inanimate machinery, propelled by external applied force, will not apply to organic bodies, which are functionated by in­ ternal intelligent, vital force. (p. 85) Mind does not control the functions. There is an intelligence that con-

156

Appendixes troIs the mind and its functions, as well as the functions of the body. {p. 90 Honesty is not policy. Policy is dishonesty. (p. 97) A subluxation perpetuates disease. (p. 100) I saw fit to date the beginning of Chiropractic with the first adjust­ ment [1895], although quite a portion of that which now constitutes Chiropractic I had collected during the previous nine years. (p. 101) An increase or decrease of tonicity in nerve tissue causes a corre­ sponding change in functions. (p. 105) The Chiropractic idea of disease and the adjusting of vertebrae, therefore, is applicable to all animals which have vertebral back bones. When Chiropractic methods are understood by veterinarians they will cease their cruel treatment. (p. 106) Many subluxated vertebrae return of their own account, others do so by suitable aCcidents, while poisons acting as antidotes should be credited with a portion. But these forces do not return all displaced, wrenched vertebrae (the M. D. 's sprains) to their normal position. Why? When movements are made more than normal, ligatures and muscles are unduly strained and stretched, the intervertebral cartilage is lacerated and torn from their bodies. This violence causes them to lose in a measure, their tonicity. (p. 126) A Chiropractor who comprehends the principles of this science will have no use for adjuncts. Just in proportion as he lacks knowledge and confidence (the two go together) he will use remedies, become a mixer. (p. 136) Chiropractors do not manipulate; they do not use the process of manipulating; they adjust. (p. 147) When it becomes a generally accepted fact among the medical pro­ fession, that vertebral luxations [subluxations] do exist; that they can

157

Appendixes be readily reduced; that by vertebral adjustments, acute diseases disap­ pear as does the morning frost before the rising sun... they... will then ask legislators to pass laws forbidding all except those who belong to their own ranks.. .to use the hands only to adjust displaced vertebrae. (p. 205) As I have said before, the M.D. 's sprain is the subluxation of the Chiropractor. (p. 209) '1"

The medical profession [is] hunting for antidotes, not causes. (p. 217) The world will be the wiser and better for my having lived. (p. 224) Chiropractic is not a system of healing. Chiropractors do not treat disease; they do not manipulate the spinal column. Chiropractors adjust any or all of the 300 joints of the body; more particularly those of the spinal column. (p. 228) Occlusion is not the cause of disease. Nerves are impinged upon, pressed against, not squeezed or pinched. (p. 275) I believe that every Chiropractor thinks that he is specific in his or her adjusting. There are those who adjust every vertebrae for any and every disease; others who adjust every other one on the first day and the alternate ones on the next, thus, in the two days, they surely do not miss any; and still others who adjust any vertebrae which seems to be out of line. They all think they are specific. (p. 310) Pathologists have considered effects as causes. (p. 351) Students of chiropractic should constantly remember that disease is not a thing, but a condition. It is an abnormal performance of cer­ tain morphological alterations of the body. (p. 358) The determining causes of disease are traumatism, poison and auto­ suggestion. (p. 359) Innate is not the mind. Innate is the intelligence back of and con-

158

Appendixes

troller of the mind as well as of every thought. There is an inborn intelligence in every living being, and in every plant that grows. Mind is a product of Innate, and is sane or insane in proportion as the ner­ vous mass, the encephalon, and its radiating branches, the nerves, possesses normal or abnormal carrying capacity. (p. 362) Vital force is inherent iP( the organ or organism. ...therefore, vital force does not move "from the brain along the nerves to the organ." (p. 379) The clicking is no evidence of luxation [subluxation). Crack one of your fingers, and tell me if it was luxated. (p. 386) Effects cannot be adjusted; causes can be. (p. 400) Chiropractic is not a healing system. It has nothing in common with any other system and is not therapeutical, does not use remedies, does not treat, cure or heal. (p. 400) "A stiff irregular spine is a sure indication of mental or physical distur­ bance." There are many, very many, exceptions to the above, in fact, the exception is the rule. Hunchbacks are as free of disease, or more so and as frequently live to a ripe old age as the ordinary. (p. 404) We, as Chiropractors, simply adjust the tensor-frame in order to return nerves and thru them muscles and organs to tone, normal tension. (p. 411) The [body] is operated by an intelligent vital force which I saw fit to name Innate - born with. (p. 413) There are only two classes in the world - doctors and patients. (p. 428) Adjusting is the result of intellectual and mechanical force on the part of Educated - not of Innate. (p. 430)

