Chapter 1 General Overview of the Chiropractic Profession

The chiropractic profession is only a little more than a century old, but manipulation in its various forms has been used to treat human ailments since antiquity. Although no single origin is noted, manual procedures are evident in Thai artwork dating back 4000 years. Ancient Egyptian, Chinese, Japanese, and Tibetan records describe the use of manual procedures to treat disease. Drawings demonstrate the application of this treatment form from the time of the ancient Greeks through the middle ages in various parts of the eastern and western world. Manipulation was also a part of the North and South American Indian cultures. Certainly, Hippocrates (460–355 bc) was known to use manual procedures in treating spinal deformity, and the noted physicians Galen (131–202 ad), Celsus, and Orbasius alluded to manipulation in their writings. The nineteenth century witnessed a rise in popularity of American and English “bonesetters,” the most well known being Mr. Hutton, who influenced the thoughts and writing of Sir James Paget and Wharton Hood. Bonesetters were often called upon to provide treatment for many types of maladies. Bonesetting was often practiced by families. It evolved from a lay practice developed from the peasant revival of manipulation after it went underground during the seventeenth century.

It was not until the days of Daniel David Palmer and Andrew Taylor Still, the founders of chiropractic and osteopathy, that these procedures were codified into a system. Palmer and Still both became acquainted with bonesetters and bonesetting techniques. In addition, the two men practiced magnetic healing, a reflex therapy that on occasion used powerful paraspinal massage.¹ Bonesetting and magnetic healing were instrumental in the founding of chiropractic and osteopathy. The early days of chiropractic and osteopathy represented major attempts to place manual procedures on firmer ground, and although the major developments in manual manipulative procedures in the late nineteenth century were largely American, developments were also occurring in other locations around the globe. At the same time, bonesetters were working in the United States and England and continued to do so into the early twentieth century. Bonesetters continue today to have an effect on health care delivery in Japan. While chiropractic was developing in the United States under the leadership of D.D. Palmer and his son, B.J. Palmer, medical manipulators from around the world were also making significant advances, as were early osteopathic researchers. The works of Mennell, Cyriax, Paget, and others are important in this regard.

Both chiropractic and osteopathy chose to focus on the musculoskeletal system, although in philosophically divergent ways. Andrew Still placed great emphasis on the somatic component of disease, largely involving the musculoskeletal system, and on the relationship of structure to function. Palmer postulated that subluxation, or improper juxtaposition of a vertebra, could interfere with the workings of the human nervous system and with innate intelligence, that power within the body to heal itself. Both emphasized the role the musculoskeletal system played in health and disease.

Coulter has described the historical concepts of chiropractic that initially defined the young and growing profession, and the emergence of a developing philosophy of care.² He suggested that chiropractic distinguished itself as a primary contact healing art by advocating for an alternative type of care, and advancing the specific philosophic tenets of critical rationalism, holism, humanism, naturalism, therapeutic conservatism, and vitalism in the care of patients. Many of these tenets have been well established and significantly advanced by the profession.³

However, to succeed in an environment as dynamic and volatile as health care, it is critical to distinguish between those aspects of a given profession that are vital to it and those aspects that are inessential and often create costly distractions.⁴ To begin to understand the aspects of the chiropractic profession that are either vital or inessential to the profession’s identity, a look at the past, the present, and the future is necessary.

The past

Daniel David Palmer (1845–1913; also known as D.D. Palmer) is considered the “father” of chiropractic. He came to the United States from Port Perry, Ontario, Canada, in 1865. He spent the next 20 years in such various occupations as farming, beekeeping, and store sales. In 1885, he opened a practice as a magnetic healer in the city of Davenport, Iowa, although he had no formal training in any healing art.

