MANIPULATION: AN HISTORICAL PERSPECTIVE

James C. Krieg, M.D.

Some of the earliest indications of body manipulation In fact, some spoke of dislocations where none were were noted in the Kong Fou Document, written around possible, or of small bones that became out of place, 2700 B.C., brought to the Western world by French where none existed. missionaries. Greek papyrus dating back to 1500 B.C. This led to a general mistrust of the manipulations by gave instructions in using maneuvers of the lower extrem- the practitioners of conventional medicine. Despite this, ities to affect low back . the methods crept into the practices of many medical Evidence of manipulation being used for various condi- practitioners. tions has been seen in the writings of the ancient Japanese, The first formal training in manipulation came with the Indians of Asia, Egyptians, Babylonians, Syrians, Hindus, birth of Osteopathic Medicine in 1874. It was Andrew Still, and Tibetans. It has been practiced in Tahiti for centuries. the founder of , who first espoused the science (Fig. 1) of . At the time, Still was a respected The history of spinal manipulation in America predates medical practitioner, and this led some credibility to what the arrival of Europeans. Hieroglyphics of ancient North had previously been, in the eyes of many, sheer quackery. Americans depict "back walking," the manipulation of the Although they manipulated all joints, the pioneers of spines of sick individuals with the feet of others. The osteopathic methods felt that the spine was the foundation Polynesian Island natives had children walk on the backs of of their craft. The "spinal lesion" was the source of all the infirmed. This practice was witnessed by explorers of disease. The lesion is described most often as the "immo- the 1500's. bilization of a joint in a position of normal movement," i.e. While the origins of "bone setting" are unknown, the a locked joint. The locked joint can interfere with the practice has existed in many societies, including early extra-articular circulation, rendering the individual suscep- America. The practitioners of bone setting had no formal tible to every variety of illness. They referred to this as training. Often their art was a mixture of religion and "lowered vitality." superstition, rather than any scientifically based practice. When discussing the development of spinal manipulation and the birth of chiropractic, it is only fair to do so in the milieu of conventional medicine at the turn of the century. Some milestones to recall are the first description of Pasteur's germ theory in the 1860's. At that time, Lister's concept of antiseptic surgery was not yet fully accepted. The 1880's saw the discovery of the tuberculus bacilli. X-rays were first introduced in the United States in the 1890's. Medical Schools did not have formal requirements regarding premedical training until 1919. Chiropractic was invented by . (Fig. 2) Mr. PaLner was born in 1845 in Port Perry, a little Canadian town near Toronto. He moved to the U.S. at a young age. He held several jobs, including grocer and teacher in Letts, Iowa. To gain extra money, he studied phrenology, the science of the brain. While lecturing on Figure 1. the subject he met Paul Caster, an internationally known Statue located in Bangkok, ca. 1275-1300 A.D. The figures depict a right SI joint manipulation magnetic healer. Caster explained his science to Palmer as such, "I devised a method where, by rubbing and slapping the entire body of a sick patient, I imparted my magne- tism. It cured the sick." Palmer was so impressed that he became a student of Caster and quickly set up a practice in Burlington, Iowa as Correspondence to: James C. Krieg, M.D. a magnetic healer. His practice did poorly, as Burlington University of Iowa Hospitals and Clinics Department of Orthopaedic Surgery already had a magnetic healer, his mentor, Paul Caster. So 200 Hawkins Drive Mr. Palmer packed his bags and moved his practice up the Iowa City, Iowa 52242-1009 Mississippi River to Davenport. His practice improved,

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Figure 3. The Palmer home and site of the original Palmer Infirmary and Chiropractic School.

Mr. Palmer soon expanded this success and applied his method to all manner of ills. He began looking for bumps to push on in people with a variety of conditions. His practice grew, and along with it his income. Soon after his great discovery, Mr. Palmer dubbed his method "Chiropractic." It comes from the Greek words cheiro and practikos, roughly translated to "done by hand." The name was meant to serve as a distinction between his method and that of conventional medicine, with its pills and early concepts of surgery. Three years after discovering chiropractic, Mr. Palmer I3.A.\1 I` I, I)AVID 11 \1 .."MI. founded the Palmer Infirmary and Chiropractic School. (Fig. 3) As the first training institution for the chiropractic method, it was started at the urging of Mr. Palmer's son, Figure 2. Daniel David Palmer, father of chiropractic Bartlett Joshua. (Fig. 4) Bart was only 17 when his father started the Palmer but he still required supplemental income to raise his School. He was one of four students in the first graduating family. He began to raise goldfish for cash. In fact, Mr. class. Upon graduation he changed his name to B.J. Palmer developed a new method of shipping the fish in low Palmer. He traveled to several towns in Michigan and volume, high surface area containers that to this day are West Virginia, having various troubles forming practices. the industry standard in shipping live fish. In 1903, B.J. returned to Davenport at his father's What has been heralded as the "Great Discovery" request. Mr. Palmer's practice was horribly in debt and occurred in 1895. Mr. Palmer was working late one night the school was failing. B.J. bought out the practice and the and struck up a conversation with Harvey Lillard, his deaf school. In 1905, B.J. incorporated the Palmer School of janitor. Inquiring as to the cause of Lillard's deafness, Mr. Chiropractic under the laws of Iowa as an educational Palmer learned that seventeen years prior, Lillard sus- institution. Meanwhile, Mr. Palmer left town broke and tained an injury to his neck. He stooped over, and heard despondent. He went back to Letts, Iowa, where he soon and felt a snap in his neck. At that moment he went fell in love and married. His wife, Molly, convinced him to suddenly deaf. In addition, from that time on, he noticed a return to Davenport. lump on the back of his neck. Mr. Palner, felt that the B.J. and his dad always had a competitive relationship. bump on the neck and the deafness were somehow This intensified upon Mr. Palmer's return to Davenport related. For three days he gave the bump thrusts. On the when he saw that both B.J.'s practice and the school were third day, Lillard jumped up, yelling, "Doc! Doc! I hear!" flourishing. He was infuriated. He attempted to regain Thus was born the Science of Chiropractic. control of both, and B.J. let him regain control over the school. However, his father remained bitter and his