159

Appendixes The Intelligent Life-Force of Creation is God. It is individualized in each of us. . . . God - the Universal Intelligence - the Life-Force of Creation - has been struggling for countless ages to improve upon itself - to express itself intellectually and physically higher in the scale of evolution. (p. 446) ... we speak of two intellects [educated and innate), two distinct think­ ing individualities; yet they are one and the same - start as one and end as one. (p. 453) An impinged nerve has pressure on one side only. The author of Chiropractic states that nerves may be impinged upon by any dis­ placed bone, but pinched only by fracture and extreme displacement. (p. 466) Displaced vertebrae gradually assume an abnormal shape ... To return them to their former position means that they will be required to resume their natural shape; to accomplish this may take the adjustor weeks or months. (p. 484) Life is but the expression of spirit thru matter. (p. 495) Do not forget for one moment that every physical function of the body is managed by Innate [the "born with" intelligence) thru the nervous system. Even nerve sheaths and the walls of blood-vessels are covered by a complete net-work of nerves to facilitate the trans­ portation of sensation, motion, transudation and circulation. (p. 498) Chiropractic diagnosis or analysis is radically different from any other method; as much so, as adjusting causes is different from treating effects. (p. 561-562) .. .it is not considered good taste to place Dr. and D. C. both to your name. Either one is correct. (p. 579) The pathology of therapeutics is not that of chiropractic. (p. 604) The practice of the old school (Allopathy) and Osteopathy differ only

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Appendixes

in degree. The Allopaths are more medical and less mechanical; while the Osteopaths are more mechanical and less medical. (p. 609) The M.D. 's wrenches and sprains of the back are Chiropractic [sublluxations. (p. 611) Innate is connected with the body; that union produces life - soul. Innate, the spiritual, has the power to conceive, judge and reason on matters, which pertains to the internal welfare of the body. (p. 616) The most of diseases is because of too much energy; not because nerve force is "shut off. " (p. 617) The body has been likened to a pharmaceutical laboratory; to an elec­ trical machine; to a gas machine; to an engine. But none of these express the action of functions directed by intelligence. (p. 621) Tone is the foundation upon which I built the science, reasoned out its philosophy and created the art of adjusting [sublluxated vertebrae. (p. 632) While embryology, myology and angiology are instructive, they are not so essential to a Chiropractor as are the branches of osteology, neurology and physiology. (p. 634) The Innate of the mother runs all the functions of the embryo and fetus until delivery. (p. 634) . . .we should see that bones of the skeletal frame of the mother are not impinging on the conveyors of impulses, which are behind vegetative functions. Remember, that the same law which governs the functions of the mother operate in a like manner in building the unborn. (p. 635) In the near future Chiropractic will be as much valued for its preven­ tative qualities as it now is for adjusting and relieving the cause of ailments. (p. 638)

16 1

Appendixes

All phenomena are the result of matter modified by inte//igence. (p. 646) Some persons are continually complaining of a weak ankle or a sprained wrist; in such cases there wi// be found [subJluxations in the lumbar and dorsal regions. (p. 646) . . . J. M. , a farmer, about 60 years of age, entered my office on crutches. In answer to my question, " Well, sir, what is the matter with you?" he said: "Three years ago a cow kicked me on the ankle. I manageed to walk to the house, but have been unable to bear any weight on that foot since. I have tried several doctors and many remedies, but nothing has done me any good. " An examination of the ankle showed no displacement, no local injury, the subjective symptoms pointing to a sprained ankle. By pressure above the ankle I discovered a hypersensitive nerve which I traced to the lumbar region. I tried to explain to him that the instant he was kicked he jerked his leg away from danger, wrenching a lumbar vertebra of his backbone, thereby placing a pressure upon the nerve which reached to, and had its ending in, the affected ankle. He did not accept my explanation. In about six months he returned; he was yet on crutches. . .. He insisted on my treating his ankle, saying his back was all right. . . I refused to touch the ankle. . . In about three months he again returned. . . He threw down a ten­ dollar bill, saying: "I might as weII fool my money away here as elsewhere. " After one adjustment of a lumbar vertebra, he walked out of the adjusting room and said: "See what I can do. I can bear considerable weight on that foot. " In time he was able to discard the crutches. (p. 647-648) The source or origin of Chiropractic principles is tension. (p. 656) . . . B. J. Palmer, the enveloper. (p. 658; In the running war between D.D. and B.J. this barb was an intentional dig at B.J."s self-appointed title as the developer of chiropractic. ) Physicians, who give us 15 minutes ' attention while we explain Chiropractic [subJluxations by the use of specimens at hand, admit