During the nineteenth century, various forms of spiritualistic and metaphysical speculation existed, all of which piqued Palmer’s curiosity. He studied and was influenced by Mesmer’s concept of animal magnetism and Mary Baker Eddy’s spiritual concepts used in her Christian Science healing. During this same time, Thoreau and Emerson’s transcendentalist philosophy, which emphasized a love of nature and independence of thought, provided a supportive environment for the pioneers of new healing methods, including D.D. Palmer.⁵ Palmer was able to blend recognized spiritual and metaphysical concepts together with then-current scientific principles to create a unique ethos for the chiropractic healing art.⁶

His formulation of chiropractic practice and theory purportedly developed from his application of a manual thrust, which he called an adjustment, to Harvey Lillard in September 1895 (coincidentally and significantly, the same year that Roentgen discovered the x-ray). This event has moved beyond that of a simple tale to an apocrypha. As the story goes, this manual adjustment was directed to the fourth thoracic vertebra and resulted in the restoration of Mr. Lillard’s lost hearing. From the reasoning used to devise this treatment, Palmer then applied similar lines of thought to other individuals with a variety of problems, each time using the spinous process of a vertebra as a lever to produce the adjustment. Palmer was the first to claim use of the spinous and transverse processes of the vertebrae as levers for manual adjustment of the spine—in effect, short lever contacts. This constituted the initiation of chiropractic as an art, a science, and a profession. Palmer wrote:

I am the originator, the Fountain Head of the essential principle that disease is the result of too much or not enough functioning. I created the art of adjusting vertebrae using the spinous and transverse processes as levers, and named the mental act of accumulated knowledge, function, corresponding to the physical vegetative function—growth of intellectual and physical—together, with the science, art and philosophy of Chiropractic.⁷

From this nearly chance opportunity came the outlines of the profession. Palmer developed the concept of a “subluxation” as a causal factor in disease, through the pressure such “displacements” would cause to nerve roots. Within 2 years of the initial discovery, Palmer had started the Chiropractic School and Cure and soon had his first student. By the year 1902, Palmer’s son, Bartlett Joshua (usually referred to as B.J.), had enrolled in his father’s school and 2 years later had gained operational control of the institution, becoming president in 1907. He maintained this post until his death in 1961.

Animosity between father and son developed. Palmer clearly stated that the only principle added by B.J. Palmer was that of greed and graft; he aspired to be the discoverer, developer, and fountainhead of a science brought forth by his father while he was a lad in his teens.⁷ The elder Palmer left the school of his name and traveled around the country, forming at least four other chiropractic schools in California, Oregon, and Oklahoma. He was also placed in jail for a short time for practicing medicine without a license. Although he might have been able to avoid jail by paying a small fine, he believed he had a more important principle to uphold. Palmer was not the last to be jailed for this crime; the process of jailing chiropractors for practicing medicine without a license continued into the next two decades.⁸ Preoccupation with the legal right to practice chiropractic no doubt led the profession to focus resources on political, ideologic, and economic concerns, rather than on research that might have influenced medical scientists.⁹

D.D. Palmer died in 1913 after enjoying only a short reconciliation with his son, B.J., who had by that time led the original Palmer School for nearly 7 years. In 1906, D.D. Palmer had already forsaken education at the original Palmer School. That year was also significant because it marked the first philosophic differences within the fledgling chiropractic profession. John Howard, one of the first graduates of the Palmer School, was unable to accept many of the philosophic beliefs relative to health care that B.J. Palmer was now openly espousing. B.J. had by then begun to preach that subluxation was the cause of all disease. Howard therefore left the Palmer School and founded the National School of Chiropractic not far from Palmer’s school in Davenport. As Beideman had noted,¹⁰ Howard wanted to teach chiropractic “as it should be taught” and therefore moved the school to Chicago, believing that chiropractic education required coursework in the basic and clinical sciences, including access to laboratory, dissection, and clinics. These two schools (now colleges) still exist today.

Willard Carver, a longtime friend of D.D. Palmer and the attorney who defended him when he was arrested for practicing medicine without a license, decided to take up the profession of chiropractic as well. After D.D. sold the chiropractic school to B.J., Carver began to distance himself from the Palmers. He never had a strong relationship with B.J., and because of disagreements on the nature of subluxation and scope of practice, he began his own school in Oklahoma.

Carver viewed chiropractic practice in a manner opposed to that of the Palmers. Carver followed what he called a structural approach, which was essentially a systems approach to subluxation. In his view, disrelations in spinal joints were the result of compensatory patterns and adaptations arising from other subluxations. He was also an advocate for other therapeutic procedures beyond adjustment that were at times outside the common scope of chiropractic practice, such as physiotherapy. This put him very much at odds with the Palmerite approach to chiropractic.