96 The Iowa Orthopaedic Journal Chiropractic Manipulation: An Historical Perspective

'; ItT I , M 111 Figure 4. Bartlett Joshua Palmer, D.C., Ph.C. previously poor business practices grew even worse. The school once again was led toward financial ruin. Matters came to a head in 1906. B.J. and his father were charged with practicing medicine without a license. Mr. Palmer was indicted first, for reasons that remain Figure 5. unclear. In fact, B.J. never stood trial. His father, on the B.J. demonstrates his technique of manipulation in The Science of other hand, was tried and convicted in Scott County v. Chiropractic, Vol. I-V. D.D. Palmer. He was fined five hundred dollars. At sentencing, Mr. Palmer angrily addressed the court. He stumbled upon the art of chiropractic, and began to condemned them for convicting him of a charge he did not develop it into a science. However, he advanced the believe. He was subsequently incarcerated in the Scott science and elevated it to a philosophy. He declared County jail. After 17 days, against his father's wishes, B.J. himself the first Ph.C., or Philosopher of Chiropractic. paid the fine and had him released. This served to widen The science of chiropractic was based on three princi- the rift between father and son. B.J. bought out his ples. Adjustment of the spine was similar to that described father's share of the business once again, and they parted by osteopaths, with some technical differences. Palpation ways for the last time. was the means by which areas requiring adjustment were With his father out of the picture, B.J. set about in identified and described. Nerve-tracing was the other key earnest to advance his practice, the Palmer School and the to diagnosis. It involved tracing one's symptoms to the field of chiropractic. He advanced his techniques in a series level of subluxation causing them. These nerves were the of books on the subject. (Fig. 5) He wrote that his father mediators of "Innate Intelligence," a natural life force that

Volume 15 97 J. C. Krieg represented the ability and desire of the body to heal itself, or return to its normal state of homeostasis. Subluxation of the spine occurs in one of a combination of six directions. The science of chiropractic, based on the subluxations present in the spine, was proven by B.J. using the extensive osteology collection at the Palmer School. The philosophy of chiropractic was set forth by B.J. as well. He wrote, "Therapeutics is wrongly based. It needs one vast revolution. This is the mission of chiropractic- the first non-therapeutical theological philosophy." Palmer be- lieved that life, death, and disease, described as the "intermediate," were insufficiently explained by the cur- rent science ("the knife") or religion ("preaching the gospel"). This void was filled by chiropractic. He aimed to bridge the spiritual and corporeal. In promoting chiropractic, he drew sharp distinctions between his science and the science of conventional medicine. He reiterated the risks of anesthesia, blood loss, and the unpredictable results often associated with early surgery. In 1909 he introduced the use of X-rays which served to mainstream chiropractic. In 1913 states began to license chiropractors. B.J. held advertising crucial to the development and spread of chiropractic. He taught advertising and patient management skills to his pupils. He encouraged them to offer free consultations (X-ray fees excluded, of course) in order to generate patients. He espoused the use of full body length X-rays with elaborate explanations given to Figure 6 patients to account for their varied complaints. After all, Ronald Reagan behind the microphone at WOC. the patients needed to understand their disorder in order to see the need for repeated adjustments. Nugent differed on this and many other subjects, including On a more personal level, he began to use the emerging the advisability of requiring college training prior to em- media of radio as a means of advertising his own practice barking on a career in chiropractic. B.J. often had disdain and his school. He purchased and developed WOC in for the college educated. Davenport, and WHO in Des Moines. He later affiliated At the same time Nugent was scrutinizing the educa- with NBC in order to gain national exposure. It was as tional institutions of chiropractic, there was essentially no owner of WOC that he first met Ronald Reagan. He was regulation of the daily practice of the science. Partly as a Reagan's first employer in what was to become a long and result of B.J.'s push to advertise, the mid 1900's were illustrious acting career. (Fig. 6) marked by a virtual explosion of unusual devices, they had In the 1930's chiropractic came under the scrutiny of names such as the Polysine Generator, the Chromoray, John Nugent. He reviewed chiropractic schools, attacking the Neurocalometer, and the Electroencephaloneuromen- the weaker ones. In 1935 he headed the National Council timpograph. (Fig. 7) The Neurocalometer's problem was on Chiropractic Examining Boards. This movement be- that in FDA testing the device proved unable to distinguish came known as "Nugentism." In 1942 the Council issued a well person from a corpse. This was the impetus for the its first report. Twelve schools, including the Palmer new, improved Neurocalometer which claimed that it School, received "provisional approval." In 1946 this list would not be confused in discerning the living from the was narrowed to four schools. Notably absent from the list dead. was Palmer's program. One of the standards set by As a result of these and other fantastic claims, the Nugent's Council was a four year curriculum, each year to division and animosity between chiropractic and conven- include at least nine months of study. Palmer had an tional medicine worsened. Claims of practicing medicine eighteen month course of study until 1958. B.J. and