162

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--

Appendixes that there may be many diseases arising from displacements of the vertebral column. But being able to replace them by hand is very much doubted until demonstrated; one practical exhibition removes all doubt. (pp. 661-662) To make an adjustment, to move a vertebra, the patient should be relaxed. . . .Quite a large share of our vertebral displacements are oc­ casioned during sleep, when we are fully relaxed and unprepared for danger. (p. 666) There are piano pounders, typewriter thumpers and Chiropractor jam­ mers. (p. 671) If you do not remove the cause, how can you expect the patient to recover from the eHects? (p. 674) The mother bequeaths to her oHspring that intelligence which I have seen fit to name Innate. This is as true in the vegetable kingdom as in the animal. (p. 680) Learn chiropractic - do less work and more good. (p. 690) The world, which has complacently witnessed the tortures and persecutions of the past in the interest of theologians - speculative as were the doctrines concerned - may tolerate in an age when materialization has dethroned God, and science has abolished religion - a medical domination equaling, if not surpassing, in tolerance the cruelties of a theological epoch. (p. 694) The basic principle of Chiropractic and adjusting vertebrae for the relief of disease has been practiced over 2, 000 years. (p. 719) Innate is not the mind, any more than the body is the mind. There is a spiritual mind and a physical mind. The former is everlasting, the latter exists during life. The mind of the spirit is augmented by the experiences of the physical mind. (p. 742) We possess two intelligences, Innate and Educated. Innate runs all the vital functions while we are asleep or awake. ...It remains for

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Educated Intelligence to keep, fix, adjust the skeletal frame so that Innate can use it as a means of communication in such a manner as desired. (p. 753) If one person who is exposed to smallpox contracts it, thereby prov­ ing it to be contagious, does not the fact that those who do not take it, disprove the contagion theory? (p. 756) Every chiropractor should be well versed in the principles of Chiroprac­ tic. (p. 766) Drugs are pathological in their action on the nervous system; they are given to produce a change in function. . . . Drugs not only change functions, but, also, the anatomical structure; they are disease pro­ ducing in their action upon both function and tissue. (p. 777) All poisons act on the nervous system as an irritant or a lenitive. By their action they draw vertebrae out of alignment. Poisons may be antidotal - having a tendency to draw vertebrae in an opposite direc­ tion to that of another poison for which it is given to counteract. The Chiropractor, instead of using a counter-irritant or a lenitive drug, accomplishes the same purpose sooner and without danger by ad­ justing the displaced vertebra by hand. (p. 777) We often think that we were born too soon, but no dog can choose his day. (p. 779) Chiropractors look upon disease as a misfortune rather than an enemy. They consider that it needs assistance rather than subjec­ tion. . . (p. 788) Clear writing requires clear thinking. One cannot convey clearly to others what is vague and indistinct in his own mind. (p. 813) Some Chiropractors waste much time using adjuncts [therapies]. If this time was utilized in studying the principles of Chiropractic and their application, the profession would be advanced. Adjunct users should read and study Chiropractic literature; but, these are the ones who do not care to advance. (p. 824)

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Recent graduates are the ones who know most - in their estima­ tion. (p. 826) If vaccination is a sure protection against smallpox, why are the parents of vaccinated children not satisfied? Why demand that their neighbor's; family should be vaccinated? Because they have no faith in its pro­

tection, fearing that their children who are immune {?) may catch it from those not vaccinated. (p. 826) Remember, if you receive Chiropractic ideas pathologically distorted, they are not physiologically Chiropractic. (p. 828) If we will use the word impingement in the sense of pressure and remember that an impingement instead of squeezing or pinching a nerve only increases its tension by stretching, we will have an ex­ planation which will explain; one which anatomists cannot gainsay. (p. 845) Chiropractors are the first to adjust the bones of the foot for the relief of corns; they do not treat effects, they adjust causes. (p. 853) I have seen Chiropractors jump up and down several times before giving a thrust. (p. 908) Tone is the foundation upon which, as a basic principle, I built my science. ...Life consists in the renitency and the elasticity of tissue; its response to impulses, life guided by intelligence... (p. 971) The quicker the move, the less force required. (p. 982) Worship truth and justice - you need no other God. (p. 983) Chiropractors do not need a stretcher for spinal extension to assist them to replace displaced bones. (p. 983) When! am dead, if men can say, ! helped the world upon its way; With all my faults of word and deed Mankind did have some little need For what I've done - then in my grave No greater honor shall! crave. (p. 985)

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A THOUGHT ON HOMEOSTASIS We know that homeostasis involves negative feedback. We even know some of the mechanisms entailed. But this knowledge does not really touch the deeper mystery of how the body "thinks" physiologically: sensory information must be endlessly integrated and efferent activity determined. The stringing together of mechanisms cannot be expected to cap­ ture the overall reality of organic, dynamic activity. Classic mechanistic thinking is rooted in the notion that the parts explain the whole. This is true of mechanistic processes such as gearing or even electronic computing. But as Aristotle observed, nature is a world of purpose.! In such a world, mechanisms are merely the instruments through which superimposing purposes work their wills. It is this marvelous, innate (inborn), purposeful nature which is the predominant, practical reality behind the mechanisms of homeostasis. Virgil V. Strang

!E.L. Allen, From Plato to Nietzsche (New York: Fawcett, 1966), p. 31.