Carver is equally well known for his legal and legislative efforts on behalf of the profession. Not only did he establish schools of chiropractic in several cities, he also wrote eight influential early chiropractic texts, published a college journal (Science Head News) that provided perspectives different from the prevailing Palmer view, and helped establish licensing laws for the chiropractic profession where none existed before.

Other chiropractic institutions were also being founded all over the country, and there was more and more internecine warfare among practitioners. B.J. Palmer had set himself up as the protector of a fundamental form of chiropractic (today referred to as straight chiropractic).

From 1910 to 1926, Palmer lost many important administrators, most of whom left to form their own institutions. Furthermore, from 1924 until his death in 1961, he was a titular leader only, keeping the flame for a fundamentalist minority and battling with most of the profession, which he saw as inevitably following the osteopathic moth into the seductive medical flame.¹¹

Regardless of the philosophic issues that were debated then, and that still divide the profession today, it is possible that without B.J. Palmer’s missionary zeal and entrepreneurial brilliance, the chiropractic profession would not exist as it is today. B.J.’s title as the “developer” of chiropractic was honestly earned.

Philosophic roots

Spiritualism, which developed in the United States in the 1840s and is based on the simple premise that humans are dual beings consisting of a physical and a spiritual component, spawned a large array of interrelated religious, healing, and paranormal investigative groups.¹² Spiritualists believed that the physical element (the body) disintegrates at death, but the spiritual element (the soul, spirit, personality, consciousness, etc.) continues exactly as it was, but in another plane of existence: the “spirit world” or heaven.

American transcendental notions also evolved during this period and helped formulate the influential philosophy of Ralph Waldo Emerson. Emerson’s concept of a dual mind, which incorporates both innate and educated elements, were very similar to D.D. Palmer’s postulates and probably had a significant influence on Palmer’s early health care philosophy and theories.¹³ D.D. Palmer stressed the concept and importance of the innate mind and its role in self-regulation and restoration of health. He stated that “spirit and body” compose a dualistic system with “innate and educated mentalities,” which look after the body physically within its surrounding environments.¹³ This idea of innate intelligence forms a critical part of a 1956 work by B.J. Palmer in which he states, “Innate is the ONE eternal, internal, stable, permanent factor that is a fixed and reliable entity, does not fluctuate up and down scales to meet idiosyncrasies.”¹⁴

D.D. Palmer and his early followers emphasized health and the absence of disease over the management of disease. Early chiropractic theory emphasized the important role of the neuromusculoskeletal (NMS) system, specifically the spine, in treating and preventing disease. The concept was that a structural problem within the spine contributes to altered musculoskeletal and neurologic function and diminishes the ability of the body to heal itself.¹⁵ Palmer asserted that either too much or too little nerve energy is “dis-ease.” Moreover, he believed that disease was the result of internal imbalances involving hyperfunction or hypofunction of organs and systems rather than the result of something external that invades the body.

Osteopathy was also emerging at the same time and within the same philosophic environment. Andrew Taylor Still, the father of osteopathy, was a strong believer in Spiritualism. He stated, “We say disease when we should say effect; for disease is the effect of a change in the parts of the physical body. Vis medicatrix naturae to the osteopath declared that disease in an abnormal body was just as natural as is health when all parts are in place.”¹⁶

In addition to his interest in Spiritualism, D.D. Palmer also dabbled in other occult philosophies of his day. He first began his practice as a magnetic healer in Burlington, Iowa, and would in years to come write extensively on his thoughts about intrinsic “inner forces.” He went on to label the inner forces and their self-regulating effects as innate intelligence. He reasoned that health could be maintained if the body’s innate intelligence was functioning properly. Diseases were viewed as conditions resulting from either an excess or deficiency of this function.¹⁷ In contemporary health care the body’s ability to self-regulate and maintain internal equilibrium is referred to as homeostasis.