98 The Iowa Orthopaedic Journal Chiropractic Manipulation: An Historical Perspective

actively shared this with his counterparts in other states. This led to Throckmorten's appointment as Chairman of the AMA Committee on Quackery. At that time the AMA was part owner of the Joint Commission on Accreditation of Hospitals (JCAH), the American College of Physicians (ACP), the American College of Surgeons, and the Amer- ican Hospital Association. This meant that Throckmorten and his policies received a great deal of credibility. This led to chiropractors being denied access to hospital facilities. In August, 1987 a federal judge ruled in favor of Wilk based on the strong opposition the AMA held toward chiropractic without evidence. The AMA, ACS, and American College of Radiology were found guilty. The AAOS, JCAH, and ACP were found not guilty. The case was upheld on appeal in 1990. As a result of Wilk v. AMA, the AMA was required to Figure 7 mail a letter to all of its members, and those of the B.J. demonstrates the electroencephaloneuromentimpograph codefendant groups, stating that opposition to chiropractic was against the principles of the AMA. Chiropractors without a license became commonplace. Many chiroprac- could no longer be denied access to health care facilities or tors were prosecuted, and some imprisoned. third party payers. This case was a turning point in the Many within the field of chiropractic recognized the . problems that the far fetched claims of their colleagues The modern practice of chiropractic is a far cry from the were causing. As a result, many began to tone down their early science of the Palmers. Chiropractic is now an rhetoric. In effect, a field that had its roots in being accepted form of treatment in many elements of our unconventional sought to become more mainstream. Less society. Third party payers recognize and compensate for was heard about Innate Intelligence and the ability of chiropractic treatment. A recent study by the RAND to cure heart and other Corporation (Shekelle, 1994) verified, by meta-analysis, manipulation diabetes, disease, that More was focused on the claim that chiropractic manipulation can be an effective treat- medical conditions. ment for acute low , without , of manipulation could aid in treating ailments of the spine. less than one month duration. Cost of treatment is On October 1, 1976, Chester Wilk and four other comparable, per episode, to treatment by orthopaedic chiropractors brought suit against the American Medical surgeons. (Shekelle, 1995). Association, American Hospital Association, American While many chiropractors have clung to their roots, and Academy of Orthopaedic Surgeons, five other medical continue to search for subluxations that are responsible for associations, and four individuals. The defendants were various medical conditions, the majority have focused their charged with violating Section 1 of the Sherman Antitrust attention on the treatment of back pain. While this may be Act-conspiring to elim-inate chiropractic through refusal causing a rift within the field, it is certainly leading to more to associate professionally with chiropractors. The case and more mainstream acceptance of spinal manipulation. went to trial in Chicago, in December 1980. The original The future of chiropractic, while uncertain, seems to be jury found for the defendants, after the judge implied to headed far beyond the expectations of D.D. Palmer when them that a defendant can escape the Sherman Act by he first cured Harvey Leggett of his deafness, or the acting in a public interest. On appeal, the Seventh Circuit ambitions of B.J. when he incorporated the Palmer School Judge ruled that the decision was in error, but refused to of Chiropractic. overturn it based on a legal interpretation. The case was ordered back to trial. In the second trial, Wilk had to prove that the primary effect, rather than intent, of the defen- dants had been to restrict competition. As a result, the defendants had to prove that they not only acted out of public interest but that, by their actions, the public had been served. The key evidence in the case was produced by Mr. Throckmorten, general counsel of the Iowa Medical Soci- ety. He had devised a plan to curb chiropractic in Iowa. He

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REFERENCES ' Chiropractic in America, J. Stuart Moore, John Hopkins University Press. Baltimore and London, 1993. 2- The Science and Art of Joint Manipulation, James Menneil, P. Blakiston's Son and Co. Philadelphia, 1939. 3- The Chiropractic Story, Marcus Bach, DeVorss and Co., Inc. Los Angeles, 1968. 4- Healing Hands, Joseph E. Maynard, Jonorm Publishers. Mobile, 1977. 5- Chiropractic Health Care, R.C. Schafer, The Foundation for and Research. Des Moines, 1978. 6- The Science of Chiropractic, Volume III, B.J. Palmer, The Palmer School of Chiropractic, Publishers, Daven- port, 1911.

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