166

INDEX OF NAMES

Aristotle...166 Barge, Fred...4, 81, 83 Bates (judicial decision) ...127 Bates, Barbara ..124-125 Bernard, Claude...48 Borror, Gregory...4 Boyd, William.. .32-33, 49, 107-108 Bunge...135 Burns, Richard ..112 Burrows, Natalie...4 Campacci, R....68 Capra, Fritjof. . 29-30 Caruso, 1.. ..67-68 Carver, Williard...12 Clerk-Maxwell... 35 Cleveland III, Carl...65-66 Cotran, Ramzi...47, 93-94 Cox, Alex...112 Crispini, L...70 Darling, P .. ..68, 72-73 DeFeo, William ..127-128 deGourmont, Remy. . 5 DenniS, Murray...127 Descartes, Rene...29 Despopoulos, A....51-52 Dubos, Rene...11, 25-26, 46 Duhem, P....47 Dyck.. 135 .

.

.

.

.

.

Earnest, Tamar...128 Ehrlich...45 Einstein, Albert...35, 36 Ewing, A.C. ..30-31 Faraday ..35 Finneson, Bernard...27, 94-95 Fleming...45 Fonti, S. ..69 Foster, A.L. ..12 Freidrich...108 Gibran, Kahlil...150 Gordienko ..108 Grostic, John...109 Grostic, John D .. 120 Guyton, Arthur...106 Hagbarth...135 Haldeman, Scott... 95, 106, 109-110 Hippocrates...11, 49, 92-93, 95 Homewood, A.E... 55, 56, 105, 107, 108-109 Hornbeck, R ...64-65 Horney, Karen ...150 Howard, John...12 Inglis, Brian . 120-121 James, William...63 Janse, Joseph...21-22, 105, 107 Joad, C.E.M.. .14, 31 .

.

.

.

.

.

.

.

.

.

.

.

167

Index of Names Jones, WilIiam...92-93 Kamieth, H....53-54 Knapp, Miland...135 Koch, Robert...11 Kohler... 36-37 Korr, Irvin...56-58, 102, 108, 134 Lambert... 135 A.W....105 LoMonaco, M....67-68 Luisetto, G....68 Luttges, Marvin...65-66 Lynch, M....66-67, 69, 70-72 Maigne, Robert...110 Mantero, E....70 Martin, Rolland...73 Martino, G.... 64-65 Mazzarelli, Joseph...64 McAndrews, Jerome...9 McDonald, WilIiam...4 Mennell, John",110-111 Murray, Henry...38 Oracle of Delphi... 150 Palmer, B.J....11, 12, 63-64, 126, 162 Palmer, 0.0....9, 11, 12, 33, 55, 56, 105, 107, 122-123, 147, 155 Panjabi, Manohar...133 Pasteur, Louis... 107 Patterson, Michael...56 Payne, Douglas...4 Pettibon, Burl. ..4, 85, 87 Pizzetti, M....67-68 Poincare, H....47

Robbins, Stanley...47, 93-94 Rossi, A....64-65 Rothman...105 Sato, Akio...106 Schaudinn...44-45 Schrodinger...35 Selye...109 Sheldon, Huntington...32-33, 49, 107-108 Sherrington...51 Silbernagl, S .... 51-52 Simeone ...105 Socrates ...150 Spano, 0....68, 72-73 Spencer... 148 Speransky ...108 Steiner, W....68 Stephenson, R.W.... 34 Stillwagon, Glenn.. .4, 75, 77, 79 Stillwell, G. Keith...135 Strang, Virgil... 3, 4, 9, 166 Szent-Gyorgi, Albert. ..32 Tagliaro, F....68 Thomas...135 Tomlin, E.W.F....5, 29 Torebjork...135 VanNuys, Kelvin...34, 36-38 vonBehring, Emile... ll Wallin... 135 Washington, Edward T .... 92-93 White, Augustus ...133 Whitehead, Alfred... 37-38 Wilk, Chester...64, 93, 121 Wolf, C. Richard...73 Zerillo, G....66-67, 70-72

Book Design: John W. McDonald Printer: Stamats Communications, Cedar Rapids, IA.

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