The early chiropractic focus on the philosophy of chiropractic and its distinct model of health care did not eliminate internal debate concerning the need for scientific training and investigation. From the early days of chiropractic’s founding, there were diverging views and debates between those stressing vitalism (the belief that the principles that govern life are different from the principles of inanimate matter) and those stressing a scientific approach to practice. D.D. Palmer believed, as noted by Waagen and Strang, that both approaches (the vitalists and the scientists) were important and that the concept of innate intelligence, which formed the early cornerstone of the philosophy of chiropractic, could be incorporated with a scientific approach to chiropractic.¹⁵

Many of the early chiropractic debates and divergent positions concerning its philosophy and health care model persist. As a result, the philosophy of chiropractic suffers from a lack of clarity and understanding of its boundaries.18 19 20 21 22 23 There is no demonstrable evidence that a body of content has been agreed upon. It is imperative that the chiropractic profession clearly delineate what exactly is meant by the philosophy of chiropractic and codify its content.²⁴

The present

Basic principles

The broad chiropractic model of health care is one of holism. In this model, health is viewed as a complex process in which all parts and systems of the body strive to maintain homeostatic balance against a dynamic environment of internal and external change. The human body is perceived as being imbued at birth with an innate ability (innate intelligence) to respond to changes in its internal and external environment. Earlier health care pioneers saw this as proof of the healing power of nature, vis medicatrix naturae. This concept emphasizes the inherent recuperative powers of the body in the restoration and maintenance of health and the importance of active patient participation in treating and preventing disease. The presence of an inherent ability within the organism to influence health and disease has been described by many different health care disciplines and is listed in Table 1-1.

TABLE 1-1 Names Given to the “Subtle” Energy of the Body Believed to Influence the Body in Health and Disease

Energy Name	Originator
Prana	Hindu
Chi	Chinese
Xi	Japanese
Libido	Freud
Orgone energy	Reich
Elan vitale	Bergson
Innate intelligence	Chiropractic
Vis medicatrix naturae	Medicine
Biochemicals of emotion	Pert

Broad-scope chiropractic care is committed to holistic health care and working with patients to optimize their health. Although the chiropractic profession’s major contribution to overall health is through the evaluation and treatment of NMS disorders, it is common for chiropractic physicians to also counsel patients on other lifestyle issues such as diet, nutrition, exercise, and stress management.

The contemporary practice of chiropractic maintains its focus on the evaluation and conservative treatment of NMS disorders and the important relationship between the functioning of the NMS system and overall well-being and health. Dysfunction or disease of the musculoskeletal system in any form is viewed as having the potential to create disorders of the locomotor system that may lead to impaired functioning of the individual. This model is supported by the underlying principle that stresses the important interrelationship that exists between structure and function of the human body.

In addition to specializing in the adjustive (manipulative) treatment of disorders of the spinal and extremity joints, it is common for chiropractors to include other treatment procedures in patient management and health promotion. Common therapies applied include dietary modification, nutritional supplementation, physical therapies, and exercise.

The chiropractic profession considers the musculoskeletal system to be a clinically neglected component of the body, although musculoskeletal disorders are common and account for significant amounts of lost time at work and recreation. The musculoskeletal system therefore deserves full consideration and evaluation whenever patients are seen, regardless of the complaint causing them to seek care.

The musculoskeletal system should be viewed as part of the whole body and subject to the same intensive diagnostic evaluation as any other system in the body. The musculoskeletal system is involved in so many alterations of function that it demands such attention and should not be removed from consideration in diagnosis, even when the initial problem appears removed from the musculoskeletal system.

Moreover, the human musculoskeletal system accounts for more than half of the body’s mass and is its greatest energy user. The large amounts of energy required by the musculoskeletal system must be supplied through the other systems in the body. If the musculoskeletal system increases its activity, an increased demand is placed on all the other body systems to meet the new, higher energy demands. Chiropractic notes that the presence of disease or dysfunction within the musculoskeletal system may interfere with the ability of the musculoskeletal system to act efficiently, which in turn requires greater work from the other systems within the body.

An important principle of chiropractic is that because the nervous system is highly developed in the human being and influences all other systems in the body, it therefore plays a significant role in health and disease. Although the exact nature of the relationship between dysfunction of the musculoskeletal system and changes in neurologic input to other body systems is not known, an enduring basic principle of chiropractic is that aberrations in structure or function can have an effect on health and the body’s sense of well-being. The nervous system’s effects on the body’s ability to fight disease through the immune response demonstrate this concept.²⁵

The nervous system also communicates with the endocrine system to maintain a state of homeostasis, defined simply as physiologic stability. This tendency of the body to maintain a steady state or to seek equilibrium despite external changes, referred to as ponos by Hippocrates, is the underlying theme in Palmer’s original concept of innate intelligence influencing health.

Manual procedures and, specifically, the adjustment are applied to address local NMS disorders and to improve NMS function. A consequence of improved NMS function may be improvement in the body’s ability to self-regulate, thereby allowing the body to seek homeostasis and improved health. In Haldeman’s outline of this process, manipulative therapy improves the function of the musculoskeletal system, which then causes a change in the input from the nervous system, which in turn may have a positive effect on other NMS tissue, organ dysfunction, tissue pathologic condition, or symptom complex.²⁶ Reflex mechanisms that support these ideas have indeed been documented, although the effects of manipulation on these reflexes have yet to be adequately assessed and demonstrated.27 28 30

Palmer developed his model of the effects on the nervous system through the belief that subluxation affects the tone of the body. In this model, tone refers to the efficiency of the nervous system and to the ability of the body to self-regulate its processes properly. This view was in opposition to the medical thought of the day, which focused on the germ theory and its relationship to disease.

Although many of the early forebears in chiropractic postulated subluxations as the root cause of all health care disorders and a “one cause, one cure” approach to health, the monocausal theory of disease has now been rejected by the overwhelming majority of practicing chiropractors. Chiropractors today certainly accept the existence and reality of germs and the role they play in creating disease. Both the chiropractic and medical paradigms recognize the health of the individual and his or her resistance to infection as critical factors. Furthermore, the chiropractic profession views the host’s susceptibility as depending on a multitude of factors. The chiropractic model postulates that the presence of joint dysfunction or subluxation may be one such factor serving as a noxious irritant to lower the body’s ability to resist disease. Within this paradigm, removal of joint dysfunction or subluxation becomes an important consideration for optimal health.

The value and importance of adhering to early chiropractic philosophic models of health and disease are debated. Some argue for strict adherence to an early fundamental paradigm because of fear that divergence from fundamental core values will lead to the dilution of the profession’s unique health care approach. Others argue that unwavering adherence to a particular belief system creates a climate of anti-intellectual dogma that retards the profession from investigating and differentiating effective from ineffective diagnostic and treatment procedures. Many of the historic philosophic chiropractic tenants are considered to fall within the realm of a belief system that can neither be refuted nor confirmed through research. Certainly the profession’s early adherence to its core principles helped established the profession as a unique and valuable branch of the healing arts. These core values continue to support the profession’s conservative approach to health care and its emphasis on the body’s inherent recuperative powers. However, it is probable that unwavering adherence to core values does create a climate that inhibits professional self-appraisal and clinical research. Questions concerning clinical effectiveness and whether “chiropractic works” are not answerable with philosophic debate.

Technically, philosophy asks questions about the nature of truth (epistemology), reality (metaphysics), the good (ethics), and the beautiful (aesthetics).³¹ None of these is susceptible to empirical scientific inquiry. Proving that “chiropractic works” has been a loudly expressed goal of the profession that offends scientific sensibilities. Concepts based on faith or intuition must not be confused with scientific theory validated by empirical data or facts.

A profession, with all its procedures and practices, cannot be demonstrated to “work.” It has not been said that research proves that medicine or dentistry works; rather, specific studies are cited identifying that a specific procedure is effective for a specific condition. Research done to “prove” something works will be looked on suspiciously because there is a clear demonstration of bias. Furthermore, chiropractic must be viewed as a profession, not a procedure. It is important to be aware of the philosophic assumptions underlying conceptions of reality and truth but not confuse them with the search for scientific truths, which are never absolute but remain forever tentative and approximate.³¹ The traditional language of the philosophy of chiropractic might be revised to more closely coincide with the current language in the biologic and life sciences without loss of appropriate philosophic meaning.³²

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